ChanBeDu/relevant_section_length · Datasets at Hugging Face

16,542

165,851

26915

Discharge summary

report

Admission Date: [**2131-6-28**] Discharge Date: [**2131-6-30**] Date of Birth: [**2051-12-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5755**] Chief Complaint: Biliary obstruction Major Surgical or Invasive Procedure: ERCP with sphincterotomy and replacement of biliary stent History of Present Illness: This is a 80 year old man with past medical history significant for biliary obstruction likely secondary to cholangiocarcinoma status post biliary stent in [**3-5**] who was transferred from [**Hospital 1474**] hospital where he presented with weakness and jaundice. Labs were remarkable for elevated LFTs, bili, and alkaline phosphatase with a normal amylase and lipase. Patient underwent CT and MRCP at [**Hospital1 1474**], prior to transfer, which showed massive dilation of the intrahepatics, stent in the common bile duct, and gallstones in the gallbladder. ERCP was attempted at [**Hospital1 1474**] for further evaluation. Note was made of a large diverticulum in the second portion of the duodenum where the ampulla was located. The stent was noted to be exiting the ampulla. Stent removal and cholangiogram were attempted but failed. Patient was thus transferred to [**Hospital1 18**] for continued care and repeat attempt for stent removal and replacement. . ROS: Pt states that prior to his procedure he felt weak and had not eating in 2 days. He denies abdominal pain, fevers, chills, N/V, dysuria, cough/SOB, chest pain. Past Medical History: 1. TB as child, spent 7.5 yrs in sanitroium 2. TIA 3. detached retina 4. hypercholesterolemia 5. history of biliary obstruction s/p plastic stent [**3-5**] at [**Hospital 6451**] Hospital - brushings concerning for adenocarcinoma, CA [**43**]-9 normal (10) in [**3-5**], CEA elevated (11) in [**3-5**], CT revealed portohepatic and gallbladder masses in [**3-5**]; patient being followed by Dr. [**Last Name (STitle) 66200**] of gastroenterology at [**Hospital1 1474**] 6. hypercholesterolemia Social History: former machinist, no ETOH for a few years, retired, lives alone, multiple pets. HCP is [**Name2 (NI) 802**] [**Name (NI) 717**] [**Name (NI) **] [**Telephone/Fax (1) 66201**] Family History: 1. brother-lung cancer 2. brother-CAD 3. sister- cancer, one with breast cancer Physical Exam: Vitals: T: 93.0 P:70s R:16 BP:90s/50s SaO2: 98% on NRB General: Somnalent but arousable. HEENT: NC/AT, PERRL, EOMI without nystagmus, scleral icterus noted, MMM, no lesions noted in OP Neck: supple, Pulmonary: Lungs CTA bilaterally (anterior exam) Cardiac: Distant. RRR, nl. S1S2, no M/R/G noted Abdomen: soft, Non-tender,distended. normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. marked icterus. Neurologic: -mental status: somnalent but arousable. gives limited history. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: Labs: hct 30.2 -> 23.1 -> 22.3 ALT 125 -> 95 AST 68 -> 46 Alk phos 1147 -> 862 t bili 9.6 -> 6.2 . CXR: stable bilateral moderate sized pleural effusions, no chf or pneumonia . Blood cultures x 2 ([**2131-6-28**]): pending . [**2131-6-28**] 04:11PM BLOOD WBC-12.5*# RBC-3.10* Hgb-8.8* Hct-30.2* MCV-98 MCH-28.5 MCHC-29.2*# RDW-20.1* Plt Ct-599*# [**2131-6-28**] 04:11PM BLOOD Glucose-409* UreaN-26* Creat-1.2 Na-134 K-3.5 Cl-104 HCO3-21* AnGap-13 [**2131-6-28**] 04:11PM BLOOD ALT-125* AST-68* LD(LDH)-166 AlkPhos-1147* TotBili-9.6* [**2131-6-28**] 04:11PM BLOOD Albumin-2.8* Calcium-8.0* Phos-5.0*# Mg-2.0 [**2131-6-28**] 04:28PM BLOOD Type-ART Temp-33.9 pO2-52* pCO2-43 pH-7.27* calTCO2-21 Base XS--6 Intubat-NOT INTUBA . ERCP [**2131-6-28**]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: A plastic stent placed in the biliary duct was found in the major papilla and impacting the internal wall of the diverticulum. A single diverticulum with large opening was found with the major papilla internally. Cannulation: Cannulation of the biliary duct was successful and deep using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. Cannulation of the pancreatic duct was not attempted. Biliary Tree: A single irregular stricture of malignant appearance that was 25mm long was seen at the middle third of the common bile duct. There was severe post-obstructive dilation. These findings are compatible with malignant biliary stricture. . Procedures: A plastic stent was removed for the bile duct using a rat tooth forceps. Given the malignant biliary obstruction (and need for metal stenting) a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Following sphincterotomy fresh bleeding was noted. Given the presnce of acute sphincterotomy bleed the plan for metal stenting was aborted due to poor duodenal visualisation and a 5cm by 10F double pig tail biliary stent was placed successfully in the common bile duct. Following double pigtail stent placement 2 x 2cc 1/10,000 adrenaline injection was applied to the apex of the sphincterotomy. Hemostasis appeared to be achieved although there was a large overlying clot. Cytology samples were obtained for histology using a brush in the middle third of the common bile duct. . Impression: Papilla major diverticulum Stent in the major papilla Stent removal Malignant appearing mid-CBD stricture Cytology Sphincterotomy Double pigtail stent placement Hemostasis with 1/10,000 adrenaline, . Recommendations: Admit to hospital for overnight stay NPO overnight , then advance diet as tolerated in AM. Check Hct now and again in 6 hours Await cytology and plan for metal stent placement in 1 month Brief Hospital Course: 80 year old male with suspected cholangiocarcinoma transferred from [**Hospital 1474**] Hospital for obstructive jaundice for stent change. . ## Obstructive jaundice: Patient admitted to [**Hospital1 1474**] with complaints of weakness and jaundic. Bili and alk phos elevated from baseline with associated elevation of his LFTs. CT and MRCP confirmed severe biliary dilation. ERCP attempted at [**Hospital1 1474**] found stent exiting the ampulla. Patient underwent repeat ERCP here at [**Hospital1 18**]. The stent was removed. Attempt was made to place a metal stent but due to bleeding following a small sphincterotomy to facilitate the stent placement, visualization was impaired and operators were forced to place a plastic stent. Patient will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) **] to arrange placement of a metal stent for improved long term management within 1 month. Brushings were obtained during ERCP for cytology given patient's diagnosis remains undifferentiated. CA [**43**]-9 has been noted to be elevated in the past with a normal CEA. Repeat CA [**43**]-9 was sent at [**Hospital1 1474**] and was pending. The patient was offerred [**Hospital1 28085**] to oncology here but wishes to follow-up with his regular primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 28085**] to an oncologist within their system. Extensive discussions were held with the patient to help him cope with his diagnosis of cancer. He was seen by both social work and palliative care and provided numbers to schedule follow-up with them as needed. On the day of discharge, patient's bili and LFTs trending down. He was tolerating a regular diet without complaints. . ## ICU course: Immediately following ERCP, patient was noted to be unresponsive with decreased respirations and O2 sats in the low 70's on nonrebreather. Given patient had received 4 mg versed and 150 mcg of fentanyl prior to his procedure, he was given flumazenil 200mg times 2 and narcan 0.2 mg with sats coming up to mid 80s, but the patient remained unresponsive. He was administered another 0.4 mg narcan which resulted in increased O2 sat to low 90s and increased level of consciousness. He was transferred to the ICU for closer monitoring. In the ICU T 93.0 oral, BP 90s/50s, HR in the 70s, RR 16-20, and O2 Sat 92% on NRB. ABG was drawn which was 7.27/43/52. WBC count was elevated at 12.5. The patient was given 1L NS bolus and 3 g of amp/sulbactam for SIRS and suspected cholangitis. His post-procedure hematocrit was 23.1, down from 30.2 but remained stable without transfusion. . ## Hypoxia: Patient's hypoxia following ERCP likely due to medications causing respiratory depression. CXR showed stable bilateral pleural effusions and following narcan and flumazenil, the patient's respiratory rate improved and he was quickly weaned to room air. . ## Hypotension: Likewise, likely related to medications +/- hypovolemia. Patient was empirically covered with amp/sulbactam x 1 dose but lactate returned 1.6, cultures remain negative, and patient continues to do well off antibiotics. He did receive a liter of NS for resuscitation but remained stable thereafter without further boluses. His post-procedure hct had dropped from 30 to 23 but his blood pressure returned to [**Location 213**] without blood transfusion. No complaints of chest pain, shortness of breath, or dizziness on the day of discharge. . ## Acute blood loss anemia: Following sphincterotomy, patient had significant bleeding requiring epinephrine injection. Post-procedure hematocrit was 23, down from 30 but remained stable without transfusion. Patient was instructed to monitor his stools for black color or bright red blood and to follow-up with his regular primary care doctor within 1 week to have his blood count rechecked. He was discharged on supplemental iron and warned of potential constipation and GI upset with this medication. . ## Prophylaxis: pneumoboots and bowel regimen. ## FEN: Initially kept NPO given above. Was then changed to a full diet. ## Access- PIVS ## Code status- Pt was full code. This was discussed with patient at length. The paperwork for making his [**Location 802**] the healthcare proxy was given to the patient. ## Comm with HCP [**Name (NI) **] [**Name (NI) 717**] [**Name (NI) **] [**Telephone/Fax (1) 66201**] Medications on Admission: ASA ocuvite vitamin C and D Discharge Medications: 1. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months: discontinue if having loose stools. Disp:*60 Capsule(s)* Refills:*0* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 1 months. Disp:*10 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: biliary obstruction hypotension hypoxic respiratory failure acute blood loss anemia Discharge Condition: good, hemodynamically stable, hct stable x 24 hours, AF Discharge Instructions: Please call your doctor or go to the emergency room if you experience dizziness, shortness of breath, chest pain, blood in your stool, temperature > 101, or other concerning symptoms. Please take the iron I have prescribed you to help restore your blood count. Please do not restart your aspirin until Thursday. Followup Instructions: Please follow-up with your regular doctor within 1 week to have your blood count rechecked and to discuss [**Telephone/Fax (1) 28085**] to an oncologist. (Dr.[**Name (NI) 65062**] office contact[**Name (NI) **] [**2131-7-2**] to schedule follow-up. They will contact patient regarding appointment Thursday, [**2131-7-5**] at 10 AM.) The gastroenterologists will contact you with the results of the cells they obtained during the procedure.

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Discharge summary

report

Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-17**] Date of Birth: [**2062-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: lethargy and hypotension Major Surgical or Invasive Procedure: None. History of Present Illness: 58 year old with history of ischemic cardiomyopathy (EF 20%), severe 3 vessel coronary artery disease, type 1 diabetes, chronic renal disease status post renal transplant in [**2103**] who presents with lethargy and fever to 102.6. He had had decreased ability to care for himself over the last few days with a progressive nonproductive cough. He notes a dry nonproductive cough. He denies chest pain, shortness of breath, nausea, vomiting, diarrhea, or hematochezia. Past Medical History: 1. Ischemic cardiomyopathy with EF 20% 2. Coronary artery disease with severe 3 vessel disease and not a cabg candidate 3. Peripheral vascular disease status post bilateral above knee amputation 4. Type 1 diabetes 5. Blindness 6. Complete occlusion of right ICA 7. Chronic renal insufficiecy renal xplant [**2103**]; baseline creatinine 1.2-1.4 Social History: He lives alone and Independent of ADL's. His sister is extremely involved in his care and stays with him 4 times a week. She sets up his medications, checks his glucose fingersticks and draws up his insulin. He has a VNA nurse [**1-19**] times per week when his sister is not there. Family History: Non-contributory Physical Exam: Vitals: Temperature:102.6 Pulse:67 Respiratory rate:25 Blood pressure:90/50 Oxygen saturation:100% on non-rebreather Gen: Frail, diaphoretic, chronically ill-appearing male in NAD HEENT: Right eye enucleated Neck: supple, JVP at ear, left carotid bruit Pulm: anteriorly with crackles throughout, no wheezes Cardiac: RR, nl. S1, S2, II/VI systolic murmur heard best USB Abd: scaphoid, soft, NT/ND, normoactive bowel sounds Ext: bilateral above knee amputations Skin: warm, diaphorectic Neuro: Sleeping but alert . Pertinent Results: Hematology: WBC-7.9 Hgb-10.1 Hct-30.8 Plt Ct-346 Neuts-87.8 Lymphs-5.8 Monos-5.5 Eos-0.8 Baso-0.2 . Chemistries: Glucose-117* UreaN-69* Creat-1.3* Na-138 K-4.4 Cl-102 HCO3-24 Calcium-8.9 Phos-2.2* Mg-1.9 . LFTs: ALT-40 AST-81 LD(LDH)-251 AlkPhos-116 Amylase-22 TotBili-0.7 . Cardiac: CK(CPK)-178 CK-MB-5 cTropnT-0.38 proBNP-[**Numeric Identifier 21050**] IMAGING: Chest x-ray: New moderate-to-severe pulmonary edema. Brief Hospital Course: This is 56 year-old male with severe ischemic cardiomyopathy (EF 20%) and Type 1 diabetes who presented with hypotension, pulmonary edema, and fever to 102.6. . 1. Hypotension/Fever: Etiology of his presentation was unclear. His hypotension responded to fluid ressucitation and pressors. He was intially treated with stress dose steroids, which were stopped once he had a normal cortisol stimulation test. Infectious work-up was negative with the exception of a possible infiltrate on chest x-ray. Urinary legionella was negative. He was treated with levofloxacin for presumed community acquired pneumonia. He was discharged to complete a 14 day course of levofloxacin. . 2. Ischemic Cardiomyopathy: He had no evidence of acute ischemia. He had 3 sets of cardiac enzymes that were negative. He was maintained on his outpatient aspirin, plavix, statin, and digoxin. His metoprolol was initially held given hypotension, but was restarted prior to discahrge. Once he was no longer hypotensive, he was restarted on his outpatient diuretics to decrease his pulmonary edema. He diuresed well. . 3. Chronic kidney disease: He is status post renal transplant. His creatinine was initially slightly above his baseline and that improved with fluid ressucitation. he was maintained on cyclosporin (level therapeutic), azathioprine, and prednisone for immunosuppression. . 4. Diabetes: While in the intensive care unit, he required an insulin drip for good glycemic control. Once on the floor, he was restarted on his outpatient glargine at 26 units at night. At the time, he was not eating regularly and he had problems with hypoglycemia. His glargine was decreased to 6 units with improvement in hypoglycemia. His glargine will need to be increased back to 26 once he is eating regularly. . 5. Anemia: He has anemia secondary to renal disease. He receives epoeitin as an outpatient and did not received any while an inpatient. He did receive 1 unit of red cells during this admission. . 6. FEN: Cardiac, low salt, diabetic diet. He had speech and swallow evaluation that recommended a soft diet. . 7. Code: full code . 8. Dispo: He was discharged to an acute rehab Medications on Admission: MEDICATIONS AT HOME: - metoprolol 12.5 mg b.i.d. - hydralazine 25 mg t.i.d. - digoxin 150 mg every other day (last [**2120-1-10**]) - Lipitor 40 mg once daily, - azathioprine 50 mg qam - prednisone 10 mg every other day (last dose [**2120-1-11**]) - cyclosporin 100 qam, 50 qpm - Lasix 40 mg b.i.d. - metoclopramide 5 mg q.i.d. - Ativan 2 mg qam, 4 mg qhs - Lantus insulin 26 units qhs - Humalog insulin sliding scale - Procrit 35,000 units,last given (Monday [**2120-1-7**]) Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Pneumonia. Diabetes. Renal disease status post-transplant. Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed and keep all follow-up appointments. . Seek medical attention if you have fevers, chills, nausea, vomiting, shortness of breath, chest pain, or anything else that you find worrisome. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2120-2-26**] 9:00 Completed by:[**2120-1-17**]

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icd9cm

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Discharge summary

report

Admission Date: [**2123-11-4**] Discharge Date: [**2123-11-6**] Date of Birth: [**2079-7-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Epigastric pain with nausea, left arm pain, hypertensive urgency Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 104318**] is a 43 year-old man with a history of Type 1 DM, ESRD on HD and frequent admissions for left sided body pain and HTN who presents with left sided body pain and hypertensive urgency noted during HD today. He reports 1 week of stomach pain with epigastric burning and vomiting after meals. He states that he has left shoulder pain which has been stable for 4 months. The pain worsens with movement of his left arm. He denies SOB, diaphoresis, or dizziness. He states he has had severe left sided flank pain intermittently over the past week. He denies any local trauma. He endorses mild constipation. . He specifically denies any symptoms of vision changes (baseline mild blurry vision), chest pain, difficulty breathing, shortness of [**Known lastname 1440**], headache, or leg pain. He produces a minimal amount of urine at baseline and denies any dysuria. . In the ED, his initial vital signs were 181/96 99%4L with general abdominal tenderness and left arm pain with movement. He received morphine 4mg, zofran 4mg, ASA 325 mg, labetalol 40mg IV in [**4-7**] mg doses, and dilaudid 1mg. A labetalol gtt was then started. Abdominal CT was unremarkable on preliminary read as was EKG. Placed RIJ central line for access. Renal consult evaluated in the ED and recommended HD in AM. Past Medical History: 1. DM1 x 17 years 2. ESRD, on HD T,Th,Sa at [**Location (un) **] [**Location (un) **] 3. HTN, poorly controlled 4. R foot operation - bone excision 5. R foot ulcer 6. Depression with h/o SA and psych hospitalizations 7. Esophagitis on EGD [**10-22**] with negative H. Pylori 8. h/o L flank pain since [**2119**] with multiple admissions and extensive work-up and no organic etiology for pain found 9. Diastolic CHF: LVEF >55% by echo Social History: His mother passed away and he now lives alone. He sees his sister and brother on the weekends. Has four children. Former floor tech. No smoking, EtOH, drugs. History of suicide attempt using "lots of pills." Family History: Diabetes in multiple relatives on both sides. Physical Exam: VS - afebrile 128/78 59 99% 3L GEN - middle aged man, falling asleep during interview HEENT - NCAT, MM dry but [**Year (4 digits) 5235**] CV - RRR, S1, S2, no rmg PULM - crackles up 2/3 left lung, right basilar crackles, no wheezes ABD - soft, ND, +BS, tenderness to light palpation over epigastric region otherwise nontender to palpation EXT - wwp, 1+ pretibial edema NEURO - CN 2-12 fxn [**Year (4 digits) 5235**], [**6-21**] MS throughout, symmetric, A*O*3 Pertinent Results: ADMISSION LABS: . [**2123-11-4**] 10:15AM PT-15.6* PTT-31.0 INR(PT)-1.4* [**2123-11-4**] 10:15AM PLT COUNT-152 [**2123-11-4**] 10:15AM NEUTS-71.4* LYMPHS-20.5 MONOS-5.3 EOS-2.2 BASOS-0.7 [**2123-11-4**] 10:15AM WBC-5.6 RBC-3.92* HGB-10.7* HCT-33.9* MCV-87 MCH-27.3 MCHC-31.6 RDW-19.1* [**2123-11-4**] 10:15AM CALCIUM-9.4 PHOSPHATE-5.4* MAGNESIUM-1.9 [**2123-11-4**] 10:15AM CK-MB-11* MB INDX-3.8 [**2123-11-4**] 10:15AM cTropnT-0.25* [**2123-11-4**] 10:15AM LIPASE-23 [**2123-11-4**] 10:15AM ALT(SGPT)-26 AST(SGOT)-27 CK(CPK)-286* ALK PHOS-156* TOT BILI-0.7 [**2123-11-4**] 10:15AM estGFR-Using this [**2123-11-4**] 10:15AM GLUCOSE-160* UREA N-36* CREAT-8.1*# SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 PERTINENT LABS/STUDIES: . Hct: 33.9 -> 31.5 -> 32.0 (baseline 33-37) Gluose: 160 -> 51 -> 135 CK: 286 -> 216 Alk Phos: 156 Troponin: 0.25 -> 0.23 (baseline elevated at 0.16 to 0.43) EKG: sinus @86. LAE. no Q waves. trace ST depressions laterally. CXR: The lungs are clear, without pulmonary airspace consolidation, effusion or evidence of pulmonary edema. Cardiac silhouette remains enlarged. Hila are within normal limits. Osseous structures are unremarkable. CT A/P ([**11-4**]): LUNG BASES: There is small right pleural effusion and minimal bibasilar dependent atelectases. The lung bases are otherwise clear. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Ascites and free fluid within the pelvis are not significantly changed. The liver, pancreas, and adrenals are unremarkable. There is small amount of pericholecystic fluid, likely related to ascites. The spleen is mildly enlarged, measuring 13.6 cm. The kidneys are small bilaterally, without focal abnormality identified. The aorta is normal in caliber. Prominent nodular soft tissue attenuation adjacent to the IVC may relate to dilated lymphatics and is unchanged. There are no pathologically enlarged mesenteric lymph nodes. The small bowel and colon are normal in caliber, without evidence of wall thickening. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Free fluid within the pelvis is unchanged. The rectum, sigmoid colon, prostate, and seminal vesicles are unremarkable. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: No suspicious lytic or blastic osseous lesion is identified. IMPRESSION: 1. Stable ascites. 2. Small right pleural effusion, decreased in comparison to [**2123-4-16**]. No evidence of acute intra-abdominal process. 3. Splenomegaly. . . DISCHARGE LABS: [**2123-11-6**] 06:10AM BLOOD WBC-4.0 RBC-3.57* Hgb-9.8* Hct-32.0* MCV-90 MCH-27.6 MCHC-30.7* RDW-17.8* Plt Ct-121* [**2123-11-6**] 06:10AM BLOOD Plt Ct-121* [**2123-11-6**] 06:10AM BLOOD Glucose-135* UreaN-24* Creat-7.0*# Na-138 K-4.7 Cl-99 HCO3-27 AnGap-17 [**2123-11-6**] 06:10AM BLOOD Calcium-8.9 Phos-5.2*# Mg-1.9 Brief Hospital Course: Patient is 44 yo man with history of Type 1 Diabetes and ESRD who presented with flank pain and hypertensive urgency in the setting of prolonged N/V/D. #. Hypertensive urgency - Patient presented with hypertensive urgency while at [**Month/Day/Year 2286**]. In the ED, his BP was 181/76. He was transferred to the MICU, where a central line was placed, and he was started on a Labetalol drip. He was weaned off the Labetalol during his first night in the MICU, after which he was able to tolerate his PO medications. It appears that this hypertensive episode was secondary to medication non-compliance amd fluid overload in the setting of N/V/D. The patient was dialyzed twice while in the hospital, and his BP returned to his baseline when PO medications were restarted. He was discharged with close outpatient follow-up. . # Flank pain: The patient has left-sided flank pain, which has been present since [**2119**]. Despite previous workup of CT, MRI, and U/S, no clear etiology has been found. It is thought that this may be secondary to thoracic neuropathy. Despite multiple pain regimens and pain service consultation, his pain has flared in this manner several times over the last 6 months requiring hospitalization for IV narcotics and BP control. The patient was ruled out for a MI, and he was restarted on his home doses of Tylenol, Lidocaine patch, Duloxetine, and Neurontin. He was also given Morphine prn for pain. Patient tolerated these medications well and stated that his pain was somewhat improved on discharge. #. Stage 5 CKD: Patient has a history of stage 5 CKD. He received [**Year (4 digits) 2286**] twice during this hospital stay. He was continued on his home regimen of B Complex-Vitamin C-Folic Acid 1 mg daily and PhosLo 667 TID, as soon as he was able to take oral medications. He did not have any acute events during this hospital stay. . #. Diabetes: Patient has a history of Type 1 Diabetes. He was continued on his home regimen of 70/30 home regimen of 15 units in the morning and 20 units with dinner. He tolerated this well and did not have any acute events during this hospital stay. . Medications on Admission: 1.Aspirin 81 mg daily. 2.Lisinopril 20 mg daily 3.Metoprolol Succinate 200 mg daily 4.Nifedipine 60 mg SR [**Hospital1 **] 5.Glycopyrrolate 1 mg TID PRN 6.Zolpidem 5 mg QHS PRN 7.B Complex-Vitamin C-Folic Acid 1 mg daily 8.Calcium Acetate 667 mg TID 9.Hydromorphone 2 mg Q6H PRN 10.Gabapentin 250 mg/5 mL 11.Valsartan 80 mg [**Hospital1 **] 12.Sevelamer 800 mg TID 14.Insulin (70-30) 15 units in the morning and 20 units at night 15.Colace 100 mg daily 16.Omeprazole 40 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 5. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: as directed Units Subcutaneous twice a day: Please use 15 Units in the morning and 20 Units at night. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertension Type 1 Diabetes Mellitus Left flank pain Secondary: Chronic Kidney Disease, Stage 5 Discharge Condition: Good. Patient is able to tolerate his oral medications, and his blood pressure is currently stable. Discharge Instructions: You were admitted to the hospital because you had nausea and vomiting and your blood pressure was extremely elevated. You were admitted to the MICU, where you were started on a Labetolol drip. Your nausea gradually improved, and you were able to start your oral medications. You were dialyzed twice during this admission, and your blood pressure returned to your baseline. While you were here, we made the following changes to your current medications: 1. We started you on Famotidine for your acid reflux. Please take all medications as prescribed. Please keep all previously [**Hospital1 1988**] [**Hospital1 4314**] Please return to the ED or your healthcare provider immediately if you experience shortness of [**Hospital1 1440**], confusion, chest pain, problems with your vision, headaches, fevers, chills, or any other concerning symptoms. Please weigh yourself every morning, and call your doctor if you gain more than 3 lbs. Please adhere to a low sodium (2 gm/day)diet. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2123-12-6**] 12:15 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **] Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2124-1-10**] 10:30 Completed by:[**2123-11-7**]

[ "428.30", "585.5", "403.01", "789.06", "357.2", "428.0", "250.61" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9927, 9933

5821, 7967

380, 388

10084, 10187

2978, 2978

11225, 11625

2430, 2477

8498, 9904

9954, 10063

7993, 8475

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276, 342

10668, 11202

416, 1731

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15074+56607+56608+56609

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2190-4-13**] Discharge Date: Date of Birth: [**2129-9-17**] Sex: F Service: MEDICINE This discharge summary will span the dates from admission [**2190-4-13**], to [**2190-5-2**]. HISTORY OF PRESENT ILLNESS: The patient is a 60 year old female who was sent to the Emergency Department secondary to delta MS from a nursing home. She was noted to have lethargy, decreased oxygen saturation in the low 80s. In the Emergency Department, the patient was suctioned with increased secretions and the saturation improved on a 40% tracheostomy mask. Prior to this presentation, the patient had had multiple complicated admissions, including from [**2190-2-27**], to [**2190-3-3**], for hepatic artery stenosis, status post dilatation and stent, complicated by acute renal failure and multiple multiresistant organisms. The patient then was admitted from [**2190-3-12**], to [**2190-4-9**], with elevated alkaline phosphatase of unknown origin, episode of [**Year/Month/Day **]/sepsis from a urinary tract infection and pneumonia requiring a Medical Intensive Care Unit transfer, questionable dystonic reaction to Phenergan, and intermittent left bundle branch block with troponin leak, and intermittent delirium, pyloric tube placed for feeding and diarrhea. In the Emergency Department, the patient denied chest pain, abdominal pain, fever, chills or sweats. She complained of shortness of breath and needing suctioning. The shortness of breath improved after suctioning. The patient also complained of buttocks pain. In the Emergency Department, the patient received Ceftazidime and Azithromycin. The patient was unable to give significant history but nodded and shook her head appropriately to questioning. PAST MEDICAL HISTORY: 1. Recent admission [**2190-3-12**], to [**2190-4-9**], increased alkaline phosphatase, sepsis, Medical Intensive Care Unit transfer for delta MS [**First Name (Titles) **] [**Last Name (Titles) **]. 2. Hepatitis C virus, status post liver transplant in [**2189-1-31**], and redo transplant in [**2189-2-28**], after hepatic artery stenosis, status post stent. 3. History of respiratory failure, status post tracheostomy. 4. Diabetes mellitus. 5. Hypertension. 6. Chronic renal insufficiency secondary to immunosuppressive toxicity. 7. Chronic right pleural effusion. 8. Chronic anasarca. 9. Tricuspid regurgitation. 10. Depression. 11. History of VRE. 12. History of spontaneous bacterial peritonitis. 13. History of Clostridium difficile. 14. Pyloric tube placed. 15. Chronic obstructive pulmonary disease. 16. Gastroparesis. 17. Decubitus ulcers. 18. Anemia. 19. History of polysubstance abuse. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Promote 45 cc/hour. 2. Plavix 75 mg once daily. 3. CellCept [**Pager number **] mg four times a day. 4. Aspirin 325 mg once daily. 5. Prevacid 30 mg once daily. 6. Paxil 20 mg once daily. 7. Vitamin C 500 mg twice a day. 8. Zinc 220 once daily. 9. Oxycodone 10 mg p.o. q4hours p.r.n. 10. Ativan 0.5 mg p.r.n. 11. Bactrim 400/80 once daily. 12. Lopressor 12.5 mg twice a day. 13. Albuterol and Atrovent nebulizers q6hours. 14. Reglan 10 mg three times a day. 15. Lasix 20 mg once daily. 16. Ursodiol 300 mg three times a day. 17. Nystatin Powder. 18. Prograf 0.5 mg twice a day. 19. Loperamide 2 mg four times a day. PHYSICAL EXAMINATION: Admission vital signs revealed temperature 98.6, pulse 90, blood pressure 127/76, respiratory rate 30, oxygen saturation 100% on 40% tracheostomy mask. In general, the patient nodded and shook her head appropriately, appeared tired, oriented to the hospital. Head, eyes, ears, nose and throat - The left pupil is slightly larger than the right, bilaterally reactive. Mucous membranes are moist. Tracheostomy was in place. The heart was tachycardic without murmurs. The lungs revealed decreased breath sounds one half way up on the right. The abdomen was soft, nontender, no masses, no definite ascites. Extremities - large pitting edema, warm. Sacral decubitus was noted to be large but did not appear infected. LABORATORY DATA: White blood cell count was 12.3, hematocrit 29.0, platelet count 639,000. INR 1.1. Sodium 140, potassium 4.9, chloride 101, bicarbonate 30, blood urea nitrogen 28, creatinine 1.0, glucose 118. ALT 21, AST 42, LDH 242, alkaline phosphatase 1016, total bilirubin 0.6, amylase 43, troponin 0.29, CK 14, albumin 3.0. Urinalysis showed greater than 30 white blood cells with many bacteria. Electrocardiogram showed sinus rhythm at 119, Q waves in V1 through V3, Q wave in III, T wave inversion in V4, biphasic T waves in V2 and V3, flat T wave in aVL. Chest x-ray showed a right PICC, postpyloric tube into the duodenum, right sided pleural effusion, no changes. HOSPITAL COURSE: 1. Pulmonary - On hospital day one, the patient had another episode of acute hypoxia requiring transfer to the Intensive Care Unit. The patient spent one night in the Intensive Care Unit where she responded to frequent suctioning and nebulizer treatments. The patient's sputum culture grew out multiresistant Klebsiella and pseudomonas. It was felt that these organisms were likely colonizers rather than representing infection. However, early in her hospital stay, the patient was having frequent episodes of desaturation and she was started on Zosyn for possible pneumonia. As the patient responded to suctioning and quickly improved her oxygen saturation, it was felt that mucous plugging was the most likely cause for hypoxia. She was treated with a seven day course of Zosyn although it was felt that the said organisms were more likely colonizers than infection. She was also diuresed for some mild congestive heart failure but the ultimate cause of her hypoxia was felt to be due to inability to clear her secretions. She required frequent suctioning and saline washes to try to reduce the viscosity of the secretions. At the time of this dictation, the patient has been stable from her pulmonary status, although still requiring frequent respiratory therapy and suctioning. In terms of her tracheostomy tube, it was noted that the patient was unable to speak with her Passy-Muir valve in place and it was wondered if there may be some upper airway stenoses causing increased resistance. ENT was consulted and noted no anatomical problem with the upper airway. Combined effort between Speech and Swallow, ENT and Transplant Surgery, it was felt that the patient would benefit from slowly reducing the size of her tracheostomy and trying to wean her off the tracheostomy. However, she continued to have frank aspiration and therefore this was not a viable option at this time. Additionally, the patient continued to have problems clearing her own secretions as mentioned above and thus a smaller diameter tracheostomy would increase the difficulty with these secretions. Her tracheostomy was changed by ENT to a #6 Shiley cuffed as it was felt that a noncuff would increase the risks for aspiration events. The patient continued to be too weak to speak with her Passy-Muir valve and it was felt that the valve should not be used until she demonstrated improvement in her strength, decreased her aspiration and we were able to clear her secretions more effectively. 2. Diarrhea - The patient continued to have profuse watery diarrhea. It was unclear what the etiology was. The type of tube feed was changed on a number of occasions to see if an alimentary formula would improve the diarrhea, however, there was not much change. Stool lytes were done, which showed evidence of an osmotic diarrhea. The patient's CellCept was titrated off thinking that that may be causing the diarrhea. She was treated symptomatically with Loperamide and Tincture of Opium. Ultimately, the diarrhea was resolved with the stopping of the tube feeds altogether and changing to TPN for nutrition. Additionally, Ursodiol was stopped and Cholestyramine was started and this may have also contributed to the resolution of the diarrhea. 3. Sacral decubitus - The patient with a large sacral decubitus ulcer which was cared for by the wound care team and then plastic surgery was consulted who did a bedside debridement. The patient had considerable pain from this ulcer and was treated with Oxycodone. There were frequent wet to dry dressings performed. Initially, the diarrhea complicated the matter as it was very difficult to keep the wound area clean. However, once the diarrhea was under control, this was less of a problem. There was a question of whether this ulcer could have led to sacral osteomyelitis. At the time of this dictation, that diagnosis was not pursued. 4. Cardiology - The patient was noted to have episodes of tachy/brady with heart rate going up into the 100 teens and down into the 30s to 40s in a junctional pattern. Cardiology was consulted. They felt that this was likely secondary to her overall status and felt that there was nothing that could be done at this point, that she was not a candidate for a pacer and that this may improve as her overall health improved. The patient's beta blocker was held for this reason. There was no evidence that the patient became symptomatic during these episodes of bradycardia. 5. Hypertension - The patient was hypertensive throughout her stay and her ace inhibitor was slowly titrated up with a close eye on her blood urea nitrogen and creatinine given her history of acute renal failure, especially in the setting of the Prograf use which was thought to be the likely culprit during her last admission. 6. Liver - Her alkaline phosphatase remained approximately where it had been, ranging between 800 and 1000. Again, there was no clear etiology for this laboratory value. There was a question of some form of rejection, although this was never substantiated. The patient's immunosuppressives were adjusted. As mentioned above, the CellCept was titrated off and the Prograf was titrated up in its place. Imuran was started as well. 7. Nutrition - The patient initially was fed with tube feeds through a postpyloric nasogastric tube. This nasogastric tube unfortunately fell out and a regular nasogastric tube was placed. As mentioned above, due to the diarrhea, the tube feeds were turned off and the patient was given nutrition through TPN in its place. The patient remained NPO due to her risk of aspiration. 8. Depression - The patient appeared extremely depressed and at times appeared ready to give up on getting better. She was on Paxil for depression although this was likely not helping very much. A family meeting was held to discuss the patient's code status and level of care desired, however, the patient's family members did not attend. The patient expressed her desire to continue with aggressive care and remain full code. 9. Anemia - The patient's hematocrit slowly titrated down throughout her stay. There were no signs of gastrointestinal bleed although this could not necessarily be excluded. It was felt to be due to blood draws and anemia of chronic disease. She was treated with Epogen and transfused one unit of packed red blood cells. The remainder of this discharge summary as well as the discharge diagnoses and medications will be dictated as part of an addendum to this summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By:[**Name8 (MD) 13747**] MEDQUIST36 D: [**2190-5-2**] 08:46 T: [**2190-5-2**] 10:58 JOB#: [**Job Number 44033**] Name: [**Known lastname 2288**], [**Known firstname 4497**] C Unit No: [**Numeric Identifier 8011**] Admission Date: [**2190-4-13**] Discharge Date: Date of Birth: [**2129-9-17**] Sex: F Service: [**Hospital1 **] Medicine This is an interim dictation covering the [**Hospital 1325**] hospital course from [**2190-5-2**] to [**2190-5-8**]. HISTORY OF PRESENT ILLNESS: Please see previous dictation covering dates [**2190-4-13**] to [**2190-5-2**], as dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3740**], regarding further information pertaining to the patient's initial hospital course. Briefly, this is a 60 year old female with a complex past medical history including hepatitis C, status post liver transplant times two with last transplant complicated by hepatic artery stenosis, status post stent, respiratory failure, status post tracheostomy and multiple transfers to the Medical Intensive Care Unit for secretion management, chronic renal insufficiency, diabetes mellitus Type 2, hypertension and chronic anasarca. She was admitted on [**2190-4-13**] to the Medicine Service for mental status changes and hypoxia. The patient improved after deep suctioning after transfer to the Medical Intensive Care Unit for more aggressive pulmonary nursing care. Sputum culture eventually grew out Pseudomonas and multidrug resistant Klebsiella. All of these were likely colonizers. She was treated with Zosyn. While in the Medicine Intensive Care Unit she failed several attempts to wean her ventilator. She was transferred to the regular medicine floor. She was doing well on the floor until [**2190-5-3**] when she was found lethargic and pulseless. A code was called. She was resuscitated after deep suctioning. It was felt that the patient had a PEA arrest secondary to mucous plugging. Of note she had had increased nasal secretions around her nasogastric tube. Amoxicillin was added to her medication regimen out of concern for sinusitis. While in the Medical Intensive Care Unit, she was continued on a regimen of deep suctioning and aggressive pulmonary toilet. She did well with this regimen and was deemed stable for transfer back to the medicine floor [**2190-5-4**] in the evening. Please see the rest of this dictation from this admission for specific details concerning her past medical history, social history, medications prior to admission and family history. PHYSICAL EXAMINATION: Physical examination upon transfer, vital signs showed temperature of 98.6, blood pressure 152/84, heart rate 88, respiratory rate 22, oxygen saturation 99% on 70% oxygen via tracheostomy collar. General appearance was that of a well developed, obese African American female who is comfortable, mouthing words in no acute distress. Head was normocephalic, atraumatic. Pupils were equal, round and reactive to light. Sclera were anicteric. Mucous membranes were moist. A nasogastric tube was in place with thick secretions around her nares. Neck was remarkable for a tracheostomy as well as a tracheostomy collar delivering oxygen. Neck was supple with no masses or lymphadenopathy. There is no jugulovenous distension. Lungs had coarse breath sounds anterolaterally with no rhonchi, rales or wheezes. Cardiac examination was regular rate and rhythm. Cardiac examination was regular rate and rhythm with S1 and S2 heart sounds auscultated. No murmurs, rubs or gallops. Abdomen was soft with mildly diffuse tenderness, moderately distended. There were positive normoactive bowel sounds. No rebound or guarding. Extremities demonstrated no clubbing or cyanosis but were remarkable for a 3+ lower extremity edema to mid thigh bilaterally. Of note, the patient also had a 5 by 3 cm sacral decubitus ulcer with necrotic tissue on her lower back. LABORATORY DATA: Laboratory data on transfer was remarkable for the following, complete blood count demonstrated white blood count of .1, hematocrit 26.0, platelets 453. Chemistry showed sodium 139, potassium 4.0, chloride 107, bicarbonate 27, BUN 59, creatinine 0.7, glucose 116. Liver function tests showed ALT 44, AST 83, alkaline phosphatase 1542, total bilirubin 0.7. Coagulation profile showed PT 13.8, PTT 34.3, INR 1.3. A chest x-ray from [**2190-5-4**], showed a stable right effusion with patchy left lower lobe lingular infiltrates concerning for pneumonia. Sputum culture from [**5-4**], demonstrated greater than 25 polymorphonuclear cells, 2+ gram negative rods and 1+ gram positive cocci in pairs. Eventually these organisms would be identified as multidrug resistant Klebsiella and pseudomonas. ADDENDUM TO HOSPITAL COURSE: 1. respiratory distress/failure - The patient continued to have thick secretions resulting in episodic mucous plugging and respiratory distress. She was continued on an aggressive regimen of pulmonary toilet with chest physical therapy and suctioning to prevent recurrent plugging. She received oxygen via tracheostomy collar with it weaned down to oxygen saturation greater than 90%. She received Lasix 40 mg p.o. q.d. to avoid pulmonary edema secondary to volume overload and low albumin state. She received scheduled Mucomyst and Albuterol nebulizer treatments q. 6 hours with metered dose inhalers as needed for shortness of breath and wheezing. Pulmonary Service was consulted regarding possible nosocomial pneumonia and right upper chest x-ray demonstrating a left lower lobe and lingular opacity as well as the increased quantity of the patient's sputum. She underwent a bedside bronchoscopy on [**2190-5-5**] which demonstrated copious thick viscous secretions with purulent appearance. She had sputum suctioning and pulmonary toilet via the bedside bronchoscopy and then had a repeat bronchoscopy the following day for a BAL and lavage sampling. The patient's sputum eventually grew out multidrug resistant Klebsiella and Pseudomonas. She was evaluated by the infectious Disease Service and was started on Zosyn. Ultimately a plan must be developed between the Liver Staff, Pulmonary Service, and Otorhinolaryngology Service regarding the best way to manage the patient's colonization with Pseudomonas and Klebsiella as well as means of diminishing her mechanical aspiration and recurrent aspiration pneumonia. 2. Status post liver transplant - The patient was continued on Aspirin and Plavix status post hepatic artery stent to maintain patency of stent. The alkaline phosphatase was persistently elevated. As questioned, this was related to her immunosuppressive therapy, however, to rule out thrombosis, she underwent a right upper quadrant ultrasound which demonstrated patency of the portal vein, hepatic vessels and the previously placed hepatic artery stent as well as normal flow. She was continued on Tacrolimus and Imuran, the dose was adjusted appropriately based on levels. 3. Sinusitis - While on the Medical Intensive Care Unit, early in this admission, the patient was noted to have increased nasal secretions around her nasogastric tube. She completed a three day course of Amoxicillin and Aspirin for sinusitis. 4. Sacral decubiti - The patient was evaluated by the Plastic Surgery and Wound Care Services with dressing changes per their recommendations. She was continued on Vitamin C and Zinc for increased wound healing. 5. Diarrhea - The patient has had a problem with persistent diarrhea during the course of this hospitalization. It is felt to be likely osmotic in nature as all culture data was negative and the patient demonstrated a dramatic decrease in her level of diarrhea after discontinuation of her tube feeds. Therefore she was maintained on total parenteral nutrition as well as Cholestyramine. 6. Hypertension - The patient was continued on Lisinopril and Norvasc titrated for blood pressure control. 7. Diabetes mellitus 2 - She was continued on regular insulin sliding scale with q.i.d. fingersticks. 8. Tachycardia/bradycardia syndrome - Earlier in this hospitalization the patient was seen by the Cardiology Service. Per their recommendations, beta blocker was being held. 9. Anemia - Iron studies demonstrated this to be an anemia of chronic disease. Hematocrit was followed serially and the patient was transfused for a hematocrit less than 25. 10. Pain - The patient experienced significant pain from her sacral decubiti which was treated with Oxycodone. Additional events regarding the [**Hospital 1325**] hospital course, discharge events, diagnoses, medications and follow up plans will be dictated as a separate addendum to this report. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**], M.D. [**MD Number(2) 5314**] Dictated By:[**Last Name (NamePattern1) 3083**] MEDQUIST36 D: [**2190-5-8**] 16:30 T: [**2190-5-9**] 06:43 JOB#: [**Job Number 8019**] Name: [**Known lastname 2288**], [**Known firstname 4497**] C Unit No: [**Numeric Identifier 8011**] Admission Date: [**2190-4-13**] Discharge Date: [**2190-5-31**] Date of Birth: [**2129-9-17**] Sex: F Service: MED ADDENDUM TO [**2190-5-10**] SUMMARY BY DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 187**] HOSPITAL COURSE (SINCE DR.[**Doctor Last Name 8020**] DICTATION: The patient continued to have episodes of mucous plugging despite continued suctioning. At one point, q 1 h suctioning divided between the nurses q 2 h and the respiratory tech q 2 h was done to maintain this intense level of suctioning. Ultimately, however, the patient's respiratory status was markedly alleviated by first the initiation of an MIE machine by pulmonary and respiratory medicine to help liberate the patient's mucous alleviate the patient's mucous, given her decreased ability to cough. Her decreased ability to cough resulted in a number of desaturations that were alleviated, in at least 1 episode, with bag ventilation which resulted in liberation of a large handful quantity worth of dark, thick yellow mucous. The patient's respiratory status was further improved by upgrading of her trach collar from a number 6 to a number 8 Shiley. This markedly facilitated suctioning of her mucous clearance, and the patient after the procedure was actually taken off the MIE and maintained on a lower O2 saturation of 35 percent O2 on a trach mask, down from her original 40 percent. However, in terms of her cognitive reactivity, the patient became more and more withdrawn during her hospitalization, initially believed to be due to her inability to speak, and then secondary due to depression. The patient was on Paxil. The patient was fitted with a Passy-Muir valve by speech and swallow. However, it was noted that the patient did not cooperate with commands to speak. Psychiatry was consulted to evaluate for possible depression, and psychiatry felt that the patient was not withdrawn and depressed, but was more likely delirious. The patient's hospitalization was also notable for a positive urinary culture which grew out Klebsiella. This Klebsiella was proved ultimately to be resistant to ceftazidime, levofloxacin and gentamicin, and so with the approval of infectious disease, meropenem was initiated. Vancomycin was continued, given the patient's long hospitalization, multiple antibiotics, and possible concern for MRSA colonization. Subsequently, the patient had serial x-rays which showed markedly improved respiratory status, although she did have a residual right-sided pleural effusion. In terms of the patient's nutritional status, TPN was continued, and the patient had repeat ultrasound performed to evaluate possible ascites, and it was found that she did still have residual ascites which would preclude the placement of a percutaneous feeding tube. In terms of her sacral decubitus ulcer, a VAC dressing was tried. Multiple attempts were actually tried, but because of her multiple episodes of diarrhea, the VAC dressing did not hold, and the dressing was discontinued. To evaluate the sacral decubitus ulcer, ideally an MRI to evaluate for osteomyelitis would have been ideal, but the silver elements of sacral decubitus dressing precluded placing her with an MRI. So, hip and pelvis radiographs were done which showed no evidence of any osteonecrosis, although soft tissue involvement could not be ruled out. Additionally, it should be noted that the patient was followed by both the wound care service, as well as by plastics, neither of which felt that the wound actually probed to bone. The patient also underwent an ultrasound-guided liver biopsy to evaluate for transplant rejection, and pathology confirmed that there was no obvious evidence of any transplant rejection at the time of the biopsy. DISPOSITION: As of the date of this dictation, her ultimate disposition will be to likely consider rehab, or skilled nursing facility as her ultimate outcome, although with her current issues it remains uncertain at this point the timing of [**Hospital **] transfer to said facility. Additional comments on this hospital course will be added-on as an additional addendum by the physician taking over the care of this patient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 8021**] Dictated By:[**Doctor Last Name 5951**] MEDQUIST36 D: [**2190-5-31**] 14:24:26 T: [**2190-6-1**] 10:19:29 Job#: [**Job Number 8022**] Name: [**Known lastname 2288**], [**Known firstname 4497**] C Unit No: [**Numeric Identifier 8011**] Admission Date: [**2190-4-13**] Discharge Date: [**2190-6-14**] Date of Birth: [**2129-9-17**] Sex: F Service: MED ADDENDUM: This is an addendum to discharge summary most recently dated [**2190-5-31**] and will complete the hospital course from [**2190-5-31**] to [**2190-6-14**]. HISTORY OF PRESENT ILLNESS: In brief, this is a 66-year-old female with a complex medical history including hepatitis C, cirrhosis, status post liver transplant times two in [**1-/2189**] with redo in [**2-/2189**], type 2 diabetes, hypertension, chronic renal insufficiency, and recurrent hypoxic respiratory failure status post tracheostomy tube placement with a severe sacral decubitus ulcer and multidrug-resistant urinary tract infections, uremia, persistently poor nutritional status with failure to tolerate PO. The patient continued to be treated aggressively for her multiple medical problems from [**2190-5-31**] to [**2190-6-14**]. However, approximately two to three days prior to her death on [**2190-6-14**] the plan and discussion along with the liver including the Gastroenterology/Liver attending, Dr. [**Last Name (STitle) 833**], along with the recommendation and discussions with the primary transplant team, palliative care, and the ethics team, a decision was made not to ressuscitte in event of a cardiac arrest. In addition, it was felt that despite all treatments offers up tothis point, that [**Known firstname **] had deteriorated. She clearly had expressed thats he did not want surgery or other invasive procedures and a decision was made no to perform further aggressive measures to prolong life. and the patient was made Do Not Resuscitate/Do Not ventilate. At this point in her hospital course she had repeatedly failed to improve with appropriate medical therapy. On [**2190-6-14**], after an hypoxic event a final decision was made to provide comfort measures only, and shortly after doing so the patient developed fever to 102 on her last vital sign check, became markedly short of breath, and vomiting. Consequently, the patient's respiratory status further declined likely related to aspiration, persistent mucus plugging, and hypoxic respiratory failure along with likely recurrent infection and sepsis. Consequently, the patient passed away at approximately 4 p.m. on [**2190-6-14**]. Her family was contact[**Name (NI) **] in the name of her son, who was made aware of his mother's passing and agreed to allow an autopsy to be performed on his now deceased mother. Autopsy confirmation was gained in the request of [**Doctor Last Name **] Bridman, the Nephrology team. Thus, in summary, the patient passed away at approximately 4 p.m. on [**2190-6-14**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 8021**] Dictated By:[**Last Name (NamePattern1) 8023**] MEDQUIST36 D: [**2190-6-22**] 17:37:27 T: [**2190-6-24**] 14:36:34 Job#: [**Job Number 8024**]

[ "518.81", "V42.7", "599.0", "707.0", "995.91", "482.0", "511.9", "496", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "50.11", "45.16", "97.23", "99.04", "33.24", "45.25", "96.72", "33.23", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

16299, 25494

14091, 16281

25523, 28176

2745, 3374

1774, 2720

62,564

180,678

44165

Discharge summary

report

Admission Date: [**2147-2-3**] Discharge Date: [**2147-2-7**] Date of Birth: [**2111-8-13**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7575**] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: intubation, lumbar puncture History of Present Illness: The pt is a 35 year-old right-handed female with h/o SLE, seizure disorder, ITP s/p splenectomy who presents with 2 seizures. This morning the patient was found on the floor by her 9 year old son. EMS was called. When they arrived the patient was awake but very confused. She was moving all four extremities and at some point even attempted to get up. They reported that she was very confused and not making sense. She would say some words and call out a name, but would not follow commands or answer questions appropriately. She would look and attend to when called. They observed that she had a disconjugate gaze and that she was somewhat combative. The patient was placed in the ambulance and brought to EMS. En route the patient was noted to have a seizure. It was described as eye deviation to the left, and stiffening of all extremities. It lasted about 30 seconds and then self resolved. The patient was then noted to be less responsive and post ictal. On arrival to [**Hospital1 18**] she was given 2mg of ativan. She was noted by the ED staff to be gurgling and not protected her airway so she underwent a rapid sequence intubation with paralytic. Per EMS's discussion with the patient's family, she had not been ill lately, and had been taking her medication, including her Keppra as planned. From OMR it is noted that the patient had a SLE flare in ~[**9-30**] and was initially on just Plaquenil, but prednisone was added as well as Imuran. This flare had been continually improving and this was noted in a clinic note at the end of [**Month (only) 404**]. She had been titrated down to 15mg of prednisone daily. It is not clear when the last time she had a seizure. It seems that she had some seizures in [**2144**], but further notes do not make a note of it. The most recent clinic documentation notes that her seizures had been quiescent on Keppra. Per EMS the family indicated that the patient has been compliant with all her medications. They did not note any other symptoms recently. Past Medical History: 1. Seizure disorder, started in [**2135**] with no obvious precipitant. 2. Disseminated GC infection with meningitis in [**2132**] (? unclear from the discharge summary for that admission notes Neisseria gonococcal bacteremia but does not appear to have meningitis or any other signs of disseminated GC infection) 3. ITP, Status post splenectomy. 4. Cluster HA 5. SLE Social History: Per OMR: The patient smokes ten cigarettes a day, occasional alcohol, remote use of cannabis, has received transfusions. She is a homemaker, lives with husband and two children. Per OMR recent family stressors with children: "Her older son, [**Name (NI) **], who is about 15,she has completely lost custody of. This is devastating to her. Her younger son who is 9 years old is fine and things are good at home with him. " Family History: unavailable Physical Exam: Exam on admission: Vitals: T: 102.2 rectally P:125 R: 16 BP:155/87 SaO2:100 intubated General: intubated, off sedation, moving bucking vent wildly. HEENT: NC/AT, alopeica, ETT in place Neck: Supple No nuchal rigidity Pulmonary: Lungs CTA Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, Extremities: No C/C/E bilaterally, Neurologic: -Mental Status: intubated and sedated. Off sedation moving all ext and head, very comfotable, eyes closed, not responsive to commands. -Cranial Nerves: I: Olfaction not tested. II: pupils ~4mm and reactive III, IV, VI: Dyconjugate gaze, VOR intact VII: face appears symmetric IX, X: Gag intact -Motor: Moving all 4 ext, symmetrically, no obvious weakness -Sensory: Withdrawing to pain at all 4 ext -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Toe up on right, down on left -Coordination and gait: Not assessed Exam at time of discharge: Normal neurological exam with no deficits Pertinent Results: [**2147-2-7**] 05:00AM BLOOD WBC-5.1 RBC-4.07* Hgb-12.0 Hct-37.1 MCV-91 MCH-29.4 MCHC-32.3 RDW-15.9* Plt Ct-323 [**2147-2-6**] 05:00AM BLOOD WBC-4.6 RBC-3.81* Hgb-11.5* Hct-34.8* MCV-91 MCH-30.2 MCHC-33.1 RDW-16.1* Plt Ct-273 [**2147-2-5**] 05:45AM BLOOD WBC-5.6 RBC-3.56* Hgb-10.4* Hct-32.8* MCV-92 MCH-29.1 MCHC-31.6 RDW-16.0* Plt Ct-234 [**2147-2-4**] 04:08AM BLOOD WBC-8.7 RBC-3.91* Hgb-11.3* Hct-36.6 MCV-94 MCH-28.8 MCHC-30.7* RDW-15.7* Plt Ct-175 [**2147-2-3**] 05:59PM BLOOD WBC-15.8* RBC-3.70* Hgb-11.0* Hct-34.2* MCV-93 MCH-29.8 MCHC-32.2 RDW-16.1* Plt Ct-258 [**2147-2-3**] 06:50AM BLOOD WBC-15.4*# RBC-4.13* Hgb-12.2 Hct-40.2 MCV-97 MCH-29.6 MCHC-30.4* RDW-15.6* Plt Ct-253 [**2147-2-3**] 06:50AM BLOOD Neuts-79* Bands-0 Lymphs-17* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2147-2-3**] 06:50AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Spheroc-OCCASIONAL Target-1+ Schisto-1+ Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) **]2+ Bite-OCCASIONAL Ellipto-2+ [**2147-2-7**] 05:00AM BLOOD Plt Ct-323 [**2147-2-7**] 05:00AM BLOOD PT-10.9 PTT-27.5 INR(PT)-0.9 [**2147-2-3**] 06:50AM BLOOD Plt Smr-NORMAL Plt Ct-253 [**2147-2-7**] 05:00AM BLOOD Glucose-77 UreaN-6 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-24 AnGap-15 [**2147-2-6**] 05:00AM BLOOD Glucose-79 UreaN-4* Creat-0.6 Na-140 K-4.0 Cl-108 HCO3-20* AnGap-16 [**2147-2-4**] 04:08AM BLOOD Glucose-110* UreaN-6 Creat-0.6 Na-141 K-3.8 Cl-109* HCO3-20* AnGap-16 [**2147-2-3**] 06:50AM BLOOD Glucose-154* UreaN-12 Creat-1.0 Na-143 K-3.9 Cl-102 HCO3-15* AnGap-30* [**2147-2-3**] 06:50AM BLOOD ALT-19 AST-34 CK(CPK)-262* AlkPhos-81 TotBili-0.2 [**2147-2-7**] 05:00AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.7 [**2147-2-5**] 05:45AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.7 [**2147-2-4**] 04:08AM BLOOD Calcium-7.3* Phos-3.0 Mg-1.8 [**2147-2-3**] 05:59PM BLOOD Acetmnp-NEG [**2147-2-3**] 06:48PM BLOOD Lactate-0.9 [**2147-2-3**] 06:51AM BLOOD Glucose-148* K-3.6 CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2147-2-6**]): Feces negative for C.difficile toxin A & B by EIA. urine [**2147-2-3**] 06:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013 [**2147-2-3**] 06:55AM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2147-2-3**] 06:55AM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2147-2-3**] 06:55AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CSF [**2147-2-3**] 10:48AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-4* Polys-6 Lymphs-81 Monos-0 Atyps-3 Macroph-10 [**2147-2-3**] 10:47AM CEREBROSPINAL FLUID (CSF) TotProt-45 Glucose-77 [**2147-2-3**] 10:47AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR- negative CSF;SPINAL FLUID #3. GRAM STAIN (Final [**2147-2-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative [**Known lastname **] blood cell count.. FLUID CULTURE (Final [**2147-2-6**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. URINE **FINAL REPORT [**2147-2-4**]** URINE CULTURE (Final [**2147-2-4**]): NO GROWTH. CT head w/o contrast [**2-3**] A few tiny , punctate calcific foci are noted in the posterior aspectof the frontal [**Doctor Last Name 534**] of the right lateral ventricle (se 2, im11; se 400b, im 41) which is new from prior study; on the psot-contrast images of the head on the prior study, there appear to be a few enhancing normal caliber vessels in this location. hence, these calcifications can relate to vascular calcification, less liekly calcifications in associated subependymal nodules. Given the h/o SLE and seizures, correlation with MR [**Name13 (STitle) 430**] per seizure protocol without and with contrast is recommended for better assessment for subependymal nodules. Minimal- mild volume loss with prominent sulci and extra-axial CSF spaces. MRI head [**2-3**] IMPRESSION: No acute infarcts seen, mass effect, hydrocephalus or abnormal enhancement identified. MRA neck [**2-3**] The neck MRA demonstrates normal flow in the carotid and vertebral arteries. The left subclavian artery is not fully visualized as it is not included in the left. IMPRESSION: Normal MRA of the neck. CT chest [**2-3**] IMPRESSION: 1. Multifocal consolidation in the left lung with associated peribronchiolar nodules, likely multifocal pneumonia. In a patient with lupus, differential diagnosis includes lupus pneumonitis and hemorrhage. A component of organizing pneumonia is also possible considering combined peribronchovascular and subpleural distribution. 2. Premature emphysema. Is there a history of IV drug abuse or risk factors for HIV infection? 3. Increased number of subcentimeter nodes throughout the axilla and mediastinum, which are not individually enlarged by CT criteria. 4. Enlarged pulmonary artery suggesting pulmonary arterial hypertension. 5. Standard position of endotracheal tube and nasogastric tube. Tests Pending [**2147-2-6**] 05:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [**2147-2-6**] 05:00AM BLOOD B-GLUCAN-PND Brief Hospital Course: Ms. [**Known lastname 1007**] was initially admitted to Neuro ICU for close monitoring and stabilisation. she was closely monitered and underwent CT scan and MRI brain which did not show any acute Pathology. Later after she was extuabated, she was transfered to neurology floor for further care. Neuro Initially she was sedated but then later took her off sedation. She did not have any more seizures and her neuro exam after extubation showed no focal deficits. She was continued on Keppra in her outpatient dose 3000 mg /day. Her CT brain and MRI did not show any new deficits. She underwent lumbar puncture to rule out meningitis or encephalitis as possible predispoing factor for seizures. The LP did not show evidence of acute infection. She was closely monitored and the neuro exam did not show any deficts after she was extubated. Pulm She was intubated initially for airway protection but later was extubated rapidly and transfered to EMU floor for further care. She was found to have left lung multiple consolidations. pulmonary was consulted who felt it to be aspiration pna and she was started on clindamyicn and levofloxacin IV. It was later switched to PO as she was transfered to floor for total duration of 7 days. CT scan of chest was obtained which showed multifocal consolidation in left lung s/o aspiration pneumonia. Given her SLE and being on immune suppresant therapy, other possibilties like SLE pneumonitis were raised but in given clinical setting, aspiration seemed more likely. She would be following up in pulm clinic in 6 weeks with PFTs and they would consider further work up as felt necessary. Rheum Her Rheumatology doctor, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] given her diagnosis of SLE. He suggested haptoglobins to rule out any hemolytic process, which was normal. Her family was contact[**Name (NI) **] and importance of medicne compliance was stressed at discharge. Medications on Admission: AMMONIUM LACTATE [LAC-HYDRIN] - 12 % Cream - top twice a day AZATHIOPRINE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day CLINDAMYCIN PHOSPHATE - (Prescribed by Other Provider) - 1 % Gel - Apply to face daily CLOBETASOL - (Prescribed by Other Provider) - 0.05 % Cream - Apply twice a day on skin one week on/one week off ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 Capsule(s) by mouth once a week for 3 months FLUOCINOLONE-SHOWER CAP [DERMA-SMOOTHE/FS SCALP OIL] - (Prescribed by Other Provider) - Dosage uncertain FOLIC ACID - 1 mg Tablet - 2 Tablet(s) by mouth once a day HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-500 mg Capsule - 1 Capsule(s) by mouth every 4-6 hours as needed for headache HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 Tablet(s) by mouth twice a day - No Substitution IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth 3 times a day as needed LEVETIRACETAM [KEPPRA] - 500 mg Tablet - three Tablet(s) by mouth twice a day - No Substitution PREDNISONE - 10 mg Tablet - [**10-24**] Tablet(s) by mouth daily ZOLPIDEM [AMBIEN] - 10 mg Tablet - 0.5-1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 - (OTC) - 500 mg (1,250 mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth twice a day --------------- Discharge Medications: 1. Ammonium Lactate 12 % Lotion Sig: One (1) Topical [**Hospital1 **] (). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (MO). 3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 4 days. Disp:*32 Capsule(s)* Refills:*0* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Clobetasol 0.05 % Cream Sig: One (1) Topical twice a day as needed. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Discharge Disposition: Home Discharge Diagnosis: seizure disorder Aspiration pneumonia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted for evaluation of seizures. You were initially admitted in ICU and then transfered to neurology floors. You were noted to have pneumonia in lung for while you were seen by pulmonary service who suggested antibiotics and follow up with outpatient. Please take your meds as advised , please call 911 or your doctor if questions. please follow up with the appointments as scheduled. Followup Instructions: 1.Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-2-14**] 1:30 2.Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-2-16**] 3.04/07/10 03:15p [**Doctor Last Name 91**]/[**Doctor Last Name **],TCC SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] PULMONARY UNIT-CC7 (SB) [**Telephone/Fax (1) 612**] 4.03/04/10 08:30a [**Last Name (LF) 11596**],[**First Name3 (LF) 11595**] (RHEUM LMOB) LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **] RHEUMATOLOGY LMOB WEST (SB) [**Telephone/Fax (1) 2226**]

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18148

Discharge summary

report

Admission Date: [**2189-7-20**] Discharge Date: [**2189-9-12**] Date of Birth: [**2104-4-22**] Sex: M Service: CARDIOTHORACIC Allergies: Coconut Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2189-7-28**] Diagnostic laparoscopy, tracheostomy and attempted percutaneous endoscopic gastrostomy [**2189-7-21**] Redo Sternotomy, Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] tissue) History of Present Illness: This 85 year old male underwent coronary bypass grafting in [**2177**] at [**Hospital1 3278**] with Dr. [**Last Name (STitle) 50180**]. He now has progressive aortic stenosis and mitral regurgitation. He was seen last in [**2188-8-17**]. At that time surgery was deferred as he was deemed extremely high risk. He was seen in clinic [**5-/2189**] asking about not only surgical but also percutaneous options. He has had dyspnea on exertion and now has had several episodes of dyspnea that awoke him from sleep. He has found it hard to go back to sleep. He was admitted to MWMC a week prior to this visit for increased shortness of breath and found to be in failure. He was discharged home on increased Lasix. His dyspnea occurs at night and at rest, and has resolved with sitting up or using his wife's oxygen. On [**6-24**] he underwent cardiac catheterization which revealed three vessel coronary artery disease with patent bypasses, severe aortic stenosis, moderate left diastolic ventricular dysfunction, and moderate pulmonary hypertension. An echo was performed which revealed an ejection fraction of 55%, critical aortic stenosis with an aortic valve area of 0.8cm, moderate aortic insufficiency, moderate mitral regurgitation, and moderate pulmonary artery hypertension. He was not a Corevalve candidate due to his mixed valve disease. -A chest CT revealed distal ascending, arch, and descending aortic calcifications. -Pulmonary function tests showed an FEV1 on 69% predicted pre-drug and 77% post-drug. FEV1/FVC pre-drug was 88% predicted and 95% post-drug. Dsb was 21, VAsb 5, DsbHb 21, and D/VAsbHb was 3.6. He returns to the [**Hospital1 **] after obtaining dental clearance for Heparin bridge in preparation for an AVR in the morning. Three days ago he was placed on Keflex for a possible right medial shin cellulitis which appears today much improved. He has also been treated for the past week for a right eye infection, also much improved per patient report. Past Medical History: Aortic stenosis Coronary artery disease chronic Atrial Fibrillation Hypertension Hyperlipidemia Cardiomyopathy Peripheral vascular disease Asthma Chronic renal insufficiency (baseline 1.7) Community acquired pneumonia [**2188**] Gout Psoriasis Kyphosis Coronary artery bypass graft surgery (LIMA>LAD, SVG>D1, SVG>D2, SVG>OM, SVG>PDA and are LV by a Y graft) [**3-/2177**] Right hernia repair [**5-/2184**] Left inguinal herniorrhaphy [**8-/2188**] Anemia Social History: Lives with: Spouse Occupation: retired - artist Tobacco: denies ETOH: [**2-19**] cans of beer a day - last beer [**6-22**] Family History: mother deceased 62 heart failure Physical Exam: Pulse: 75 B/P 144/76 Resp: 18 O2 sat: 95% RA General: NAD-kyphotic posture Skin: Dry [x] intact [x] healed mid line sternotomy, healed right leg incision and lower left leg. Right medial shin with slight erythema. HEENT: PERRLA [x] EOMI [x]R eye with slight redness Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [**3-22**] harsh systolic Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: multiple varicosities bilateral Neuro: Grossly intact, non focal exam Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +1 Left: +1 Carotid Bruit: radiated murmur bilaterally Pertinent Results: Conclusions The left atrium is dilated. The right atrium is moderately dilated. There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Left ventricular dysnchrony is present. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is a probable vegetation on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy. Function is difficult to assess due to likely dyssynchrony (wide QRS). The apex may be hypokinetic. The right ventricle is not well seen but again, is probably normal. There is a small echodensity on the posterior leaflet of the mitral valve -- see images #81-84. This could be a vegetation, a chordal remnant or fibrin attached to mitral annular calcification. AVR with normal gradients, cannot exclude a vegetation. Mild mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [**2189-7-24**], the echodensity on the posterior leaflet may have been present on the prior study also. Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2189-8-24**] 15:47 Intra-op TEE [**2189-7-21**] Conclusions PRE-CPB: The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. 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 ascending aorta is mildly dilated. There are grade 4 atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**1-18**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate central MR. [**Name14 (STitle) 50182**]: There is a bioprosthetic valve in the aortic postion. There is a significant paravalvular leak in the area of the right coronary cusp next to the commisure between the right and left cusps, causing moderate AI. The peak gradient across the aortic valve is 12mmHg, the mean gradient is 7mmHg. The MR is now mild to moderate. Biventricular function remain normal. Brief Hospital Course: The patient was admitted on [**2189-7-20**] for Heparin bridge and brought to the Operating Room on [**2189-7-21**] where he underwent a redo Sternotomy and aortic valve replacement (23mm RSt. [**Male First Name (un) 923**] tissue valve). Please see the operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on Propofol and Neo Synephrine drips in stable condition for recovery. On POD 1 the patient was extubated and weaned from vasopressor support. On POD 2 he was re-intubated following an episode of unresponsiveness/respiratory distress. He developed thrombocytopenia and a HIT panel later returned negative. On post-operative day six he began to present with a septic picture and was seen by the Infectious Disease service. He was treated for ventilator associated pneumonia with ciprofloxacin, Zosyn and vancomycin. Likely due to sepsis he developed multi-system organ failure. He developed acute tubular nephrosis and started CVVHD on post-operative day eight. He developed liver failure with an elevated bilirubin requiring a glucose infusion. On post-operative day seven he had melena so he was started on a Protonix infusion and the Gastrointestinal service was consulted. A CT of the abdomen and pelvis showed no bowel ischemia. On [**7-28**] he underwent an exploratory laporatomy and trach placement. The abdominal exploration revealed no abnormal abdominal processes. A PEG tube was unable to be placed secondary to anatomy. His platelets continued to drift downward and a seratonin assay was sent. He received a platelet transfusion after bleeding was noted at his trach and right forearm skin tears. A wound care consult was requested secondary to bleeding at the right forearm and aquacel dressings were recommended. A family meeting was held on [**7-29**] and a decision was made to continue care. A dobhoff tube was placed in interventional radiology and tube feeds started. He developed an ileus and TPN was subsequently begun as he was intolerant of tube feeding. Heparin was continued for his chronic atrial fibrillation. He continued to do poorly. A tunnelled dialysis catheter was eventually placed in the left internal jugular vein after a new right subclavian line was placed. CVVH was resumed. He developed herpetic stomatitis and was treated with IV Acyclovir. He continued on CVVH and was diuresed well taking off 200cc/hr for several days. He eventually was converted to hemodialysis. Several family meetings were held to discuss his progress and critically ill condition. It was decided that the family does not want compressions if the patient arrests. Chemically coding and shocking the patient is permissible. He did not tolerated tube feeds as he had melena whenever tube feeds were increased. He was on TPN for a period of time and then transitioned backl to tube feeds successfully.Subsequently, a repeat echo revealed a MV vegetation. ABX therapy adjusted per ID consultation. The patient continue to fail all attempts to wean his pressor requirement and to wean from mechanical ventilation. On [**9-11**] the family decided to make him comfort measures only. His pressors were stopped and he passed away about 90 minutes later Medications on Admission: Lisinopril 2.5 mg daily Cartia XT 180 mg daily Warfarin 5 mg ECASA 81 mg daily Advair 250/50 1 puff daily Magnesium Oxide 400 mg daily Lasix 60 mg daily Potassium 10 meq daily Simvastatin 20 mg daily Zantac 300 mg daily Folbee daily (folic acid/vit b6/vit b12) Purelax 3350 twice a month Allopurinol 100 mg daily Colchicine 0.6 mg daily Ferrous gluconate 5 grains daily Vitamin C daily Calcium and vitamin D 600 daily Vigamox 0.5% eye drops R eye six times daily starting [**7-16**] for 4 days and then four times daily for ten days. Erythromycin 0.5% R eye two times per day for ten days. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Aortic stenosis S/P redo sternotomy, aortic valve replacement [**2189-7-21**] s/p exploratory laparotomy, tracheostomy [**2189-7-28**] s/p tunneled dialysis catheter [**2189-8-6**] Coronary artery disease Chronic Atrial Fibrillation Hypertension Hyperlipidemia Cardiomyopathy Peripheral vascular disease Asthma acute renal failure hepatic failure respiratory failure mitral valve endocarditis deep vein thrombosis sepsis Chronic renal insufficiency (baseline 1.7) Community acquired pneumonia [**2188**] Gout Psoriasis Kyphosis s/p Coronary artery bypass graft surgery (LIMA>LAD, SVG>D1, SVG>D2, SVG>OM, SVG>PDA and are LV by a Y graft) [**3-/2177**] Right hernia repair [**5-/2184**] Left inguinal herniorrhaphy [**8-/2188**] Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2189-9-16**]

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icd9cm

[ [ [] ] ]

[ "96.6", "33.24", "54.21", "99.15", "39.61", "38.95", "31.1", "35.21", "96.72", "39.95" ]

icd9pcs

[ [ [] ] ]

11573, 11582

7632, 10900

295, 507

12353, 12362

4020, 7609

12418, 12456

3160, 3195

11541, 11550

11603, 12332

10926, 11518

12386, 12395

3210, 4001

235, 257

535, 2524

2546, 3003

3019, 3144

76,994

171,121

36581

Discharge summary

report

Admission Date: [**2160-7-24**] Discharge Date: [**2160-8-5**] Date of Birth: [**2077-3-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Dyspnea, with RLE pain/edema Major Surgical or Invasive Procedure: Left thoracentesis [**2160-7-25**] Bronchoscopy [**2160-7-31**] History of Present Illness: The patient is an 83 year old Chinese/[**Month/Day/Year 8230**] speaking man with HTN, Type II DM, ESRD on HD (T/T/S), transfered from dialysis with reported pain and swelling of his RLE. History was obtained from his son, records and translator. . Per patient he had been in his regular state of health, and receiving dialysis on T/Th/Sa without complication. At dialysis on day of admission, staff noted that his RLE was swollen, and warm to palpation. Patient notes that it has been painful for a few days. Denies any specific injury. Patient also said he has felt warm, but no recorded fevers. He is somehwat confused on exam, and it is difficult to tell how much of this is from difficulty with translation, or baseline dementia. . In the ED initial VS were: T 100.6 HR 94 BP 178/58 RR 18 SpO2 94/2L. On exam, he was noted to have RLE erythema, and 1+ DP pulse on R, with discoloration and discoloration of the third toe. Vascular surgery was called, and believed that this was related to cellulitis. WBC 14.4, lactate 1.2, RLE U/S showed no DVT. CXR showed a large L pleural effusion worse from prior study [**3-5**]. Patient was admitted to medicine for treatment of cellulitis. VS on transfer HR 87 BP 162/57 Sp O2 98% on unknown O2. . ROS was otherwise positive for SOB, which patient feels at rest, worsened by any activity. This is not new. ROS otherwise negative. The pt denied recent unintended weight loss, headaches, dizziness or vertigo, changes in hearing or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: ESRD on HD (T/Th/Sat schedule) Diabetes Mellitus Type 2 Hypertension Diastolic CHF: Last ECHO [**2159-12-6**] showed LVEF>55%, mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction. Dilated aortic sinus Hypercholesterolemia Asthma COPD Social History: Lives with caretaker (mainly [**Name (NI) 8230**] speaking only) who takes care of him. Also has son who lives nearby and involved in his care (occasionally goes to hemodialysis with him). Other son lives out of state and is also involved in his care (visits him 1-2 times a week, sets his medications out for him and pre-draws his insulin, fixed dose). Denies alcohol use or illicit drugs. Does smoke 1 pack/2-3 days X years. Family History: Non-contributory. Physical Exam: Vitals: T 97.3, 118/52, 56, 16, 100/5L General: NAD, alert, appears comfortable [**Name (NI) 4459**]: [**Name (NI) 12476**], PERRL, EOMI Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: diffuse rhonci bilaterally, decreased breath sounds on lower left lung fields Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: no edema or erythema Neurologic: Cranial nerves grossly intact Pertinent Results: Admission Labs: [**2160-7-24**] 06:00AM BLOOD WBC-14.4*# RBC-3.62* Hgb-10.1* Hct-31.0* MCV-86 MCH-27.9 MCHC-32.6 RDW-16.1* Plt Ct-298 [**2160-7-24**] 06:00AM BLOOD Neuts-92.7* Lymphs-4.6* Monos-2.3 Eos-0.3 Baso-0.1 [**2160-7-24**] 06:00AM BLOOD Glucose-157* UreaN-11 Creat-2.2*# Na-140 K-4.0 Cl-100 HCO3-31 AnGap-13 [**2160-7-24**] 06:13PM BLOOD Lactate-1.2 [**2160-7-25**] 03:48AM BLOOD Glucose-234* Lactate-1.1 Na-137 K-4.5 Cl-92* [**2160-7-25**] 09:30AM BLOOD PT-13.4 PTT-32.9 INR(PT)-1.1 [**2160-7-25**] 03:10PM BLOOD Calcium-7.6* Phos-3.4 Mg-1.7 [**2160-7-25**] 03:10PM BLOOD WBC-7.8 RBC-3.28* Hgb-9.2* Hct-28.7* MCV-88 MCH-27.9 MCHC-31.9 RDW-16.0* Plt Ct-281 [**2160-7-25**] 03:10PM BLOOD Neuts-94.6* Lymphs-4.3* Monos-1.0* Eos-0.1 Baso-0 [**2160-7-25**] 03:10PM BLOOD Glucose-287* UreaN-30* Creat-3.4*# Na-131* K-4.2 Cl-94* HCO3-25 AnGap-16 Other Notable Labs: [**2160-7-26**] 08:08AM BLOOD CK(CPK)-71 [**2160-7-26**] 12:06PM BLOOD ALT-25 AST-29 CK(CPK)-103 AlkPhos-82 TotBili-0.3 [**2160-7-26**] 10:42PM BLOOD CK(CPK)-84 [**2160-7-27**] 03:51AM BLOOD CK(CPK)-67 [**2160-7-26**] 08:08AM BLOOD CK-MB-3 [**2160-7-26**] 12:06PM BLOOD CK-MB-6 cTropnT-0.10* [**2160-7-26**] 10:42PM BLOOD CK-MB-5 cTropnT-0.13* [**2160-7-27**] 03:51AM BLOOD CK-MB-5 cTropnT-0.13* [**2160-7-26**] 12:06PM BLOOD Albumin-3.2* Calcium-7.8* Phos-4.5 Mg-1.7 [**2160-7-26**] 12:06PM BLOOD Albumin-3.2* Calcium-7.8* Phos-4.5 Mg-1.7 [**2160-7-29**] 08:30AM BLOOD CK-MB-2 cTropnT-0.11* [**2160-7-25**] 12:46PM PLEURAL WBC-55* RBC-130* Polys-29* Lymphs-60* Monos-4* Eos-1* Baso-1* NRBC-1* Meso-1* Macro-3* [**2160-7-25**] 12:46PM PLEURAL TotProt-1.5 Glucose-333 LD(LDH)-51 [**2160-7-31**] 03:36AM BLOOD WBC-14.5* RBC-3.51* Hgb-9.7* Hct-30.2* MCV-86 MCH-27.6 MCHC-32.2 RDW-17.1* Plt Ct-313 [**2160-8-1**] 04:43AM BLOOD WBC-15.4* RBC-3.36* Hgb-9.4* Hct-28.9* MCV-86 MCH-28.0 MCHC-32.5 RDW-17.3* Plt Ct-283 [**2160-8-2**] 06:04AM BLOOD WBC-13.9* RBC-3.27* Hgb-9.2* Hct-28.4* MCV-87 MCH-28.1 MCHC-32.2 RDW-17.4* Plt Ct-317 [**2160-8-3**] 03:19AM BLOOD WBC-13.8* RBC-3.43* Hgb-9.7* Hct-30.0* MCV-87 MCH-28.2 MCHC-32.3 RDW-17.7* Plt Ct-314 [**2160-8-4**] 09:05AM BLOOD WBC-9.8 RBC-3.40* Hgb-9.6* Hct-29.6* MCV-87 MCH-28.1 MCHC-32.3 RDW-17.3* Plt Ct-320 [**2160-8-1**] 4:50 pm BRONCHIAL WASHINGS **FINAL REPORT [**2160-8-3**]** GRAM STAIN (Final [**2160-8-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2160-8-3**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Brief Hospital Course: Mr. [**Known lastname 724**] is an 83-year-old chinese/[**Known lastname **]-speaking man with a history of HTN, Type II DM, ESRD on HD, dCHF, COPD, and chronic left pleural effusion who was admitted for dyspnea and RLE pain/edema, underwent thoracentesis for large left pleural effusion on [**7-25**], and had a PEA arrest during his hemodialysis session on the morning of [**2160-7-26**]. He was transferred to the CCU for further management. . # PEA arrest/respiratory failure: occurred in the setting of rapidly worsening hypoxia after removing 1L at hemodialysis; acute on chronic in etiology, as was requiring 4L at time of admission. Also underwent left thoracentesis for 1.5L on evening prior to arrest. DDx broad and included PE (unlikely given improvement on vent following HD and no specific therapy), tension pneumothorax (not present on CXR post intubation), mucous plug, worsening pneumonia (there were new infiltrates apparent on CXR), bronchospasm (long history of COPD), flash pulmonary edema (given hypertensive episode and CXR appearances), and worsening effusion, in terms of respiratory causes. No tamponade was present on bedside ECHO by the cardiology fellow. Did receive multiple doses of haloperidol on [**7-25**] and during morning, though no clinical evidence of respiratory depression. A follow-up CXR revealed that his effusion appeared smaller. He was not initiated on the cooling protocol, as CPR was ~10-15 minutes and initiated immediately, and patient was appropriately agitated once ROSC. We continued empiric vanc/cefepime and added azithromycin which was changed to levofloxacin for atypical coverage. A formal echo demonstrated focal LV systolic dysfunction with normal RV function and evidence of diastolic dysfunction and no significant valvular abnormality. A trivial pericardial effusion was seen without evidence of tamponade and his EF was 45-50%. He remained afebrile and he was weaned off the ventilator. Cardiac enzymes were unremarkable with TnT max 0.13 with a normal CK-MB. He was consinued on IV methylprednisolone and was dialysed on [**7-26**] with 3.5L removed with clinical improvement. By [**7-27**], he was appropriate off sedation and not agitated - with ABGs showing improved oxygenation. He was extubated [**7-27**]. # Pleural effusion: concerning for malignancy given chronic nature, unilaterality, and lack of evidence for acute heart failure. S/p thoracentesis for -1.5L on [**7-25**], serosanguinous, labs consistent with transudate, gram stain neg. On [**2160-7-29**], CXR revealed white out of left lung, read was suggestive of mucus plug with lung collapse. Patient was given duonebs with chest PT with no improvement of CXR on following morning. Pulmonary was consulted, who obtained a CT of the chest, showing large loculated effusion on the left with lung collapse likely secondary to mucus plugging, along with small to moderate pleurel effusion on the right with some ground glass opacities in the upper lobes. Chest PT and mucolytics were started with minimal improvement. Bronchoscopy was done on [**2160-7-31**], removing a large amount of mucus from the left lung. Sputum culture grew MRSA. Patient had been on 8 days of vancomycin to that point, which was continued. Respiratory status initially improved after bronchoscopy, but later that night had respiratory decompensation; likely flash pulmonary edema which resolved with nitro drip. Follow up CXR's showed little improvement of left pleural effusion and lung collapse. Right pleural effusion would improve post dialysis. Patient had similar cycle over follow days with occasional improvement one day with following respiratory decompensation, with subsequent stabilization. At time of discharge, patient had received total of 12 days of Vancomycin and had O2 saturations in mid 90s and stable. . # RLE erythema/?Cellulitis: RLE edematous, warm, and tender on exam. Numerous lesions noted between the toes. He was treated with IV cefepime, vancomycin (after HD for MRSA coverage) and azithromycin which was changed to levofloxacin for additional pseudomonal coverage. On arrival to the CCU there was no evidence of celulitis on examination. Patient was given full course of Vancomycin per hemodialysis protocol for cellulitis. Vancomycin was continued for possible MRSA pneumonia. . # dCHF/HTN: Appears euvolemic on exam. We held anti-hypertensives initially and his BP remained stable. Once cleared by speech and swallow, patient was restarted on Amlodipine and Labetalol, with Lasix MWF and [**Date Range 1017**]. Patient was over 7 liters negative during his stay after dialysis and ultrafiltration. Patient was negative 14 liters during his stay, with some improvement on CXR on right side. Overall, blood pressure was well controlled. . # COPD: On arrival to the CCU he did not have any evident wheeze on examination and his CXr gives appearances of COPD with hyperinflated chest and residual pleural effusion post thoracocentesis on [**7-25**]. His COPD have played a role in the development of possible mucus plug. We continued albuterol and ipratropium nebs and he was treated with short course of methylprednisolone to cover a COPD flare. . # Delirium: Per the pt's sons, Mr. [**Known lastname 724**] has a baseline delirium with occasional agitation. Unclear etiology. Patient would occasionally become agitated during the evening and overnight, including self d/c'd foley and IVs on multiple occasions. Patient often became agitated in the evening, initially controlled with Zyprexa. Patient had episode of unresponsiveness after dose of Haldol and Zyprexa. QTc was monitored with EKG and increased to 512. Zyprexa and Haldol were discontinued. Patient was subsequently controlled with Ativan prn; however, patient became more oriented and less agitated towards end of hospitalization. . # ESRD on HD: On HD T/T/S, 1L removed prior to PEA arrest. We continued his renal meds and 3.5L was removed on transfer to CCU with resultant improvement in his oxygenation and his ventilatory requirements diminished initially; however, accumulation of right pleural effusion devloped on non-dialysis days. He was followed by renal team. A total of 15 liters were removed for LOS. Patient was continued on his Lasix dose on non-dialysis days. . # DM2: Patient was initially continued on 8 units of NPH in AM, which was increased to 12 units due to some elevated sugars, along with ISS. Patient did have episode of hypoglycemia that resolved after amp of D50. Basal dose was decreased with continuation of sliding scale. # Goals of care: family has had multiple discussions about code status, goals of care; may have been previously on hospice, and code status previously dni/dnr. Both patient and son desired full code status when initially hospitalized. It became clear as the patient's respiratory status declined after bronchoscopy that it was becoming very difficult to consistently and adequately treat his respiratory symptoms. The goals of care were reassessed with the patients son [**Name (NI) 382**] and it was understood that the main goal was to get the patient comfortable and back home. The patient's code status was changed to DNR/DNI and is being discharged home with hospice care. . Medications on Admission: Simvastatin 20 mg PO DAILY Senna 8.6 mg PO BID Aspirin 81 mg PO DAILY Sevelamer Carbonate 1600 mg PO TID Amlodipine 10 mg Tablet PO DAILY Labetalol 800 mg PO TID Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. Furosemide 120 mg Tablet PO QMOWEFRSU (NON HD DAYS) Albuterol nebs q6 Ipratropium nebs q6 Nicotine Patch 14mg qday Nephrocaps 1 tab PO DAILY Olmesartan 40 mg PO DAILY Trazodone 25 mg PO QHS prn insomnia Omeprazole 20 mg PO DAILY Fluticasone-Salmeterol 250-50 INH [**Hospital1 **] Insulin NPH 8 units with breakfast Zyprexa 5 mg PO DAILY prn agitation Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Use for 12 hours during the day, take off at night. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 7. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 8. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous once a day: give before breakfast. Please hold if not eating. 9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO every Mon, Wed, [**Hospital1 **], Sun: Non- dialysis days. Disp:*48 Tablet(s)* Refills:*2* 12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day: give with meals. Disp:*180 Tablet(s)* Refills:*2* 15. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 16. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for agitation. Disp:*30 Tablet(s)* Refills:*2* 17. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) vial Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*90 vials* Refills:*2* 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*90 vials* Refills:*2* 19. oxygen O2 1-4 L NP to keep O2 sat > 88% or for pt comfort Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: PEA arrest bilateral pleural effusion Methecillin resistant staph aureus pneumonia Right lower extremity cellulitis 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: Mr. [**Known lastname 724**], You initially came to the hospital because of an infection on your leg and shortness of breath. You were given antibiotics for your leg infection. You were getting dialysis when your heart had trouble pumping. You were resuscitated and brought to the Cardiac Care Unit for monitoring. While in the Cardiac Care Unit you began having worsening fluid accumulation in your lungs. We attempted to remove fluid both through your chest and through dialysis. The lung doctors looked at your lungs with a camera and removed a large amount of mucus. Lab results showed that you had an infection in your lungs, which was treated with antibiotics. . Medication changes: 1. Stop taking simvastatin . Daily weights. Please report these to dialysis Followup Instructions: D/C home with [**Hospital 2188**] . Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 641**] Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 46146**] Phone: [**Telephone/Fax (1) 2115**] Appt: [**8-20**] at 12pm [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "293.0", "428.0", "682.6", "934.1", "585.6", "285.21", "747.29", "250.00", "482.42", "E915", "428.33", "V02.54", "403.91", "493.22", "E849.7", "518.0", "518.84" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.56", "96.71", "33.24", "96.04", "99.60", "39.95" ]

icd9pcs

[ [ [] ] ]

17291, 17342

7101, 14340

342, 407

17502, 17502

3565, 3565

18471, 18874

3006, 3025

15000, 17268

17363, 17481

14366, 14977

17680, 18350

3040, 3546

18370, 18448

274, 304

435, 2205

3582, 7078

17517, 17656

2227, 2545

2561, 2990

61,738

168,197

54067

Discharge summary

report

Admission Date: [**2127-12-27**] Discharge Date: [**2128-1-13**] Date of Birth: [**2067-2-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11892**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Intubation PICC Placement ([**2128-1-6**]) History of Present Illness: The patient is a 60 year old man with no significant PMH who presents with a one-week history of increasing fatigue, cough, and chest pain. Per the patient and his [**Month/Day/Year 802**], he was in his normal state of health until approximately 3 weeks ago, when he developed a non-productive cough, congestion/rhinorrhea, and dysphonia. Over the past week, he has felt increasing fatigue and has been unable to perform his work at home. He has also had subjective chills and was found to have a temperature of 99.0 at home. He states that he has had associated chest pain, which started three days ago and has since resolved. He described it as a dull, constant, [**4-20**] pain that was located on the right side of his chest and occasionally radiated to his LLSB. He states that it started when he woke up on Wednesday morning and lasted for approximately 3 days, and he denies associated symptoms. Of note, the patient has had a 20 lb weight loss in the past 3 weeks. He denies shortness of breath, myalgias, diarrhea, nausea. Given this constellation of symptoms, he was urged to come to the ED by his [**Month/Year (2) 802**]. . In the ED, his initial vs were: T 97.6, P 121, BP 165/93, RR 16, SpO2 96% RA. He had a CXR, which demonstrated a RUL PNA. EKG showed sinus tachycardia with ST elevation in V2 and V3. He was given ASA 325 mg, 1 L of NS and was started on Levofloxacin and Vanc for PNA. His VS at the time of admission were T 97.9, HR 106, BP 138/79, R 20, O2 96% on RA. . On the floor, the patient denies current shortness of breath but states that he has been very "run down" recently. He also states that he has a ventral hernia, which bothered him tremendously this past week whenever he coughed. It is no longer painful now. . Review of systems: (+) Per HPI (-) Denies fever, night sweats. Denies headache, sinus tenderness, shortness of breath. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: None reported Social History: The patient currently lives in [**Location 86**] with his mother, [**Location 802**], and two cousins. [**Name (NI) **] is the co-caretaker of all the members of his household, many of whom are not in good health. He smokes 1 ppd and has smoked cigarettes for 44 years. He drinks ~12 beers throughout the week and has never had alcohol withdrawal. Family History: His mother has HTN, CHF, AFib, and a AAA s/p repair. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.0, BP: 141/92, P: 117, R: 24, O2: 95% on RA General: Cachectic appearing man, pleasant, in NAD HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bronchial breath sounds in the RUL with minimal inferior wheezing. Dullness to percussion in the RUL. Otherwise, CTA CV: Tachycardic, no r/m/g appreciated Abdomen: soft, non-tender, ventral hernia in place, easily reducible. no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, ?mottled skin on hands Neuro: oriented x3, CNII-XII intact, no gross sensory or motor deficits, negative pronator drift, gait not assessed . DISCHARGE PHYSICAL EXAM: VS: T 96.8, BP 126/74, HR 103, RR 20, SpO2 97 on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Sitting in chair. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored. Diffuse coarse breath sounds and rhonchi. Abd: BS present. Soft, NT, ND. Easily reducible unbilical hernia. No organomegaly detected. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: No rashes, ecchymoses, or other lesions noted. Neuro: CN II-XII grossly intact. Moving all four limbs. Pertinent Results: ADMISSION LABS: [**2127-12-27**] 09:23PM BLOOD WBC-13.3* RBC-3.84* Hgb-12.0* Hct-34.3* MCV-89 MCH-31.4 MCHC-35.1* RDW-13.6 Plt Ct-450* [**2127-12-27**] 09:23PM BLOOD Neuts-83.3* Lymphs-10.4* Monos-5.9 Eos-0.1 Baso-0.3 [**2127-12-27**] 09:23PM BLOOD PT-12.8 PTT-24.8 INR(PT)-1.1 [**2127-12-27**] 09:23PM BLOOD Glucose-123* UreaN-22* Creat-0.6 Na-128* K-4.2 Cl-85* HCO3-32 AnGap-15 [**2127-12-27**] 09:23PM BLOOD cTropnT-<0.01 [**2127-12-28**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2127-12-28**] 06:10AM BLOOD CK(CPK)-25* [**2127-12-28**] 06:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 [**2127-12-28**] 06:10AM BLOOD Osmolal-270* [**2127-12-27**] 09:28PM BLOOD Lactate-1.8 K-3.9 . [**2128-1-8**] 05:07AM BLOOD WBC-9.7 RBC-2.60* Hgb-7.9* Hct-22.9* MCV-88 MCH-30.6 MCHC-34.7 RDW-13.6 Plt Ct-468* [**2128-1-8**] 05:07AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-139 K-3.1* Cl-99 HCO3-37* AnGap-6* [**2128-1-7**] 03:15AM BLOOD calTIBC-127* VitB12-782 Folate-17.4 Ferritn-555* TRF-98* [**2127-12-28**] 07:38PM BLOOD TSH-0.89 [**2127-12-28**] 07:38PM BLOOD Free T4-0.93 [**2128-1-5**] 11:36AM BLOOD HIV Ab-NEGATIVE [**2128-1-3**] 06:17PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [**2128-1-3**] 11:16AM BLOOD B-GLUCAN-Test . DISCHARGE LABS: [**2128-1-13**] 06:45AM BLOOD WBC-11.1* RBC-3.46* Hgb-10.2* Hct-30.7* MCV-89 MCH-29.6 MCHC-33.3 RDW-15.1 Plt Ct-608* [**2128-1-13**] 06:45AM BLOOD Glucose-112* UreaN-19 Creat-0.7 Na-135 K-4.7 Cl-96 HCO3-28 AnGap-16 [**2128-1-13**] 06:45AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0 . IMAGING / STUDIES: # CHEST XRAY ([**2127-12-27**]): IMPRESSION: Consolidative opacity in the right upper lobe concerning for pneumonia. Followup radiographs after interval treatment are recommended to ensure resolution of this finding. . # CT CHEST ([**2127-12-28**]): IMPRESSION: Extensive consolidation, which may be chronic, involving primarily the right upper lobe with smaller ground-glass opacities seen in the left upper lobe and right middle lobe and lymphadenopathy. The presence of underlying discrete mass is not well evaluated. Bronchoscopy with lavage may be helpful . # CT CHEST ([**2128-1-2**]): IMPRESSION: 1. Progression of right-sided pneumonia with cavitation in the right upper lobe and progression of consolidation in the right lower lobe. 2. Heterogenous ground-glass opacity in the right middle and upper lobe and perihilar left lung are suggestive of new pulmonary edema. 3. New bilateral mild-to-moderate pleural effusions. 4. New left lower lobe atelectasis. . # CXR ([**2128-1-6**]): FINDINGS: Single portable AP radiograph was obtained of the chest. Since the prior film, there has been interval insertion of a right-sided PICC line with the tip terminating at the right high/mid SVC. There has been interval extubation and removal of an orogastric tube. There is mild improved aeration of the right upper lung field. There still is residual opacification and cavitation from cavitary pneumonia with improvement in the patchy area of opacification in the left perihilar region. IMPRESSION: 1. Successful PICC insertion. 2. Mild improvement of persistent cavitary pneumonia. . Brief Hospital Course: ===================================== FLOOR COURSE ([**2127-12-27**] to [**2127-12-29**]) The patient is a 60 yo man with no significant PMH who presents with a 3-week history of cough and fatigue and was found on XRay to have a RUL consolidation concerning for PNA vs. mass, or postobstructive PNA. . # RUL PNA/Respiratory Distress: Mr. [**Known lastname 4020**] presented with a 3-week history of dry cough and 1-week history of fatigue and chills. On CXR, he was found to have a RUL consolidation, concerning for PNA. He has a significant smoking history and recent 20 lb weight loss, which is very concerning for an underlying lung malignancy. On discussion with radiology, it is difficult to assess for a mass, given his large consolidation; however, there are no obvious secondary signs of malignancy at present. . While in house, he was originally started on levofloxacin (and received 1 dose). On HD2, we switched him to IV CTX and Azithromycin. A CT Scan was done out of concern that there was an underlying mass given his significant smoking history, and out of concern that there would be a need to treat for a post-obstructive PNA. The CT Chest revealed consolidation without obvious mass in the RUL, however unable to r/o mass. Sputum Cxs were attempted, however unable to be sent as not able produce phlegm. Attempted induced, however did not work either. Of note, the pt was persistently tachycardic throughout his stay, and was bolused and was fluid responsive (see below for further discussion). His BP remained normotensive--> elevated during his floor course, and thought was that level of insensible losses was high requiring fluid repletion. He remained afebrile starting HD2, and his white count normalized on HD2--> to mildly elevated on HD3 (11.3). Throughout this time, the pt was maintained on 3L of O2 (satting mid 90s). The am of HD3, pt noted to have increasing respiratory distress. Pt c/o increase work of breathing. Repeat set of vitals at the time showed hypoxia to 60s on 3L, increased to low 90s on 100% NRB mask. ICU c/s was initiated, and given clinical picture, ICU transfer initiated. ABG done at time showed severe retention of CO2 and acidosis. . # Tachycardia: Pt has noted to be tachycardic throughout floor stay (up to 140s at times). Usually fluid responsive, and actually received >5L of fluid for tachycardia. Multiple EKGs done which show sinus tach. TSH/Free T4 sent given h/o weight loss as well, however seem to be WNL. Concern for peri-septic etiology, however BP remained elevated. Notably, HR would decrease to 90s with some fluid boluses. . # Hyponatremia: The patient's Na on admission was found to be 128. He is clinically dry on physical exam, so this appears to be hypovolemic hyponatremia. However, given the patient's current lung pathology, SIADH is also on the differential. Na improved with IVF. With aggressive IVF repletion, pt's sodium normalized to 136. . #. Chest pain: The patient states that he had chest pain for the past 3 days, but it is now resolved. His characterization for the pain is very atypical for ACS and more likely is secondary to underlying PNA. Denies CP right now. CE negative x 2, EKG no ST-T changes. Thought is likely [**1-14**] PNA. . # Run of V-tach o/n: No h/o arrythmia, Pt was asx. Unclear etiology. We ensured adequate repletion of lytes (K>4, Mg>2). Thought is that could stand small dose of beta blocker, however did not start given tachycardia. . # FEN: IVF boluses for tachycardia, regulars, replete lytes # Prophylaxis: Subcutaneous heparin, no indication for ppi, bowel regimen # Access: peripherals # Code: Full (confirmed) # Communication: Patient, [**Name (NI) **] [**First Name9 (NamePattern2) 96454**] [**Name (NI) **] - [**Telephone/Fax (1) 96455**]) <-- informed regarding ICU transfer . ===================================== ICU COURSE ([**12-28**] to [**2128-1-8**]) . # Hypoxic/hypercarbic respiratory failure/multifocal pneumonia: Patient was found to have multifocal consolidations with extensive consolidation of the right upper lobe, which is concerning for an infectious vs. malignant process. Acute decompensation was thought multifactorial including PNA with superfluous secretions causing mucous plugging. Significant weight loss is concerning for Tb vs. malignant process. AFB smears x 3 were negative. Sputum cultures revealed gram positive cocci and GNR on gram stain, but nothing has grown out so far. Further, patient seized on arrival to MICU (see below) and could have had resultant aspiration PNA prior to transfer. In setting of long standing smoking history and wheezing on exam, may be element of bronchospasm contributing to respiratory decline. Since he had clinically deteriorated on ceftriaxone/azithromycin therapy on the floor his antibiotic coverage was broadened to vanco/zosyn/levo and will likely need a prolonged course given the cavitation seen on CT. He was intubated in the setting of his seizure. A sputum culture with cytology showed no malignant cells. Flu swab was negative. . Barriers to extubation over his course included copious sputum. On [**1-3**] he has an increase in his ventilator requirements. A Chest CT was repeated to look for empyema or other cause of worsening ventilatory status which showed progression of right sided PNA with cavitation in the right upper lobe and progression of consolidation in the right lower lobe. Also with heterogeneous ground glass opacity in the right middle and upper lobe and perihilar left lung suggestive of new pulmonary edema. He was diuresed and underwent bronchoscopy on [**1-3**] which showed some purulent sputum which was suctioned and cultures were sent. Fungal markers were also sent and are pending. . He was extubated on [**1-5**] without complications and was weaned down to NC O2 and transferred to floor. Plan for antibiotics will be to complete 10 day course on [**1-8**] and change to PO Augmentin on [**1-9**] for at least 2 week course. He will need repeat imaging and follow up with pulmonary in [**1-15**] weeks as an outpatient. . # Seizures: Patient found to be seizing upon arrival to MICU, likely secondary to transient hypoxia. However, in the setting of alcohol consumption and persistent tachycardia, there was some concern as well for DRs. [**Last Name (STitle) **] was kept on Versed gtt initially and then transitioned to Ativan PRN. no further seizure activity was noted during ICU course. Head CT without acute process. . # Tachycardia: Likely secondary to hypovolemia in the setting of aggressive infection. Resolved with multiple IVF boluses prn. . # Hyponatremia: Improved with IV fluids, consistent with hypovolemic picture. . # LUE edema and erythema: Patient was noted to have erythema and edema worse on the left upper extremity around the wrist than on the right. Upper extremity u/s revealed superficial thrombophlebitis involving the left cephalic vein with no deep venous thrombosis present so his PIV was pulled and heat packs/elevation were started. . Comm: [**Name (NI) **] [**Name2 (NI) 96454**] [**Name (NI) **] - [**Telephone/Fax (1) 96455**])-> main contact, no assigned HCP. Mother is 92. [**Name2 (NI) 7092**]: Full code . ===================================== FLOOR COURSE (1/27/1 to [**2128-1-13**]) . # Pneumonia: Multilobar PNA with cavitation s/p 10 days of Vanc/Levo/Zosyn. He remained afebrile with stable WBC count after returning to the floor. Fungal markers returned negative. His respiratory status improved and he was weaned off oxygen with SpO2 in the mid to high 90s at rest and stable during ambulation. He was discharged on a planned two week course of Amoxicillin/Clavulanate. Plans were made for repeat chest imaging, pulmonary outpatient appointment, and repeat bronchoscopy in [**3-17**] weeks. . # HTN: He was initially hypertensive but his BP was better controlled after starting HCTZ. He was continued on HCTZ 50 mg PO daily at discharge. . # Delirium: His mental status remained altered for several days after transfer from the ICU. He was oriented only to person, requiring frequent redirection and reorientation, as well as a 1:1 sitter for fall safety. He was given Olanzapine 5 mg QHS as needed. His mental status improved dramatically over the last few days before discharge. By the time of discharge, he had been A+Ox3, pleasant, and cooperative for several days and no longer required a sitter. . # Anemia: His Hct trended up after he was transferred to the floor and was 30.7 on the day of discharge. . # Followup: -- No pending labs or reports -- Followup appointment with his PCP scheduled one week after discharge -- Followup in Pulmonary clinic on [**2128-2-5**] -- Repeat chest imaging and bronchoscopy will be needed to guide further treatment Medications on Admission: None Discharge Medications: 1. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days: Last dose evening of [**2128-1-26**]. Course may be extended by PCP on followup. Disp:*28 Tablet(s)* Refills:*0* 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Cavitary Pneumonia Acute Delirium Anemia of Chronic Inflammation 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 after developing cough, chest pain and shortness of breath. You were found to have a severe pneumonia and required transfer to the Intensive Care Unit and intubation for part of your stay. You were treated with antibiotics and your condition improved. You will need to complete a 14 day course of antibiotics and have close followup and repeat imaging to determine whether you will need a longer antibiotic course to completely clear the infection. START: Amoxicillin-Clavulanic Acid (Augmentin) 875 mg by mouth twice daily Your blood pressure was found to be elevated during your stay and you were started on the blood pressure medication Hydrochlorothiazide. You should continue taking this medication after discharge. You were also started on several vitamins, which you should continue taking until stopped by your PCP. START: Hydrochlorothiazide 50 mg by mouth daily START: Multivitamin 1 tab by mouth daily START: Folic Acid 1 mg by mouth daily START: Thiamine 100 mg by mouth daily You have a followup appointment scheduled with your PCP at [**Name9 (PRE) 778**] next Monday. It is very important that you keep this appointment to set up repeat imaging and guide your future treatment. Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 798**] Appointment: Monday [**2128-1-19**] 9:00am This will be your new primary care physician. [**Name10 (NameIs) 357**] bring your insurance information. Department: PULMONARY FUNCTION LAB When: THURSDAY [**2128-2-5**] at 10:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2128-2-5**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU

[ "486", "786.52", "276.1", "285.9", "427.1", "780.09", "458.9", "305.1", "780.39", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.72", "96.04", "38.97", "33.24" ]

icd9pcs

[ [ [] ] ]

17041, 17047

7561, 16345

326, 371

17175, 17175

4429, 4429

18588, 19682

2866, 2920

16401, 17018

17068, 17154

16371, 16378

17326, 18565

5658, 7538

2960, 3666

2168, 2447

267, 288

399, 2149

4445, 5642

17190, 17302

2469, 2485

2501, 2850

3691, 4410

42,800

183,804

42226

Discharge summary

report

Admission Date: [**2193-6-15**] Discharge Date: [**2193-6-19**] Date of Birth: [**2138-4-22**] Sex: F Service: SURGERY Allergies: Codeine / Penicillins / Percocet / morphine / Zomig / Celexa Attending:[**First Name3 (LF) 598**] Chief Complaint: nonhealing wounds on buttocks/thigh bilaterally Major Surgical or Invasive Procedure: On [**2193-6-15**] pt underwent excision of both right buttock and left posterior thigh decubitus ulcers. History of Present Illness: 55F with recent h/o depression who reported approximately 4 weeks of very limited mobility due to depression. Over the course of the 4 weeks pt noted worsening irritation on L thigh and R buttock, but initially assumed irritation was secondary to recent bouts of diarrhea. She was seen at both a wound care clinic as well as an OSH, where she was hypotensive, which was concerning for sepsis. Pt then transferred to [**Hospital1 18**] for further management on [**2193-6-15**]. Pt was started on vanco, clinda, and tigecycline and OSH and was immediately admitted to ICU upon transfer. On admission, she denied fevers, CP, SOB but did endorse chills, decreased appetite and pain in her buttocks. PE at time of admission notable for a large necrotic area on her R buttock and surrounding erythema near her rectum as well as a smaller area of ulceration on L posterior thigh. Pt was afebrile on admission and otherwise stable (98.8 78 120/73 28 98%RA). Past Medical History: HTN, HLD, Mitral regurg, Asthma, depression, HCV, OSA, fibromyalgia Social History: lives on own, not employed, smokes 0.5 packs of cigarettes daily, no EtOH Family History: Mother: CAD Physical Exam: Physical Exam: Vitals: 98.8 78 120/73 28 98%RA GEN: A&O, NAD HEENT: No scleral icterus, CV: RRR, No M/G/R PULM: wheezes to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood. R buttock, learge necrotic areas with erythema in the surrounding tissues, close to the rectum Ext: No LE edema, LE warm and well perfused Pertinent Results: On admission: 9.9 >-----< 341 21.4 Abd/Pelvis CT ([**6-15**]): extensive tissue defect in R buttock with patches of subcutaneous air and stranding. No drainable fluid collections. Brief Hospital Course: Ms [**Known lastname **] was admitted to the ICU following debridement of her decubitus ulcers given concern for possible acute return to OR. She did very well after the first debridement on [**6-15**], coming off the ventilator and pressors soon after. She had an uneventful evening in the ICU and her dressing was changed at the bedside POD 1. She tolerated this dressing change fairly well with Dilaudid, and the wound bed showed no purulence or necrotic tissue. Her antibiotics were held as the wound appeared sterile and she was transferred to the surgical floor that day. [**Hospital 1094**] hospital course since arriving on the floor was notable only for 1 episode of hypotension (70/30s) overnight on [**6-16**]. Pt normalized quickly and all test results, notably EKG and cardiac enzymes, following this episode were completely normal. Pt experienced no further episodes of hypotension throughout the remainder of her hospital course. Pt was discharged on [**6-19**] following assessments by psychiatry, PT, and SW, all of whom felt the pt was ready and able to be discharged to a rehab facility for wound care. Pt is in agreement with this course of action and was transferred to rehab facility on [**2193-6-19**]. Medications on Admission: Clindamycin top [**Hospital1 **], polyethylene glycol prn, Ketotifen, Nitroglyerin 0.4mg sl q5hr, Ca + Vit D po bid, cholecalciferol po qd, ranitidine 300 po qhs, maxalt 10mg po bid prn, crestor 10mg po qd, singulair 10mg po qpm, doxycycline 100mg po qhs, nortriptyline 100mg po qhs, lyrica 150mg po bid, [**Doctor First Name 130**] 180mg po qd, prazosin 2-6mg po qhs prn, clonazepam 2.2mg po qhs, albuterol 20mg po qd, fentanyl 25mcg qhr transdermal, prozac 40mg po qd, nexium 40mg po qd, lisinopril 40mg po qd, warfarin 5mg po bid, atenolol 50mg po bid, flecainide 50mg po q12, hydrocodone 7.5/730mg po q6hr Discharge Medications: 1. atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 6. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Bactrim 400-80 mg Tablet Sig: Two (2) Tablet PO twice a day for 14 days. 9. Pt may resume warfarin at home. Discharge Disposition: Extended Care Facility: Willow Manor - [**Hospital1 189**] Discharge Diagnosis: Bilateral decubitus ulcers, R>L. Discharge Condition: Discharge condition: Good/Stable Mental Status: AAOx3 Ambulatory: Pt is ambulatory/independent. Discharge Instructions: Pt to be discharged to a rehab facility for help with wound care. * You were admitted to the hospital with pressure ulcers on your buttocks and thigh requiring debridement in the Operating Room and frequent dressing changes. * Your wounds are improving with dressing changes and you will need to be vigilant with wound care. * Stay off of your back to give these ulcers time to heal. * We anticipate your stay in rehab for wound care will be less than 30 days. * You have a prescription for a ROHO cushion to help with pressure distribution when you are sitting. * The Psychiatric service recommended stopping your Abilify and increasing your Fluoxetine to 60 mg daily which has been started. * You will need to follow up with your psychiatrist after discharge to help you with your depression and improve your self esteem. All that will help in the healing process. * Continue to eat well and stay well hydrated. Increasing your protein intake will help with healing. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in 1 week. Keep your follow up appointment in [**Month (only) 216**] with your psychiatrist Dr. [**Last Name (STitle) 40612**] at [**University/College **] Vangard in [**Location (un) 15749**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2193-6-19**]

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icd9cm

[ [ [] ] ]

[ "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

4914, 4975

2356, 3585

367, 475

5073, 5085

2143, 2143

6169, 6588

1656, 1669

4246, 4891

4996, 5031

3611, 4223

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1699, 2124

280, 329

503, 1457

2158, 2333

5100, 5150

1479, 1549

1565, 1640

15,423

172,425

20830

Discharge summary

report

Admission Date: [**2149-10-4**] Discharge Date: [**2149-10-20**] Date of Birth: [**2086-10-24**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 10644**] Chief Complaint: confusion Major Surgical or Invasive Procedure: VP shunt History of Present Illness: 62 yo female with a history of metastatic melanoma to liver and lungs with unknown primary on weekly taxol(last dose 11/8) who presented with nausea and vomiting for the past 6 days and increasing confusion for the past 2 days per her husband. Pt complained of severe frontal headache as well as some mild neck stiffness w/o photophobia. She also complained of diffuse abdominal pain which she said had been present since last [**Month (only) 547**]. She reported fatigue for the past week with more confusion over the past 2 days. Husband was concerned about her talking nonsense and with possible delusions, so he called [**Hospital **] clinic and she was referred to the ED. Per her husband she had no recent, cough, SOB,fever, chills, dysuria, diarrhea. In the ED she was given Ativan for nausea, and morphine for pain. CT head was negative and MRI showed question of leptomeningeal enhancement. LP performed for hx concerning for meningitis which revealed xanthocromia with fourth tube with 35 wbc(2 neuts, 45 lymphs, 6 monos, 33% atypicals), and 356 RBC's with protein >583 and glucose 28. Pt started on Acyclovir for herpes encephalitis, but leptomeningeal spread of melanoma was higher on the differential. Pt transferred to [**Hospital Unit Name 153**] with hydrocephalus, as demonstrated by LP and CT/MRI, secondary to leptomeningeal spread of her metastatic melanoma. Pt seen by neurosurgery for placement of ventricular drain at bed side for a communicating hydrocephalus with functional obstruction by atypical cells. Past Medical History: 1. Melanoma- dx on [**11-24**] due to elvated LFT with bx consistent w/melanoma began biochemotherapy [**2149-5-12**] but not tolerated due to nausea, vomiting, diarrhea, changed to cisplatin, vinblastine, and dacarbazine started recently on weekly taxol 2. Hypothyroidism 3. RA 4. Pilonidal cyst 5. HTN 6. diverticulitis 7. tubal ligation Physical Exam: VS: HR: 61 BP: 118/43 RR: 12 SaO2: 95% Pain: 0/10 -Gen: pt is a well nutritioned pale women with significant alopecia. She is not particularly communicative, but does responds to questions with nodding and gesturing and is otherwise cooperative (s/p olanzapine and ativan prior to imaging this evening). -HEENT: pupils are 2mm bilaterally and due to their small size, difficult to assess for reactivitiy -CV: RRR, S1, S2, no murmurs, rubs, gallops -Chest: CTA bilaterally -Abd: soft, NT, ND, BS+ (s/p morphine prior to CT scan) -Ext: warm, well perfused, no clubbing, cyanosis, edema . Pertinent Results: [**2149-10-4**] CXR: "No acute cardiopulmonary abnormality" . [**2149-10-4**] Non-contrast head CT: "IMPRESSION 1. No acute intracranial hemorrhage or evidence of acute major vascular territorial infarction. No overt mass is seen. This study, however, cannot excluded metastatic disease. Further evaluation with contrast enhanced MRI may be performed to exclude metastatic disease. 2. Ventricular dilatation out of proportion to the degree of focal atrophy. Is there clinical evidence of normal pressure hydrocephalus? " . [**2149-10-4**] Head MRI: "IMPRESSION 1. Prominent ventricular system including the temporal horns. This may represent early hydrocephalus. This is seen in association with high signal in the periventricular white matter, consistent with trans- ependimal CSF flow. No obstructing lesions are identified. 2. No enhancing lesions are identified." . [**2149-10-4**] CSF: " Brief Hospital Course: 1. Melanoma-Leptomeningeal enhancement on MRI with atypical cells in CSF were concerning for metastatic melanoma. Cells sent for cytology and revealed melanoma cells. Pt initially had wasing and [**Doctor Last Name 688**] mental status which responded well to serial LP's so neurosurgery was consulted and placed an [**Doctor Last Name 55500**] shunt. Her mental status continued to decline despite drainage from her [**Last Name (LF) 55500**], [**First Name3 (LF) **] neurooncology was consulted and decided along with oncology and the pt's huspband to make an attempt at intrathecal chemotherapy. The pt received 2 doses of intrathecal thiotepa with poor response and it was decided at that point she would be made [**First Name3 (LF) 3225**]. 2. Headache-headache, nuchal rigidity, and xanthocromia and lymphocytic predominance on LP was concerning for HSV. She was continued on acyclovir until HSV culture came back negative. CT findings of enlarged ventricles suggested NPH and this was confirmed by response to serial LP's as above. NPH due to blockage of CSF circulatory system due to leptomengial spread of melanoma. 3. Abdominal pain-Pt with elevated alk phos but actually lower than pt baseline. Pain appears to be longstanding and she has no fever to suggest infection. Pt family refused RUQ US. We cont pain control with IV morphine and with the addition of zyprexa for agitation. Morphine contributed to urinary retention as seen in high PVR so foley placed. 4. HTN-cont on her oupatient atenolol dose and HTN was well controlled. 5. Hypothyroidism-normal TSH so cont on outpatient dose of levothyroxine 6. Px-SC heparin, bowel regimen, pt was taking good PO's until day 5 of hospitalization 7. Code-DNR/DNI discussed in full with husband and pt and confirmed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and eventually with Dr. [**Last Name (STitle) 38669**]. After extensive discussion with Heme/Onc and Neurooncology with husband she was made [**Name (NI) 3225**]. Medications on Admission: Medications on Transferr: 1. Acetaminophen 2. Acyclovir 350mg IV Q8 hours 3. Atenolol 25mg PO once daily 4. Bisacodyl 10mg PO QHS 5. Dolasetron Mesylate 12.5mg IV Q8 hours PRN 6. Docusate 100mg PO BID 7. Levothyroxine 75mcg PO once dialy 8. Lorazepam 0.5mg IV Q4 hours PRN 9. Metoclopramide 5mg PO IV QIDACHS 10. Morphine sulfate 2-4mg IV/SC Q4hours PRN pain 11. Senna 1 tab PO BID PRN Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20mg PO q1-3 h : [**Month (only) 116**] give PO/SL. Disp:*qs 60ml* Refills:*2* 2. Morphine Sulfate 8 mg/mL Syringe Sig: 1-5 mg Injection q2h as needed for pain uncontrolled by acetaminophen. Disp:*qs 20* Refills:*2* 3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2) Injection Q12H (every 12 hours) as needed for nausea. 7. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous three times a day as needed for nausea. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: hospice or [**Location (un) 5089**] Discharge Diagnosis: Leptomeningeal spread of melanoma Discharge Condition: Comfortable Discharge Instructions: You will be taken care of by a specialized staff at the facility which you are being transferred to who will make sure that you are comfortable. Followup Instructions: You will be followed by Dr. [**Last Name (STitle) **] at the facility which you are being transported to.

[ "331.4", "401.9", "197.7", "198.4", "197.0", "714.0", "198.3", "199.1", "244.9" ]

icd9cm

[ [ [] ] ]

[ "03.31", "92.29", "02.2" ]

icd9pcs

[ [ [] ] ]

7176, 7238

3762, 5790

280, 290

7316, 7329

2844, 2935

7522, 7631

6237, 7153

7259, 7295

5816, 6214

7353, 7499

2237, 2825

231, 242

321, 1858

2944, 3739

1880, 2222

46,355

121,814

4525

Discharge summary

report

Admission Date: [**2140-10-12**] Discharge Date: [**2140-10-17**] Date of Birth: [**2095-1-17**] Sex: M Service: CARDIOTHORACIC Allergies: Latex / Adhesive Tape Attending:[**First Name3 (LF) 4679**] Chief Complaint: Multiple pulmonary sarcoma metastasis Major Surgical or Invasive Procedure: [**2140-10-12**] Left thoractomy and multiple wedge resections of pulmonary metastasis. History of Present Illness: The patient is a 45-year-old male who has undergone resection of a synovial sarcoma. He has bilateral pulmonary metastases and has been admitted for left thoracotomy and wedge resection of multiple pulmonary nodules. Past Medical History: 1. Synovial sarcoma - Biopsy on [**2139-5-7**] showed a malignant spindle cell neoplasm, intermediate grade, most consistent with synovial sarcoma, predominantly monophasic type. The immunohistochemical stain for EMA is positive, while actin, desmin, cytokeratin cocktail, MNF-116, CD34 and S100 were negative. He completed neoadjuvant adriamycin/radiation followed by resection of left pelvic the synovial sarcoma on [**2139-9-10**]. The resection included excision of the left external iliac artery and vein with a 10-mm Dacron graft reconstruction extending from the proximal origin of the external iliac to the common femoral artery 2. Cardiomyopathy - idiopathic, ?secondary to steroid abuse, EF previously 35%, improved to 55% 3. Depression/Anxiety 4. Gerd 5. Chronic sinusitis s/pt surgery with middle meatal antrostomy and anterior ethmoidectomy [**2131**] 6. Asthma - induced by exercise and cold weather 7. H/o MRSA folliculitis 8. Latent syphilis 9. HSV labialis Social History: - single, lives with parents - EtOH: rare - tobacco: denies - exposure: radiation therapy ([**7-/2139**]) Family History: mother: COPD maternal grandmother: colon cancer in her 60s Physical Exam: VS: T: 98.4 HR: 84 SR BP: 90/60 Sats: 98% RA General: 45 year-ol male ambulating in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenapathy Card: RRR Resp: decreased breath sounds throughout without wheezes or crackles GI: benign Extr: warm no edema Incision: left thoracotomy site clean dry intact, no erythema. margins well approximated Neuro: Awake, alert, oriented. MAE Pertinent Results: [**2140-10-14**] WBC-5.2 RBC-3.78* Hgb-10.8* Hct-32.7 Plt Ct-223 [**2140-10-13**] WBC-7.1 RBC-4.03* Hgb-11.6* Hct-34.2 Plt Ct-225 [**2140-10-12**] WBC-9.9# RBC-4.38* Hgb-12.7* Hct-37.1 Plt Ct-252 [**2140-10-14**] Glucose-111* UreaN-8 Creat-0.8 Na-134 K-4.0 Cl-99 HCO3-30 [**2140-10-13**] Glucose-94 UreaN-12 Creat-0.9 Na-135 K-4.2 Cl-100 HCO3-27 [**2140-10-12**] Glucose-119* UreaN-12 Creat-0.8 Na-137 K-3.9 Cl-103 HCO3-27 [**2140-10-11**] UreaN-12 Creat-1.0 Na-137 K-3.9 Cl-97 HCO3-31 [**2140-10-11**] ALT-18 AST-19 LD(LDH)-152 AlkPhos-104 TotBili-0.3 [**2140-10-14**] Calcium-8.3* Phos-2.8# Mg-2.2 CXR: [**2140-10-15**] The left-sided chest tube has been removed. There is a small left apical pneumothorax which has developed since the chest tube removal. Surgical clips are seen within the left upper lobe. There is a right-sided Port-A-Cath with the distal lead tip at the cavoatrial junction. There is coarsening of the bronchovascular markings. Sutures are seen within the right lower lung field. Small bilateral pleural effusions are also present. Subcutaneous emphysema is seen within the left lower chest wall. [**2140-10-14**]: Tiny left pneumothorax, new or newly apparent. No appreciable left pleural effusion, two left pleural tubes still in place. Right basal atelectasis worsened. Subcutaneous emphysema in the left neck and chest wall, unchanged. Heart size normal. Right subclavian infusion port ends low in the SVC. No right pneumothorax. [**2140-10-12**]: Low-lying left chest tube as described. Probable small lateral left pneumothorax. Brief Hospital Course: Mr. [**Known lastname 1511**] was taken the operating room on [**2140-10-12**] where he underwent left thoracotomy and multiple wedge resections for pulmonary metastasis. He recovered in the PACU, and transferred to the floor in stable condition. Respiratory: aggressive pulmonary toilet, incentive spirometer and nebulizers he titrated of supplement oxygen with oxygen saturations of 96% room air. Chest-tube: 2 apical with tiny persistent air leak for 24 hrs and basilar were to low-wall suction then changed to water-seal without leak. The basilar tube was removed on [**2140-10-13**]. The apical on [**2140-10-15**]. Chest films: serial chest films were done and showed stable left small apical pneumothorax and small bilateral effusions. Cardiac: immediately postoperative he was hypotensive (SBP 80's) which responded to fluid challenge (SBP 90-100). His lisinopril, Lasix and spironolactone were held. The Coreg 12.5 was changed to Lopressor 12.5 tid which he was able to tolerate. The digoxin was continued. He remained in sinus rhythm 80-90 and BP 90-100 on this regime. On discharge he was instructed to take Coreg 6.25 mg [**Hospital1 **] increase as BP tolerates. Restart lisinopril when BP > 110. Lasix perform daily weights take prn for weight gain of [**4-7**] pounds. GI: PPI and bowel regime continued Nutrition: tolerated a regular diet Renal: function stable with good urine output. Pain: Bupivacaine and hydromorphone epidural was placed and managed by the acute pain service. While in the PACU his pain was not well controlled and required an epidural split with Hydromorphone PCA and Toradol. The epidural was titrated multiple time for good pain control. On [**2140-10-15**] the epidural was removed, he was restarted on MS Contin 30 increased to tid from [**Hospital1 **] and hydromorphone 4 mg prn. On discharge he was MS Contin 30 [**Hospital1 **], hydromorphone and Motrin. IV access: His Port-a-cath was accessed and de-accessed prior discharge. Disposition: He was discharged to home on [**2140-10-17**] with VNA. He will follow-up with Dr. [**First Name (STitle) **] as an outpatient. He will also contact his PCP management of his cardiac and pain medication. Medications on Admission: CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth daily DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth at bedtine LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once daily LORAZEPAM - 1 mg Tablet - [**2-6**] to 1 Tablet(s) by mouth daily as needed for nausea, anxiety MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice a day ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every eight hours as needed for nausea OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day Approved by MassHealth as of [**2139-11-11**] SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 (One) Tablet(s) by mouth as directed prior to sexual activity SPIRONOLACTONE [ALDACTONE] - 25 mg Tablet - 1 Tablet(s) by mouth once a day Please call doctor's office and schedule an appointment TRAMADOL - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth four times a day as needed for pain ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): restart when BP consistently > 110. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): restart when weight up 3-4 pounds. 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take [**2-6**] tablet until BP > 100. 10. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day. 11. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**5-10**] hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 13. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO four times a day as needed for pain. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital3 **] Home Health & Hospice Discharge Diagnosis: Metastatic sarcoma Dilated cardiomyopathy Hypertension Depression GERD anxiety, asthma, hx of MRSA abscess of the groin, chronic sinusitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops draingage -You may shower. No tub bathing or swimming until all incisions healed Call your PCP [**Name9 (PRE) 19288**] with questions or concerns regarding your blood pressure and restarting your previous medications Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2140-10-25**] 11:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Completed by:[**2140-10-17**]

[ "300.4", "493.90", "197.0", "428.22", "425.4", "458.29", "097.1", "530.81", "V10.89", "428.0", "305.93" ]

icd9cm

[ [ [] ] ]

[ "32.29" ]

icd9pcs

[ [ [] ] ]

9057, 9126

3910, 6122

328, 418

9309, 9309

2324, 3887

9882, 10234

1810, 1871

7426, 9034

9147, 9288

6148, 7403

9460, 9859

1886, 2305

251, 290

446, 665

9324, 9436

687, 1670

1686, 1794

61,249

102,941

37153

Discharge summary

report

Admission Date: [**2200-10-1**] Discharge Date: [**2200-10-4**] Date of Birth: [**2140-1-22**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 443**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: 1. Cardiac catheterization 2. Stenting of the right internal carotid artery History of Present Illness: 60yo M PMHx CAD s/p CABG and mult PCIs, sCHF, HL, PVD, tobacco abuse and [**Country **] stenosis who was referred for cardiac catheterization for chest pain of increasing frequency now s/p carotid stenting of asymptomatic progressive [**Country **] stenosis. Regarding his CAD, prior to this admission last cardiac cath ([**2200-4-30**]) w native CADx3, known occluded RCA, patent LIMA/RIMA, restenosis of the native RCA distal to the touchdown site of the RIMA, successfully treated with DES. Patient reports that since [**Month (only) **] he has had recurrence of anginal symptoms, exertional and progressive. Regarding his extensive PVD, he was recently found to have progression of known [**Country **] stenosis to 80-99% range, without associated visual/neurologic symptoms. Patient initially admitted to [**Hospital1 1516**] service for cardiac cath ([**9-30**]), which did not demonstrate any significant new disease. On day of transfer to CCU the patient underwent [**Country **] stenting with 8-6 protege [**Country **] stent, via R femoral artery without any noted complications. Following the procedure remained hemodynamically stable without any vagal episodes. He was then transferred to CCU for further post-procedure monitoring. . On arrival to the floor, patient denies any HA, dizziness, numbness/weakness. Review of symptoms significant for above complaints as well as chronic claudication. Past Medical History: 1. CARDIAC RISK FACTORS: -DM, +HLD, +HTN 2. CARDIAC HISTORY: -CABG: [**2183**] CABG (LIMA-LAD, RIMA-RCA, SVG-D1, SVG-RV branch- PDA-OM) -CAD: SVG to OM1 Known occluded, SVG to PDA known occluded, RIMA to RCA patent, LIMA to LAD patent -sCHF: EF 45% in [**2197**] -PCI: RIMA to RCA PTCA [**11/2198**], [**1-/2199**], stent [**4-/2200**] -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -Right renal artery stenosis -[**4-/2200**] right brachial pseudoaneurysm s/p radial access for cath -hyperlipidemia -PVD with right carotid disease awaiting CEA -Dyslipidemia -Tobacco abuse (currently smoking [**11-17**] PPD) -GERD -Anxiety/ depression -Arthritis -GOUT -Hypothyroid Social History: Lives with: landlord and stepbrother, no girlfriend, and son [**Name (NI) 6644**]. Occupation: Disabled. Smokes [**11-17**] PPD for 45 years. ETOH: Rare ETOH and denies illicit drug use. Family History: Mother with MI in her 40??????s Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.3 114/84 59 16 99%RA GENERAL: NAD, comfortable HEENT: NCAT, PERRL, OP clear NECK: Supple, JVD 6cm CARDIAC: nlS1/S2, no m/r/g LUNGS: Resp unlabored, dry crackles bilaterally, no wheezes/rales/ronchi ABDOMEN: Soft, obese, NTND, +BS EXTREMITIES: R groin cath site c/d/i, non-tender, no bruit PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ . DISCHARGE PHYSICAL EXAM: VS: 97.7 125/77 72 14 100%RA GENERAL: NAD, comfortable HEENT: NCAT, PERRL, OP clear NECK: Supple, JVD 6cm CARDIAC: nlS1/S2, no m/r/g LUNGS: Resp unlabored, dry crackles bilaterally, no wheezes/rales/ronchi ABDOMEN: Soft, obese, NTND, +BS EXTREMITIES: R groin cath site c/d/i, non-tender, no bruit PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ NEURO: CN's III-XII intact, [**3-20**] motor in all 4 extremities, intact to light touch throughout, appropriate reflexes, downward going toes on plantar reflex, no cerebellar signs Pertinent Results: ADMISSION LABS: . [**2200-10-1**] 05:35PM BLOOD WBC-7.3 RBC-4.48* Hgb-14.0 Hct-41.6 MCV-93 MCH-31.4 MCHC-33.7 RDW-13.2 Plt Ct-222 [**2200-10-1**] 05:35PM BLOOD Plt Ct-222 [**2200-10-1**] 05:35PM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-137 K-4.5 Cl-101 HCO3-30 AnGap-11 [**2200-10-1**] 05:35PM BLOOD CK(CPK)-218 [**2200-10-1**] 05:35PM BLOOD CK-MB-4 cTropnT-<0.01 [**2200-10-1**] 05:35PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2 . PERTINENT LABS: . [**2200-10-1**] 05:35PM BLOOD CK-MB-4 cTropnT-<0.01 [**2200-10-2**] 06:45AM BLOOD CK-MB-3 cTropnT-<0.01 [**2200-10-2**] 06:45AM BLOOD ALT-18 AST-17 CK(CPK)-152 AlkPhos-56 TotBili-0.3 . DISCHARGE LABS: . [**2200-10-4**] 09:00AM BLOOD WBC-6.7 RBC-3.83* Hgb-12.0* Hct-36.0* MCV-94 MCH-31.4 MCHC-33.4 RDW-13.0 Plt Ct-238 [**2200-10-4**] 09:00AM BLOOD Glucose-151* UreaN-15 Creat-0.8 Na-140 K-3.7 Cl-106 HCO3-26 AnGap-12 [**2200-10-4**] 09:00AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9 . MICRO/PATH: None . IMAGING/STUDIES: . C.CATH [**10-1**]: FINAL DIAGNOSIS: 1. Known two vessel native coronary disease. 2. Patent LIMA and RIMA arterial conduits. 3. 70% stenosis in the proximal right renal artery. 4. 60-70% stenosis in the right iliac. 5. 60% stenosis in the left iliac. . Carotid Series Complete [**10-2**]: IMPRESSION: 70-79% stenosis in the right internal carotid artery. No evidence of significant stenosis in the left internal carotid artery. . Renal Artery Doppler [**10-2**]: IMPRESSION: 1. Findings consistent with right renal artery stenosis. 2. Normal left renal vascular flow. 3. Multiple bilateral exophytic and cortical renal cysts. . C.CATH [**10-3**]: FINAL DIAGNOSIS: 1. Severe [**Country **] stenosis. 2. Successful stenting of [**Country **] with 8-6x40mm Protege carotid stent. 3. Goal sbp 100-120mmHg 4. Monitor in CCU overnight 5. ASA, plavix Brief Hospital Course: 60 year old gentleman patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] with known CAD, s/p PTCA of RIMA to RCA on [**2198-12-4**], DES after RIMA touchdown to RCA 6/11, now with recurrent and more frequent chest pain at rest, had cardiac catheterization that was unchanged from prior cath, found to have renal artery stenosis (right). He also has asymptomatic progressive [**Country **] stenosis and was scheduled for carotid stenting on [**2200-10-3**]. After stenting, he was transferred to CCU for further management. . ACTIVE DIAGNOSES: . # Coronary Artery Disease s/p CABG and PCI to RIMA to RCA: Pt presented with chest pain since 9/[**2199**]. He had coronary catheterization on [**2200-10-1**] which did not reveal new occlusion. He was continued on aspirin, plavix, statin, imdur, morphine and SL nitro. He was instructed not to overuse nitro tablets as he was doing at home. His imdur dose was increased from 60 mg to 90 mg daily. Outpatient cardiologist was contact[**Name (NI) **] regarding the reason of not being on beta blocker or ACEi. He was not on ACEi because his outpatient cardiologist did not want to drop his SBP to < 140 given he has severe right ICA stenosis to avoid possible stroke. He was not on betablocker because of the same reason in addition to his heart rate being usually in the 50's. He was discharged with follow-up with his PCP and cardiologist and with study-related follow-up. . # Renal Artery Stenosis: Found on cath to have 70% stenosis in the proximal right renal artery. Right renal US was done and showed stenosis as well as multiple bilateral simple exophytic and cortical renal cysts. No stent was placed and he was instructed to follow up with his PCP and other outpatient providers. . # Carotid Artery Stenosis: Pt had a carotid US in [**2199**] which showed right ICA 60-79% stenosis with 1-39% left ICA stenosis. Repeat in [**7-/2200**] showed critical [**Country **] stenosis of 80-99%. He was on aspirin 81 mg daily, plavix 75 mg daily, and lovastatin 20 mg daily as home medications. Repeat carotid US showed 70-79% stenosis in the right internal carotid artery. In the cath lab he was found to have significant [**Country **] stenosis with successful stenting using 8-6x40mm Protege carotid stent. He was monitored overnight in the CCU with tight blood pressure control and had an unremarkable clinical course. He was discharged with study-related follow-up in addition to PCP and cardiology [**Name9 (PRE) 702**]. He will need to be continued on aspirin and plavix and should not discontinue either unless told by his cardiologist. . # Peripheral Vascular Disease with Claudication: He describes having symptoms of vascular claudication on exertion in his legs and had an ABI of 0.66 right, 0.72 left. On cath he was found to have 60-70% stenosis in the right iliac and 60% stenosis in the left iliac. He was continued on aspirin, plavix, and his home statin. He may benefit from vascular intervention of his PAD in the future. . CHRONIC DIAGNOSES: . # Chronic Systolic Congestive Heart Failure: TTE in [**2197**] showed Dilated LV with apical dyskinesis, septal akinesis and inferior basilar dyskinesis with EF 45%. on lasix 20 mg every other day. Imdur 60 mg daily. He was stable without clinical evidence of CHF exacerbation. We increased his imdur dose to 90 mg daily which he tolerated well. . # Hyperlipidemia: Stable. Continued on home ezetimibe, gemifibrozil, and statin. . # Hypothyroidism: Stable. Continued on home levothyroxine 50 mcg daily. . # GERD: Stable. Continued on home lansoprazole. . TRANSITIONAL ISSUES: # He will need appropriate study follow-up in addition to regular PCP and cardiology [**Name9 (PRE) 702**] . # He will need to be on aspirin and plavix. He should not discontinue either medication unless told to do so by his cardiologist. . # He may benefit from further vascular intervention to address his symptoms of claudication. Medications on Admission: -albuterol sulfate 90mcg HFA Aerosol Inhaler 1 puff [**2-19**] times/day prn -bupropion HCl 75 mg Tablet once a day -clopidogrel 75 mg Tablet daily -ezetimibe 10 mg Tablet daily -furosemide 20 mg Tablet every other day -gemfibrozil 600 mg Tablet by mouth daily -isosorbide mononitrate 60 mg Tablet ER 24 hr daily -lansoprazole 30 mg Capsule (E.C.) daily -levothyroxine 50 mcg Tablet by mouth daily -lorazepam 1 mg Tablet by mouth twice a day -lovastatin 20 mg Tablet by mouth every other day (was on [**Last Name (un) **] day but developed muscle aches which resolved by decreasing the dose) -mom[**Name (NI) 6474**] 50 mcg Spray, Non-Aerosol 2 sprays daily prn allergies -morphine 15 mg Tablet by mouth four times per day for chest pain -nitroglycerin 0.4 mg Tablet, SL [**11-18**] Tablet(s) SL prn chest pain -salmeterol 50 mcg Disk with Device one puff daily -aspirin 81 mg Tablet, (E.C.) by mouth daily - tolerates with food -cholecalciferol 400 unit Tablet, Chewable by mouth daily -omega-3 fatty acids-vitamin E [Fish Oil] 1,000 mg Capsule daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD (). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. lovastatin 20 mg Tablet Sig: One (1) Tablet PO every other day. 11. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2) sprays Nasal once a day as needed for allergies. 12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for chest pain. 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**11-18**] Tablet, Sublinguals Sublingual Q5MIN () as needed for chest pain. 14. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 1 months. Disp:*30 Patch 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Carotid artery stenosis, Atypical chest pain, Coronary artery disease, Peripheral vascular disease Secondary Diagnosis: Chronic systolic congestive heart failure, Hypertension, Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Chest pain free. Discharge Instructions: It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were admitted for chest discomfort, and a cardiac catheterization revealed stable coronary artery disease. As your right internal carotid artery was found to be highly narrowed, a stent was placed to open up this narrowing. Your blood pressures were monitored after the procedure in the cardiac care unit and these remained stable. The etiology of your chest pain is unclear. [**Name2 (NI) **] should consider consultation with a gastroenterologist and discuss this with your cardiologist and PCP. There were no changes made to your medication regimen. Please continue to take aspirin and plavix every day without exception. Do NOT stop taking these medications unless your cardiologist instructs you to do so. You should try to stop smoking. Smoking is extremely bad for your health and is directly related to your heart and widespread artery disease. We have provided you with a nicotine patch to help assist you in quitting. Followup Instructions: Please report to [**Hospital Ward Name **] 4 on the [**Hospital Ward Name 517**] on [**2200-11-4**] at 11:00AM to meet with the research team and complete the registry follow up appointment. If you have any questions, please call Dr.[**Name (NI) 8664**] office or the cardiology department at [**Hospital1 18**]. Please follow up with Dr. [**First Name4 (NamePattern1) 11249**] [**Last Name (NamePattern1) 11250**] within one week. Please follow up with your PCP to review your chronic medical issues. Please discuss Gastroenterology consultation with your medical providers. Completed by:[**2200-10-9**]

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icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "00.61", "00.63", "00.45", "88.48", "00.40", "88.42" ]

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[ [ [] ] ]

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18624

Discharge summary

report

Admission Date: [**2130-4-30**] Discharge Date: [**2130-5-10**] Date of Birth: [**2074-6-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: AMS/Fever Major Surgical or Invasive Procedure: None History of Present Illness: 55M with MS (non-verbal at baseline), diabetes and untreated prostate cancer presents from [**Hospital1 1501**] w/ fever/AMS. This morning at nursing home was noted to be more lethargic and not responding like normal. He was also noted to have fever. Of note he has had repeated episodes of PNA, most recently 2-3 weeks ago and was treated with azithromycin. Per his sister he initial got better but 3 days ago began to have cough again. He was also noted to have chills and night sweats. Also of note he has had daily loose foul smelling stools. He does not respond to questions so it is difficult to ascertain symptoms but he does not have obvious abd pain or dysuria. . In the ED initial vitals were: 98, 125, 139/69, 18, 93% on 2L. An EKG showed Sinus tachy at 119, NA, NI, PR depression in V2, no ischemic changes. CXR showed possible retrocardiac opacity per ED read. He was given flagyl/levo/vanc for possible aspiration PNA. Initial Lactate was 3.3. He received 2L NS and repeat lactate was 3.7 and he was still tachycardic to the 120s. . On arrival to the MICU, initial vitals were: 117 140/81 18 97% on 2L. He was uncomfortable appearing with some tremulousness. He does not respond to querstions. . Review of systems: (+/-) Per HPI Past Medical History: Multiple sclerosis Diabetes type 2 Prostate cancer dementia neurogenic bladder Obesity OSA - not on CPAP osteoporosis GERD Neuropathy Social History: Previously lived in [**Location 8545**], [**State 350**], with his wife and daughter. Now lives in [**Location 86**] Home [**Hospital1 1501**]. No tobacco or EtOH. Previously worked as security guard and as worker for troubled youth. Family History: Second cousin has multiple sclerosis. Positive family history for hypertension. Physical Exam: ADMISSION EXAM: Vitals: T: 98.3 BP:117 BP 140/81 RR18 O2 97% on 2L General: Makes eye contact but does not repsond to questions or commands. Uncomfortable appearing, mildy tremoulous. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds from upper airway transmitted throughout lungs. No complying with exam but within limits no obvious wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: Vitals: T: 98.7 BP 117-127/70-71 HR 85-88 RR 18 O2 97% on RA 800/875 + BM 0/500 General: Makes eye contact but does not respond to questions or commands. NAD. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse coarse breath sounds, no wheezes. Mild crackles. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: condom cath in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: unable to answer questions appropriately, does track with eyes, cannot follow commands. He reflexively grips his hands. Unable to lift arms, move legs. Pertinent Results: ADMISSION LABS: [**2130-4-30**] 01:18PM WBC-15.9*# RBC-4.99 HGB-13.4* HCT-41.5 MCV-83 MCH-26.8* MCHC-32.2 RDW-13.5 [**2130-4-30**] 01:18PM NEUTS-93.5* LYMPHS-2.8* MONOS-2.4 EOS-0.8 BASOS-0.4 [**2130-4-30**] 01:18PM GLUCOSE-156* UREA N-9 CREAT-0.4* SODIUM-141 POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-26 ANION GAP-20 [**2130-4-30**] 01:18PM ALT(SGPT)-32 AST(SGOT)-23 LD(LDH)-182 ALK PHOS-65 TOT BILI-0.6 [**2130-4-30**] 01:18PM LIPASE-26 [**2130-4-30**] 01:18PM cTropnT-<0.01 [**2130-4-30**] 01:39PM LACTATE-3.3* [**2130-4-30**] 02:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2130-4-30**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2130-4-30**] 03:49PM D-DIMER-805* . LACTATE [**2130-4-30**] 01:39PM BLOOD Lactate-3.3* [**2130-4-30**] 03:15PM BLOOD Lactate-3.7* [**2130-4-30**] 08:23PM BLOOD Lactate-6.5* K-3.3 [**2130-5-1**] 12:32AM BLOOD Lactate-6.7* K-3.4 [**2130-5-1**] 03:55AM BLOOD Lactate-3.0* [**2130-5-1**] 11:07PM BLOOD Lactate-2.0 . [**2130-5-4**] 03:47AM BLOOD LD(LDH)-142 TotBili-0.5 [**2130-5-5**] 05:13AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 [**2130-4-30**] 03:49PM BLOOD D-Dimer-805* [**2130-5-4**] 03:47AM BLOOD Hapto-462* [**2130-5-3**] 06:00AM BLOOD Vanco-18.9 . CXR [**2130-4-30**] FINDINGS: Single frontal view of the chest was obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. Cardiac silhouette is top normal, likely accentuated by AP technique. No overt pulmonary edema is seen. IMPRESSION: Low lung volumes; however, given this, no acute cardiopulmonary process is seen. . CT CHEST/ABD/PEL [**2130-4-30**] IMPRESSION: 1. No evidence of pulmonary embolism. 2. Bilateral bibasal patchy opacification consistent with pneumonia. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Hepatosteatosis 5. Bilateral hypodensities within the kidneys bilaterally, which are too small to characterize. 6. Moderate prostatic enlargement. 7. Hypertrophied bladder wall with possible nodular filling defect superiorly. Cystoscopy is recommended. . VIDEO SWALLOW [**2130-5-2**] Aspiration or penetration of all barium consistencies, although less with nectar-thick liquids. Please refer to the speech language pathology report for further detailed of the findings. . CXR [**2130-5-3**] PICC PLACEMENT The tip of the right PICC now terminates in the low SVC. There is no pneumothorax. Low lung volumes and bibasilar atelectasis are unchanged. The cardiomediastinal silhouette is stable. IMPRESSION: Right PICC terminates in low SVC. . EKG [**2130-4-30**] Sinus tachycardia. QS complex in lead V2 consistent with an anteroseptal myocardial infarction, age undetermined. Otherwise, no other diagnostic abnormalities. No previous tracing available for comparison. . CXR [**2130-5-9**] FINDINGS: AP and lateral chest radiographs demonstrate persistent low lung volumes and opacification at the left lung base that may represent pneumonia in the proper clinical setting. The cardiomediastinal silhouette is stable. The right lung is clear. There is no pneumothorax. The right PICC terminates in a standard position. IMPRESSION: Probable left basilar pneumonia. [**2130-5-8**] BLOOD CULTURE X2-PENDING [**2130-5-8**] URINE CULTURE-NEGATIVE [**2130-5-5**] URINE CULTURE-NEGATIVE [**2130-4-30**] STOOL C. difficile NEGATIVE [**2130-4-30**] BLOOD CULTURE -NEGATIVE [**2130-4-30**] SPUTUM GRAM STAIN-OROPHARYNGEAL FLORA; RESPIRATORY CULTURE-OROPHARYNGEAL FLORA [**2130-4-30**] MRSA SCREEN -{POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} [**2130-4-30**] URINE Legionella Urinary Antigen -NEGATIVE [**2130-4-30**] BLOOD CULTURE NEGATIVE [**2130-4-30**] URINE CULTURE-NEGATIVE [**2130-4-30**] BLOOD CULTURE -NEGATIVE . [**2130-5-5**] 09:57AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2130-5-5**] 09:57AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 . DISCHARGE LABS [**2130-5-8**] 10:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2130-5-8**] 10:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 [**2130-5-10**] 05:59AM BLOOD WBC-11.1* RBC-3.81* Hgb-10.1* Hct-32.2* MCV-84 MCH-26.4* MCHC-31.3 RDW-13.6 Plt Ct-499* [**2130-5-10**] 05:59AM BLOOD Glucose-144* UreaN-7 Creat-1.1 Na-143 K-3.4 Cl-108 HCO3-26 AnGap-12 Brief Hospital Course: 55M with MS, diabetes and untreated prostate cancer presents from [**Hospital1 1501**] w/ fever/AMS and possible PNA admitted to the MICU for concern for evolving sepsis, with hypernatremia and concern for likely repeated aspiration pneumonias. . #Sepsis, Pneumonia: Met 3 sirs criteria with fever, tachycardia, and elevated WBC count at time of admission. PNA seen on chest CT. Treated with vancomycin, zosyn, levofloxacin for HCAP since he lives in a nursing facility and has recently received antibiotics. His urine legionella was neative so the levofloxacin was discontinued. His fever, tachycardia and elevated WBC count resolved. He was not able to produce a sputum sample so he was continued on vanc/zosyn for a planned 7 day course, started [**4-30**], completed [**5-6**]. He did have a fever to 100.8 on the day following discontinuation of abx, but remained afebrile since. He also developed a leukocytosis on the day prior to discharge, which was up to 11 and stayed stable on day of discharge. The patient had repeat AP and Lat CXR to evaluate for pna, which showed LLL pna, but this is consistent with prior known pna and felt to likely represent no new process. . # Goals of Care: the patient developed hypernatremia to 148, which resolved with free water IVF. This is likely secondary to decrease in free water PO given change in speech and swallow recommendations to take nectar thick liquids. The possibility of PEG was raised with the family, which would ensure adequate hydration and avoid hypernatremia and renal failure. [**Name (NI) **] [**Name (NI) **], HCP and patient's sister, as well as his mother, felt strongly on repeated occasions that PEG is not what [**Known firstname **] would desire. They choose to continue to administer free water by mouth despite risk of aspiration. They understand that continued administration of water will likely lead to repeated pneumonias, and that he may not be able to meet his needs for free water, and hypernatremia or pneumonia could lead to death. They also desire to avoid repeated courses of antibiotics. The possibility of "do not rehospitalize, do not escalate care" was broached, but it was NOT agreed upon. The family, at this point, do continue to desire antibiotics, IVF and hospitalization if indicated. . # Hypernatremia: up to 148, improved with free water by IVF. Please see discussion of goals of care above. . #Multiple sclerosis: His clinical condition has continued to decline, particularly over the past three years. Because of his frequent PNAs and risk for aspiration he was evaluated by speech and swallow. After a video swallow study he was started on nectar thick liquids and full solids. Please see discussion of goals of care, above. . #Anemia: He presented with a hematocrit >40 but decreased to 32.9. Hemolysis labs were negative and his stools were guaiac negative. His HCT stayed stable around 33 and was felt to be likely related to draws from his PICC not being adequately flushed and phlebotomy. He remained hemodynamically stable and did not require transfusion. . #[**Last Name (un) **]: His creatinine was 0.6 on admission then increased to 1.5. Review of prior records showed that his baseline is actually closer to 0.9. He was given IVF since his PO intake was poor. His Cr trended to 1.1 at time of discharge. This is likely secondary to pre-renal etiology. . CHRONIC ISSUES . #Diabetes type 2. On metformin at home. Insulin sliding scale was started on admission and he was transitioned back to metformin on discharge. . #Prostate cancer: Elevated PSA to 11.4 in [**3-23**]. Followed by Dr. [**Last Name (STitle) **] here at [**Hospital1 18**]. . TRANSITIONAL ISSUES: CODE: DNR/DNI CONTACT: sister, [**Name (NI) **] [**Name (NI) **], HCP. [**Telephone/Fax (1) 51131**] (work) PENDING STUDIES TO ADDRESS AT FOLLOW UP: - BLOOD CULTURES X2 ISSUES TO ADDRESS AT FOLLOW UP - Hypertrophied bladder wall noted on CT pelvis. Cystoscopy is recommended. - resolution of pna - Goals of Care discussions with family Medications on Admission: Alendronate 70mg Qmonday loratadine day Acetaminophen 1000mg Qday Calcium carbonate 625mg [**Hospital1 **] Cranberry docusate 100mg [**Hospital1 **] Famotidine 10mg [**Hospital1 **] Fluticasone propionate nasal 50 mcg [**Hospital1 **] metformin 1000mg [**Hospital1 **] mucinex 600 mg [**Hospital1 **] MVI Azelastine 137 nasal spray TID Gabapentin 300 mg QHS mylanta cepacol senna loperamide milk of magnesia guaifenesin Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a day. 2. loratadine Oral 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO once a day. 4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: Two (2) PO BID (2 times a day). 5. cranberry Oral 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. famotidine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Nasal twice a day. 9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 11. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 12. azelastine 137 mcg Aerosol, Spray Sig: One (1) Nasal three times a day. 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 14. Mylanta Oral 15. Cepacol Sorethroat-Cough Oral 16. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as needed for constipation. 17. loperamide Oral 18. Milk of Magnesia Oral 19. guaifenesin Oral 20. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Home Inc Discharge Diagnosis: primary diagnosis: hospital associated pneumonia multiple sclerosis diabetes mellitus secondary diagnosis: prostate cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted with pneumonia. You are being treated with antibiotics for this infection. You should complete your course of these antibiotics and follow up with your physicians. We discussed your hospital stay with Dr. [**Last Name (STitle) 51132**]. Please note the following changes to your medications. - please START thiamine daily Followup Instructions: Department: NEUROLOGY When: MONDAY [**2130-6-5**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2131-3-22**] at 2:00 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

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2594

Discharge summary

report

Admission Date: [**2117-4-10**] Discharge Date: [**2117-4-17**] Service: SURGERY Allergies: MD-76 R Attending:[**First Name3 (LF) 4691**] Chief Complaint: fall down stairs Major Surgical or Invasive Procedure: [**2117-4-10**] - Bilateral chest tubes History of Present Illness: 88yo male with PMH of CAD who had a mechanical fall backwards down five steps earlier today. He said he normally uses the rail but his hands were full. Denies any dizziness, syncopal or presyncopal feelings prior to fall. He landed on his right shoulder and denies any headstrike. Per ED he denied loss of consciousness however in TICU he states he may have passed out for some time. The fall was unwitnessed and he was laying on the ground for an hour and a half as he was unable to stand up independently. He primarily endorses right shoulder and left groin pain but endorses mild neck tenderness. Per EMS he was alert and oriented while en route, however, he had a twenty second "seizure" while in triage where he became rigid and his eyes deviated to the left. In the ED he had chest tubes placed for a right sided hemothorax and left sided pneumothorax. He received 3u pRBCs for 500cc of blood put out from the right chest tube. Upon arrival to the TICU he was hypotensive and was bolused 500ml LR. A right radial arterial line was placed. Past Medical History: PMH: HLD, CAD (IMI/CABG [**2099**]), Prostate CA (XRT [**2105**]) PSH: 4-vessel CABG [**2099**], PTCA/stent LCX [**2104**], repair RFA pseudoaneurysm Social History: lives at home denies tobacco, denies EtOH Family History: NC Physical Exam: Exam on admission: T 97.8 P 90 BP 130/70 RR 20 O2 100%4L Gen: AOx2, confused, lethargic; GCS 14 Resp: decreased breathsounds bilaterally, poor inspiratory effort [**1-28**] pain. chest wall mild tenderness palpation A/P and lateral. no crepitus. CV: RRR, no r/m/g abd: S/NT/ND GU: no perineal ecchymosis, no blood at meatus Ext: superficial abrasions on UE, large ecchymosis R shoulder; 6x8cm eccymosis R flank. pulses 2+ throughout. FAST negative Pertinent Results: LABS: [**2117-4-10**] 02:55PM WBC-21.2*# RBC-3.64* HGB-12.1* HCT-36.6* MCV-100*# MCH-33.2* MCHC-33.1 RDW-12.7 PLT COUNT-110* PT-11.3 PTT-27.2 INR(PT)-1.0 GLUCOSE-135* UREA N-14 CREAT-0.9 SODIUM-132* POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16 [**2117-4-10**] 03:08PM LACTATE-3.3* [**2117-4-10**] 07:18PM LIPASE-31 [**2117-4-15**] 04:40AM BLOOD WBC-6.2 RBC-2.86* Hgb-8.9* Hct-26.9* MCV-94 MCH-31.0 MCHC-33.1 RDW-15.6* Plt Ct-95* Glucose-94 UreaN-20 Creat-0.5 Na-139 K-3.8 Cl-105 HCO3-27 AnGap-11 Calcium-8.2* Phos-2.0* Mg-2.1 [**2117-4-16**] 05:50AM BLOOD WBC-6.6 RBC-2.83* Hgb-8.7* Hct-26.8* MCV-95 MCH-30.9 MCHC-32.6 RDW-16.0* Plt Ct-103* IMAGING CT head [**4-10**]: no acute hemorrhage or major vascular territory infarction CT Cspine [**4-10**]: *unofficial* no cervical spine fracture. CT abd/pelv [**4-10**]: right [**1-5**] rib fractures, left 1 rib fracture, left pelvic superior and inferior pubic rami fractures, right gluteal hematoma R shoulder xray: There is a fracture of the distal clavicle with mild displacement of fracture fragments. Some degenerative changes are seen about the acromioclavicular joint. Some irregularity of the area of the greater tuberosity suggests abnormality of the rotator cuff. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT [**4-10**]: IMPRESSION: Left inferior and superior pubic rami fracture and sacral fractures as previously described. No visualized femoral fracture CHEST (PORTABLE AP)[**4-11**]: FINDINGS: In comparison with the study of [**8-10**], there is a small apical pneumothorax on the right, there may be minimal residual basilar pneumothorax. Extensive subcutaneous gas is seen bilaterally, much more prominent on the left. [**Numeric Identifier 13098**] PELVIS SEL/SUPERSEL A-GRAM; [**Numeric Identifier 4239**] EXT BILAT A-GRAM; [**Numeric Identifier 7534**] INITAL 2ND ORDER ABD/PEL/LOWER EXT A-GRAM [**2117-4-11**]: CONCLUSION: 1. No evidence of active arterial extravasation on nonselective pelvic arteriogram and on selective DSA injection of the right internal iliac artery. 2. Limited anatomical detail on several injections was encountered due to motion-induced image degradation. CHEST (PORTABLE AP) [**4-12**]: Bilateral apical chest tubes are in place. There is no evident pneumothorax or enlarging pleural effusions. Bilateral subcutaneous emphysema has improved on the left. Cardiomediastinal contours are unchanged. There are low lung volumes. Bibasilar opacities have improved. There are no new lung abnormalities. Sternal wires are aligned. CHEST (PORTABLE AP) [**4-13**]: FINDINGS: As compared to the previous radiograph, there is unchanged evidence of bilateral chest tubes. Known rib fractures, known soft tissue gas accumulations bilaterally. The presence of a minimal right apical pneumothorax cannot be excluded. No evidence of tension. Minimal fluid overload, borderline size of the cardiac silhouette. No focal parenchymal opacity suggesting pneumonia. CHEST (PORTABLE AP) [**4-13**]: FINDINGS: As compared to the previous radiograph, the right and left chest tubes have been removed. Lung volumes have increased, likely reflecting improved inspiration. The pre-existing miniscule right apical pneumothorax is no longer clearly visible. Unchanged mild air collections in the left and right perithoracic soft tissues. Minimal atelectasis at the right lung base. Borderline size of the cardiac silhouette, no pulmonary edema. Normal hilar and mediastinal structures. Unchanged proximal right clavicular fracture. CHEST (PORTABLE AP) [**4-14**]: FINDINGS: As compared to the previous radiograph, there is little change. Currently, there is no evidence of pneumothorax. The lung volumes are normal. Only at the right lung base, minimal atelectasis is seen. The image shows absence of pleural effusions and pulmonary edema. Unchanged borderline size of the cardiac silhouette with moderate tortuosity of the thoracic aorta. The soft tissue air collection in the right chest wall is constant. Unchanged sternal wires and clips after CABG. CHEST (PORTABLE AP) [**4-15**]: IMPRESSION: No significant interval change. HUMERUS (AP & LAT) RIGHT [**4-15**]: TWO VIEWS, RIGHT HUMERUS: There is no acute fracture or dislocation. There is normal mineralization. No suspicious lytic or sclerotic lesion. Mild acromioclavicular joint degenerative changes are noted. Brief Hospital Course: Mr [**Known lastname 13099**] was taken to the [**Hospital1 18**] Emergency Department on [**4-10**], [**2116**] after enduring a mechanical fall during which he sustained multiple fractures including right-sided first through tenth ribs, left-sided first rib, left superior and inferior pubic rami and left sacrum, left-sided pneumothorax, moderate right-sided hemothorax and a right-sided hematoma within the gluteal musculature with evidence of active contrast extravasation noted on Abd/ Pelvic CT scan; Head/Spine CT were negative for additional acute processes. The patient was subsequently admitted to Acute Care Surgical Service and transferred to the trauma ICU following placement of bilateral chest tubes in the Emergency Department. In brief, he made steady improvement since admission with clearing mental status, stabilizing hematocrit, and decreased chest tube output. On [**4-13**] (HD4) his chest tubes were removed and he was transferred to the floor. His hospital course is outlined below by organ system: Neurologic: Pain control was achieved with intermittent PRN morphine and standing acetaminophen. He was evaluated for an epidural, but given the superior extent of his rib fx (up to 1st rib bilaterally) he was deemed a poor candidate. His C-collar was removed after clinical and radiologic clearance. His possible seizure activity did not recur and no further work-up was indicated. At the time of discharge, the patient was not requiring pain medication. Cardiovascular: He was initially hypotensive from acute blood loss. He responded well with PRBC resuscitation (6u total over 3 days). He also received 1 unit of platelets. He was on aspirin at home given his CAD and this was held until [**2117-4-15**] as he had no further evidence of bleeding and remained stable from a cardiovascular standpoint. Pulmonary: He had a right hemothorax drained by a chest tube placed in the ED by the surgical team. This tube drained 400cc blood initially, and another 300cc blood over the next 24 hours before changing to sero-sanguinous decreased output. His left pneumothorax was drained initially by a chest tube placed in the ED by the ED team, then that tube was swapped out in the ED by the surgical team for a more appropriately placed one. This tube had minimal drainage. Both tubes were put to waterseal [**2117-4-12**] with no evidence of airleak [**4-13**] so both tubes were removed. His rib fractures (minimally displaced) never caused significant pain but did limit ability to cough forcefully and breathe deeply. He continued to require supplemental oxygen throughout the remainder of his hospitalization and was discharged with 1-2 L supplemental O2 via nasal cannula. Nutrition: He was transitioned to a regular diet on HD2, which he tolerated. Renal: He had a foley placed for urine output monitoring during his resuscitation. The patient failed a voiding trial on [**2117-4-13**], which remained in place at the time of discharge; tamsulosin was initiated on [**2117-4-15**]. Hematology: His dropping hematocrit was presumed to be primarily due to the acute blood loss in his right hemithorax, but he did have a large R flank hematoma with evidence of active extravasation (CTA confirmed) of the right gluteal muscle. On HD 2, interventional radiology attempted to embolize this gluteal but did not find an area of active bleed so embolization was deferred. HSQ was held during resuscitation and resumed on [**2117-4-13**]. Additionally, pneumoboots were used to prevent LE DVT. Infectious Disease: No antibiotics were indicated. MSK: His pubic rami fractures were evaluated by an Orthopedics consult and deemed to be non-operative. He was made WBAT, but required 2 person assistance from bed to chair. The patient was subsequently evaluated by both Physical and Occupational Therapy (please see note for details) with recommendations for acute rehab. Additionally, Orthopedics recommended obtaining a right shoulder x-ray due to presence of a large hematoma. A distal clavicle fracture with mild displacement of fracture fragments was noted on clavicle x-ray; the right arm was subsequently placed in a sling. At the time of discharge on [**2117-4-16**], the patient afebrile with stable vital signs. Additionally, he remained stable from both a cardiovascular and pulmonary standpoint; he was tolerating a regular diet and voiding adeuqately. He continued to ambulate with assistance and was subsequently transferred to The [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] in [**Location 1268**] for ongoing rehabilitation. Medications on Admission: lisinopril 2.5mg daily, simvastatin 60 mg daily, vitamin C, aspirin 162 mg daily, vitamin D3. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours): Do not exceed 3000 mg per 24 hour period. 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 20 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: s/p Mechanical Fall: -Right clavicular fracture -Right-sided first through tenth rib fractures -Left-sided first rib fracture -Left superior and inferior pubic rami and left sacrum fractures -Left-sided pneumothorax -Right-sided hemothorax -Right-sided hematoma within the gluteal musculature 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 after a fall during which you sustained multiple injuries including multiple fractures, a hemothorax, pneumothorax and a hematoma. You recovered in the hospital, however, will require further rehabilitation at The [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] in [**Location 1268**]. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2118-1-19**] at 10:00 AM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2117-4-16**]

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icd9cm

[ [ [] ] ]

[ "34.04", "88.47" ]

icd9pcs

[ [ [] ] ]

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231, 272

12133, 12133

2087, 6432

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22,126

181,598

52169

Discharge summary

report

Admission Date: [**2149-10-25**] Discharge Date: [**2149-11-6**] Service: MEDICINE Allergies: Diphenhydramine / Isordil / Meclizine / Amoxicillin / Hydrochlorothiazide / Ceclor / Hydroxyzine / Doxepin / Zantac / Corgard / Prinivil / Vasotec / Digoxin / Prilosec / Cozaar / Morphine Attending:[**First Name3 (LF) 398**] Chief Complaint: GIB Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a [**Age over 90 **] year old female with PVD s/p recent fem-fem bypass who presents with GI bleeding. According to the patient's family she was feeling well until yesterday when she acted more weak and related mild nausea with associated gagging. Today she had a large black bowel movement with fresh BRB and clots and felt weak, fatigued, clammy, nauseous, and SOB. No hemetemesis, LH, abdominal pain, diarrhea or fevers. The patient's daughters brought her into [**Name (NI) **] this evening after this episode. Per the patient's daughters, the patient had been in significant amount of pain after her surgery on [**10-6**] but did not like how percocet made her feel. Therefore she changed to tylenol around the clock and added motrin to this regimen, 400mg Q8H with an additional 600 mg QHS, totaling 1800 mg of motrin/day. Patient is also on plavix and ASA for her CAD. No ETOH. . In the ED patient had maroon blood in vault and positive NGL (coffee ground initially, then BRB, then coffee ground which cleared after 2L). She was afebrile with BP 130/81 but her HCT was found to be 23 from last [**Location (un) 1131**] of 28 on [**10-12**] (baseline 40's prior to surgery, low 30's after surgery but trended down to 28 prior to d/c) and she was tachycardic (120). She recieved 2 units PRBCs, 500cc NS, octreotide 25 mg IV x 1, and protonix 40 mg IV x 1. Patient was found to be in Afib with RVR to 120 and EKG was concerning for ST depressions in lateral leads (V4-V6) as well as I, II, aVF - cardiology consulted and felt likely demand ischemia in setting of RVR and GIB and recommended aggressive transfusion. Social History: retired, lives alone. Has two daughters who visit often. No h/o smoking. Drinks one glass of wine per day. No h/o illegal drug use. Family History: Father died of fatal MI; mother died of ??????old age.?????? Daughter has HTN. No diabetes. brother with [**Name2 (NI) **] CA (smoker), Physical Exam: PE: Vitals: 96.5, 109/89, 117, (98-117), 19, 100% on 2L Gen: sleepy, arousable HEENT: PERRL, EOMI, pale conjunctivaanicteric sclera, MMM, OP clear Neck: supple, no LAD, no thyromegaly Cardiac: tachy, irregular, NL S1 and S2, III/VI SEM radiating to carotids Lungs: slight crackles as bases bilaterally, R>L Abd: soft, NTND, NABS, no HSM, no rebound or guarding Ext: warm, 2+ DP pulses, 1+ pitting edema in LLE > R (recent surgery Neuro: CN III-XII intact, MAE Skin: ecchymosis on lower abdomen Pertinent Results: [**2149-10-25**] 07:45PM BLOOD WBC-12.1* RBC-2.49* Hgb-8.3* Hct-23.1* MCV-93 MCH-33.6* MCHC-36.1* RDW-15.4 Plt Ct-233 HCT 28.1, 26.9, 32.0, 32.9, 36.7, 38 [**2149-10-25**] 07:45PM BLOOD Glucose-231* UreaN-32* Creat-0.8 Na-131* K-5.0 Cl-98 HCO3-24 AnGap-14 [**2149-10-25**] 07:45PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2149-10-26**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2149-10-26**] 12:35PM BLOOD CK-MB-NotDone cTropnT-0.04* . EGD [**2149-10-26**]: Impression: Mucosa suggestive of Barrett's esophagus Erythema, congestion and erosion in the antrum and stomach body compatible with erosive gastritis Ulcers in the duodenal bulb (thermal therapy) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: # GIB - Initially felt to be UGIB in setting of melena, +NGL, NSAIDs (ulcer, gastritis, esophagitis, AVM), but likely brisk as patient had BRBPR. Patient placed on protonix gtt, transfused 4 units PRBC's, held ASA, plavix, BP meds, and HCT followed closely. Had EGD on [**10-25**] with demonstrated 2 duodenal ulcers, one with visible bleeding vessel that was cauterized. Patient remained hemodynamically stable throughout her course and melena decreased. She had drops in hematocrits several times and had two further EGDs with hemostasis cautery applied. She remained stable. Changed to IV PPI and metoprolol was added back slowly. Continued to hold ASA, plavix, and advised pt to avoid all NSAIDS. She was transfered to the floor where she did have several dark stools but had a stable HCt and they were felt to be residual blood. She was hemodynamically stable and was discharged following demonstration of stable hematocrits. She was continued on 4 times daily PPI and sucralfate per GI, with a follow up endoscopy in three weeks. . # CAD - Lateral ischemic changes on EKG, likely due to demand ischemia in setting of GIB and Afib with RVR. Negative troponins and flat CK/CK-MB. Held aspirin and plavix in setting of GI bleed, but ASA restarted while on [**Hospital1 **] PPI. [**Hospital1 **] PPI should be continued for one month and then changed to QD for life. Repeat EKG when rate controlled showed no further ischemic changes. . # Afib with RVR - Likely precipitated by GI bleed. Allowed pt to be tachycardic while having GI bleed because wanted to avoid lowering BP. Added back metoprolol and uptitrated slowly, monitoring BP. No anticoagulation (not on coumadin as outpt d/t h/o hematoma) . # Code - FULL - discussed with family who will discuss amongst themselves and the patient Medications on Admission: Levothyroxine 50 mcg PO QD ASA 325 PO QD Amlodipine 5 PO QD Atorvastatin 10 PO QD Percocet prn Plavix 75 PO QD Bisacodyl Colace Metoprolol 100 PO BID Xalatan 0.005 ophth soln Flonase Nitro SL Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO four times a day. Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Upper Gastrointestinal Bleed duodenal Ulcerations Acute Blood loss anemia Discharge Condition: tolerating POs, Hct stable, ambulating. Discharge Instructions: Please take all medications as prescribed. Attend all follow up appointments. Followup Instructions: Please attend your follow up geriatrics visit on monday. It is important that you have your blood counts checked. . You also are scheduled for GI to perform an upper endoscopy to check on the healing of the ulcers with Dr. [**Last Name (STitle) **] on [**11-24**], with an arrival time of 7:30AM. If you need to re-schedule you may call [**Telephone/Fax (1) 463**]

[ "401.9", "272.0", "443.9", "244.9", "425.4", "285.1", "707.07", "427.31", "532.40" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "44.43" ]

icd9pcs

[ [ [] ] ]

6393, 6442

3640, 5448

399, 404

6560, 6602

2906, 3617

6728, 7097

2238, 2376

5691, 6370

6463, 6539

5474, 5668

6626, 6705

2391, 2887

356, 361

432, 2068

2084, 2222

3,021

103,992

18910

Discharge summary

report

Admission Date: [**2145-8-2**] Discharge Date: [**2145-8-10**] Date of Birth: [**2086-1-19**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with type 2 diabetes and extensive history of alcohol abuse, who is admitted to an outside hospital for alcohol withdrawal after she was found on the floor. She was discharged to a skilled-nursing facility for rehab and she was taken to the outside hospital ED on [**2145-8-1**] for increased fatigue, abdominal girth, and leg swelling. The patient, however, reports that she only drinks socially until [**Holiday 1451**] [**2143**], when she started to drink heavily as she drinks heavily during the holiday and continues to drink about three Manhattans per day until [**Month (only) 216**] when she did some binge drinking before her first admission. She denies any previous episodes of ascites or jaundice. She had decreased appetite since the first admission, and also some nausea and vomiting, but no fevers, chills, diarrhea, dysuria, cough, no history of upper GI or lower GI bleed. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Alcohol abuse. MEDICATIONS ON ADMISSION: 1. Lasix. 2. Remeron. 3. Insulin. 4. Multivitamin. 5. Spironolactone. ALLERGIES: 1. Penicillin. 2. Sulfa. SOCIAL HISTORY: Lives in [**State 622**], but vacations in [**Hospital3 **] over the summer. She is a high school teacher, who lives with her husband, who also is an alcohol abuser, but no history of tobacco use and only one sexual partner, and she has only had one blood transfusion which was in [**Month (only) 216**] of this year at this hospital and she denies any other IV drug use. VITALS ON ADMISSION: Temperature 97.6, pulse 90, blood pressure 110/50, respiratory rate 22, and O2 98% on 2 liters. PHYSICAL EXAM: In general: She is icteric. Looking older than her stated age, but comfortable. HEENT is icteric sclerae. Extraocular muscles are intact. Moist mucous membranes. Oropharynx clear. Neck: There is no lymphadenopathy. Cardiovascular: Tachycardic, though with regular rhythm. Lungs: Left lung base without breath sounds and left mid lung with crackles, no rhonchi or wheezes. Abdomen is markedly distended, positive shifting dullness and no caput medusa. Extremities: There is 2+ edema up to the knee bilaterally. Positive Dupuytren's contractures and no pallor or erythema. Neurologic: Is awake, alert, and oriented times three with mild asterixis. Skin with scattered petechiae over the abdomen, no spider angioma. LABORATORIES ON ADMISSION: White count 14.3, hematocrit 39, platelets 545 with 77% neutrophils, 3% lymphocytes, 14% monocytes. Sodium is 126, potassium 4.9, chloride is 88, bicarb 27, BUN 17, creatinine 0.4, glucose 341. INR of 1.4. Calcium 8.5, magnesium 2.2, phosphorus 3.6. Lactate was 2.5. Urinalysis with negative leukocyte esterase, trace blood, nitrite negative, no white blood cells, no red blood cells, occasional bacteria, and moderate yeast. ALT is 41, AST 162, alkaline phosphatase 268, LDH 470, amylase 58, lipase 56, T bilirubin 18.1, albumin 2.5, and total protein 5.5. Diagnostic tap in the ED was 68 white blood cells and [**Pager number **] protein, glucose 1.0. CT of the abdomen with no intrahepatic focal cholelithiasis, pancreas, spleen, kidney all normal. Pelvis normal. Only large ascites. Chest x-ray was bilateral pleural effusions left greater than right bibasilar atelectasis. Liver ultrasound: No biliary tract dilatation, gallbladder wall edema, no evidence of acute cholecystitis. EKG: Normal sinus rhythm at 100, normal axis, normal intervals, low voltage, no ST changes. HOSPITAL COURSE: The patient was admitted for liver failure, which was felt to be acute alcoholic hepatitis. Her bilirubin decreased over the course of her stay from 18.1 to 12. Her LFTs also remained within normal range. Patient had therapeutic paracentesis on the 5th with removal of four liters of fluid. Patient had started to require oxygen to maintain sats in the 90s. After the tap, the patient's O2 saturations remained normal without oxygen. Patient was also followed by the Hepatology service, who performed an EGD on the 2nd secondary to some coffee-ground emesis in the morning. The EGD showed no evidence of varices, but did show some esophagitis and some candidiasis, and recommended proton-pump inhibitor, and antifungal. Patient also had multiple serologies sent. Her hepatology serologies were all negative. Her iron studies were all normal except for slightly elevated ferritin, which was considered consistent with her acute inflammatory state and her lipid profile was also within normal limits. Her [**Doctor First Name **] and other rheumatologics were also within normal. Patient was continued on her Lasix and aldactone, and a stable level with blood pressure remaining in the 110s. Patient had a diagnostic paracentesis in the Emergency Room, which ruled out SBP and patient was not started on antibiotics. Otherwise patient was also started on pentoxifylline 400 mg t.i.d. for a total course of four weeks, which per studies had shown to improve short-term survival in severe alcoholic hepatitis. Patient had mild evidence of asterixis on admission, and was started on lactulose initially, but as she had no other encephalopathic signs, was discontinued upon further course. Patient was transferred to the Intensive Care Unit for the EGD secondary to concerns of varices and risk for bleeding during her EGD. The patient tolerated the stay well and although did become slightly hypotensive during her stay with some oliguria, which resolved on its own. Patient's hematocrits remained stable after her upper GI bleed, and scope, and did not require blood transfusion. However, patient was also fluid restricted secondary to her hyponatremia and her ascites to 1 liter q.d. Patient tolerated it well and he sodium remains stable around 131. Patient had some oliguria during her ICU stay with a FENa of 0.2%, which is consistent with prerenal in the setting of her hypotension and decreased effective volume. Her urine output improved and she was stable for discharge back to the floor. She was continued on fluid restriction, but remains stable otherwise. She was tolerating p.o. diet well, and tolerating her Lasix and spironolactone well. For her insulin dependent-diabetes mellitus, originally the patient had been on oral glycemic agents, but because of her liver disease, was started on insulin. Initially, she was started on sliding scale with poor control and then was switched to NPH 70/30 fixed scale with sliding scale inbetween and her fingersticks remained in the 100 range and were fairly stable. For patient's alcohol abuse, the patient was evaluated by Additions and Social Work. Social Work tried to recommend and discussed with patient about followup. Patient states that she had been to AA meetings while at rehab and admitted that she would like to continue working to decrease her alcohol intake. Patient seems to be compliant and had no evidence of withdrawals during her stay. Patient is to be followed by PT and OT throughout her course. Physical Therapy initially recommended patient to getting out of bed with assistance and to ambulate with assistance as tolerated and increasing strength. Otherwise, she would require some endurance training prior to discharge. The patient was evaluated and seen by Nutrition, who recommended a regular low sodium diet with the addition of supplements secondary to decreased p.o. intake. For patient's depression, the patient was continued on her Remeron 15 mg daily and seems stable through the course of her stay. For nutrition, the patient was on a house diet with low salt with nutritional supplements t.i.d. For prophylaxis and for her GI esophagitis, patient was continued on her Protonix twice a day. Patient's electrolytes remained normal on fluid restriction and was repleted as needed, but was not necessary. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Discharged to acute skilled-nursing facility. DISCHARGE DIAGNOSES: 1. Alcoholic hepatitis. 2. Ascites. 3. Alcohol abuse. 4. Type 2 diabetes. 5. Depression. DISCHARGE MEDICATIONS: 1. Ursodiol 1600 mg p.o. b.i.d. 2. Lasix 40 mg p.o. q.d. 3. Protonix 40 mg q.12. 4. Spironolactone 25 mg p.o. q.d. 5. Multivitamins one p.o. q.d. 6. Miconazole topical t.i.d. as needed. 7. Remeron 15 mg p.o. q.h.s. 8. Pentoxifylline 400 mg p.o. t.i.d. 9. At breakfast, patient is on 7 units of NPH and 3 units of regular insulin. At dinnertime, patient gets 3 units of NPH and 2 units of regular, and sliding scale as needed inbetween. FOLLOW-UP INSTRUCTIONS: The patient is to followup with her primary care physician in [**Name9 (PRE) 622**] in [**12-3**] weeks, and also setup with a hepatologist in [**State 622**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2145-8-9**] 11:28 T: [**2145-8-9**] 11:30 JOB#: [**Job Number 51713**]

[ "571.1", "578.9", "530.19", "511.9", "250.00", "789.5", "311", "305.01" ]

icd9cm

[ [ [] ] ]

[ "54.91", "45.13" ]

icd9pcs

[ [ [] ] ]

8025, 8098

8119, 8209

8232, 8670

1179, 1287

3682, 8003

1813, 2558

168, 1092

2573, 3664

8695, 9080

1114, 1153

1304, 1685

30,156

136,379

33691

Discharge summary

report

Admission Date: [**2139-4-21**] Discharge Date: [**2139-5-4**] Date of Birth: [**2116-10-15**] Sex: F Service: CARDIOTHORACIC Allergies: Dilaudid Attending:[**First Name3 (LF) 2969**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD), left thoracotomy, repair of esophageal perforation. History of Present Illness: 22F tx OSH w Boerhaave's, found down after dry heaving at 5am, found eyes rolled back into her head,?DKA, intubated for unresponsiveness, CT Chest:pneumomediastinum, w RLL Aspiration/PNA, ?esoph tear, being admitted to MICU for control of DKA. Past Medical History: IDDM at 12yrs old(hx 5 DKA's/yr for which she is hospitalized) Appendectomy [**2137**] Tonsillectomy [**2133**] Drug Use:coccaine GERD Social History: Current smoker, occasional EtOH, occasional cocaine, unemployed Family History: No early coronary disease. Paternal grandparents with CHF and CAD, though no early. Aunt with pulmonary embolism. Physical Exam: General: 22 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Lungs: decreased breath sounds on left, clear on right Heart: RRR, S1S2 GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Incision: left thoracotomy site clean dry, intact, steri-strips. no erythema Neuro: non-focal Pertinent Results: [**2139-4-21**] WBC-31.5* RBC-4.89 Hgb-14.9 Hct-46.5 Plt Ct-579* [**2139-5-3**] WBC-3.9* RBC-2.99* Hgb-8.7* Hct-25.4* Plt Ct-518* [**2139-4-21**] Glucose-1430* UreaN-21* Creat-1.0 Na-105* K-3.9 Cl-81* HCO3-<5 [**2139-4-21**] Glucose-361* UreaN-24* Creat-0.9 Na-144 K-4.3 Cl-118* HCO3-6* [**2139-4-22**] Glucose-252* UreaN-21* Creat-0.9 Na-145 K-4.2 Cl-122* HCO3-5 [**2139-4-22**] Glucose-47* UreaN-9 Creat-0.5 Na-148* K-3.3 Cl-122* HCO3-21* [**2139-5-3**] Glucose-144* UreaN-11 Creat-0.4 Na-139 K-3.8 Cl-108 HCO3-22 CHEST (PA & LAT) [**2139-5-2**] Again seen is a small left apical pneumothorax, smaller than on [**2139-4-30**]. Otherwise, no acute pulmonary process is identified. ESOPHAGUS [**2139-4-29**] FINDINGS: A right internal jugular central venous catheter is noted with tip terminating at the region of the mid SVC. Water-soluble contrast with Conray was first administered, followed by multiple continuous sips of thin barium. Single and double contrast views of the esophagus with focus at the distal esophagus and gastroesophageal junction were performed without demonstration of a [**Year/Month/Day 3564**]. A thin mediastinal drain is detected adjacent to the left distal esophagus. IMPRESSION: No evidence of esophageal [**Year/Month/Day 3564**]. CT CHEST W/CONTRAST [**2139-4-21**] A small to moderate amount of gas is noted throughout the mediastinum. A tube is present with termination in the mid esophagus. Contrast which has been administered through the tube is present throughout the lower esophageal lumen. A very small amount of hyperdensity appears to layer along the paraesophageal left hemidiaphragm, presumably within the pleural space, concerning for possible extraluminal esophageal contrast (series 401b, image 21). There is a tiny focus of high density associated with mediastinal gas adjacent to the lower esophagus which could also possibly represent extravasated contrast (series 4, image 193). No definite site of esophageal perforation is demonstrated. No fluid collection or abscess is seen in the mediastinum. The patient is intubated with ET tube terminus approximately 2.7 cm above the carina. A right internal jugular central catheter terminates in the superior vena cava. There is no pneumothorax. A small amount of dependent consolidation is noted at the lung bases, right greater than left, probably due to aspiration. There is no appreciable pleural fluid. The heart and great vessels of the chest are unremarkable. On a limited evaluation of the upper abdomen, periportal edema is noted of the liver. IMPRESSION: 1. Pneumomediastinum concerning for esophageal perforation. Possible very small foci of extraluminal esophageal contrast adjacent to the the distal esophagus and layering in the pleural space along the paraesophageal left hemidiaphragm. No definite site of esophageal perforation demonstrated. 2. Small amount of dependent consolidation at the lung bases, right greater than left, concerning for aspiration. 3. Non-specific periportal edema, could be related to fluid resuscitation. Brief Hospital Course: The patient was admitted to [**Hospital1 18**] critically ill in severe DKA. A CT scan demonstrated pneumomediastinum concerning for esophageal perforation. Possible very small foci of extraluminal esophageal contrast adjacent to the the distal esophagus and layering in the pleural space along the paraesophageal left hemidiaphragm. No definite site of esophageal perforation demonstrated. Small amount of dependent consolidation at the lung bases, right greater than left, concerning for aspiration. Her DKA was treated with an insulin drip, a bicarbonate drip, and several liters of IV fluids. She was started on Levaquin and Clindamycin. Once her acidosis stabilized, she was taken to the OR for an esophagogastroduodenoscopy (EGD), left thoracotomy, repair of esophageal perforation. Please see operative note for details. On POD 1, TPN was started and we attempted to wean to extubate, but she had too much airway edema, no cuff [**Hospital1 3564**]. She had 2 left sided chest tubes to suction and one right chest tube. She was making good urine and her finger sticks stabilized on an insulin drip. She was in a lot of pain. Dilaudid helped, but she demanded a lot. Vancomycin was added empirically. All cultures turned out negative. On POD 2, we extubated her. On POD 3, we added Toradol to help her pain. Chest tubes were put to waterseal. She was making good urine. Her NG tube was removed. She developed a right pneumothorax on waterseal and was put back to suction. An extra stitch was applied to her right chest tube. The pleurovac was changed. She was neutropenic, possibly secondary to Pepcid or Vancomycin. On POD 4, her Zosyn was discontinued, her chest tubes were put to waterseal, and she was transferred to the floor. On POD 5, her left chest tube was removed and left [**Doctor Last Name 406**] went to bulb. She did have a pneumothorax post pull. On POD 6 her right chest tube was removed. [**Last Name (un) **] was consulted for gluocse control. On POD 7, she had a swallow study which showed no [**Last Name (LF) 3564**], [**First Name3 (LF) **] she was started on sips. On POD 9, her [**Doctor Last Name **] was removed, diet was advanced to fulls. On POD 10, she tolerated soft solids. Her TPN was stopped. Her elevated blood sugars continued to be managed my [**Hospital **] Clinic. She was discharged to home and will follow-up with [**Hospital **] Clinic and Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Lantus insulin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Lantus 100 unit/mL Solution Sig: 35 Units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Esophageal perforation s/p repair Diabetes Mellitus Type 1 Diabetic Ketos Acidosis x5/yr requiring hospitaization GERD Depression s/p appendectomy [**2137**], tonsillectomy [**2133**] Discharge Condition: good Discharge Instructions: Please call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] with any fevers > 101, nausea, vomiting, shortness of breath, productive cough, difficulty swallowing or any other worrisome issues. Follow-up with [**Last Name (un) **] recommendations: Lantus 35 units at bedtime Continue insulin sliding scale. Take Protonix's once daily for Reflux Disease Followup Instructions: Follow-up with [**Female First Name (un) **] or [**Location (un) 1439**] (NPs) Date/Time:[**2139-5-12**] 10:00 in the Chest Disease Center, [**Hospital Ward Name 121**] Building [**Location (un) **]. Report to the [**Location (un) **] Radiology Department in the [**Hospital Ward Name 517**] Clinical Center for a Chest X-Ray 45 minutes before your appointment. Follow-up with [**Hospital **] Clinic: on [**5-18**] at 9:30 am with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1510**] [**Telephone/Fax (1) 77979**] Completed by:[**2139-5-5**]

[ "530.4", "512.1", "507.0", "250.13", "530.81", "V58.67", "288.00", "997.3" ]

icd9cm

[ [ [] ] ]

[ "45.13", "42.89", "99.15", "34.09", "38.93" ]

icd9pcs

[ [ [] ] ]

7415, 7421

4483, 6947

292, 380

7650, 7657

1407, 4460

8076, 8725

909, 1025

7012, 7392

7442, 7629

6973, 6989

7681, 8053

1040, 1388

236, 254

408, 653

675, 812

828, 893

15,976

148,541

54281

Discharge summary

report

Admission Date: [**2133-7-30**] Discharge Date: [**2133-8-17**] Date of Birth: [**2056-1-16**] Sex: F Service: SURGERY Allergies: Penicillins / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 1481**] Chief Complaint: Acute onset nausea and vomiting Major Surgical or Invasive Procedure: [**7-30**] Endotracheal intubation [**7-31**] Placement of Left internal jugular central lumen catheter [**7-31**] IVC Filter [**8-8**] Dobhoff feeding tube placement [**8-14**] Gastrostomy tube placement History of Present Illness: The pt is a 77 y/o female transferred from Briarwod Nursing Facility recently discharged from [**Hospital 620**] Hosp for bilat DVTs on coumadin with an INR goal of [**1-23**]. Presents this am with 2-3 episodes of emesis with WBC 34K. In ED she became acutely hypotensive to 60/palp and tachy to 150s after IV contrast from CT scan. She was intubated, resuscitated, and transferred to [**Hospital1 18**] for further management. She was admitted to the surgical service under the care of Dr. [**Last Name (STitle) **]. Past Medical History: Past Medical History: GERD Alzheimers-Dementia Bilat DVTs [**6-25**] H/O C.Diff [**7-26**] Spinal Stenosis Osteoporosis NIDDM HTN B/L LE Cellulitis Past Surgical History: Open cholecystectomy TAH Social History: Transferred from [**Hospital3 16749**] Facility, she has a history of Dementia and Alzheimers. Family History: Non-contributory Physical Exam: Upon admission: Initial: 100.7 63 115/64 During Exam: 150, 60/palp 23 99% RA Gen: Awake, alert, understanding, but cannot respond Skin: Pale, cold, diaphoretic, REJ site site oozing copiously CV: Tachycardic, regular, No M/R/G Pulm:CTA B/L no wheezing Abd: Soft, NT, ND, no tympany, no rebound, no guarding, midline laparotomy, large ecchymosis at Left periumbilical Ext: Palpable DP/PT B/L, no edema Pertinent Results: Initial: [**2133-7-30**] 07:39PM BLOOD WBC-27.5* RBC-2.73* Hgb-8.2* Hct-23.5* MCV-86 MCH-30.0 MCHC-34.8 RDW-16.4* Plt Ct-252 [**2133-7-31**] 07:07AM BLOOD Neuts-92* Bands-1 Lymphs-6* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2133-7-31**] 07:07AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL [**2133-7-30**] 07:39PM BLOOD PT-19.1* PTT-34.2 INR(PT)-1.8* [**2133-7-30**] 07:39PM BLOOD Glucose-152* UreaN-14 Creat-0.8 Na-148* K-3.2* Cl-116* HCO3-19* AnGap-16 [**2133-7-30**] 07:39PM BLOOD ALT-15 AST-20 CK(CPK)-119 AlkPhos-77 Amylase-235* TotBili-1.0 [**2133-7-30**] 07:39PM BLOOD Lipase-90* [**2133-7-30**] 07:39PM BLOOD CK-MB-4 cTropnT-<0.01 [**2133-7-30**] 07:39PM BLOOD Albumin-3.4 Calcium-7.0* Phos-3.8 Mg-1.8 [**2133-7-30**] 07:56PM BLOOD Type-ART pO2-134* pCO2-43 pH-7.28* calTCO2-21 Base XS--6 [**2133-7-30**] 07:56PM BLOOD Lactate-4.5* [**2133-7-30**] 11:55PM BLOOD O2 Sat-97 [**2133-7-30**] 07:56PM BLOOD freeCa-0.93* Discharge: [**2133-8-13**] 07:00PM BLOOD WBC-9.2 RBC-4.60 Hgb-13.9 Hct-40.7 MCV-88 MCH-30.2 MCHC-34.2 RDW-16.4* Plt Ct-520* [**2133-8-5**] 02:20AM BLOOD Neuts-87.3* Lymphs-8.1* Monos-3.7 Eos-0.6 Baso-0.2 [**2133-8-13**] 07:00PM BLOOD PT-11.9 PTT-34.2 INR(PT)-1.0 [**2133-8-13**] 07:00PM BLOOD Plt Ct-520* [**2133-8-13**] 07:00PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-137 K-4.8 Cl-106 HCO3-21* AnGap-15 [**2133-8-8**] 09:56PM BLOOD CK(CPK)-10* [**2133-8-13**] 07:00PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 BILAT LOWER EXT VEINS PORT Reason: Please assess for thrombosis and to which level as patient l [**Hospital 93**] MEDICAL CONDITION: 77 year old woman with history deep venous thrombosis REASON FOR THIS EXAMINATION: Please assess for thrombosis and to which level as patient likely needs IVC filter placement HISTORY: DVT. BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler ultrasound of the left and right common femoral, common superficial femoral, and popliteal veins was performed. There is no comparison available. There is occlusive echogenic thrombus within the left common femoral, superficial femoral, and popliteal veins. There is no evidence of flow or compressibility within these expanded veins. There is also occlusive thrombus within the right superficial femoral vein without evidence of flow or compressibility. There is a partial occlusive thrombus within the right popliteal vein. IMPRESSION: Occlusive DVT within the left common femoral, superficial femoral, and popliteal veins. Occlusive thrombus within the right superficial femoral vein and nonocclusive thrombus within the right popliteal vein. Name: [**Known lastname 111216**], [**Known firstname **] Unit No: [**Numeric Identifier 111217**] Service: VASCULAR Date: [**2133-7-31**] Date of Birth: [**2056-1-16**] Sex: F Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**] PREOPERATIVE DIAGNOSIS: Left iliofemoral deep venous thrombosis. POSTOPERATIVE DIAGNOSIS: Left iliofemoral deep venous thrombosis. PROCEDURE: IVC filter placement.Venogram. Slective renal vein catheterization ASSISTANT: [**First Name4 (NamePattern1) 11805**] [**Last Name (NamePattern1) 29316**], M.D. INDICATIONS FOR PROCEDURE: The patient is a 77 year old female recently admitted from another hospital with acute episodes of GI bleeding likely due to excessive anticoagulation that the patient had been no for treatment of a chronic left lower extremity DVT. The patient was admitted to the intensive care unit and was brought down to the catheterization suite for IVC filter placement so that the anticoagulation could be discontinued. PROCEDURE: With the patient supine upon the catheterization table after adequate induction of intravenous sedation, the patient's groins were prepped and draped in the usual sterile manner. Acccess was gained through a right femoral venous approach with the use of a micropuncture kit. The [**Location (un) **] wire was advanced into the infrarenal IVC with the use of a C2 catheter. We then exchanged this for a pigtail catheter that was placed at the iliac bifurcation and then IVC venogram was taken. The right iliac and infrarenal IVC was patent and free of thrombus. The left iliac vein was not visualized. We then proceeded to insert the device with its 8.5 French sheath with the infrarenal IVC and a tulip IVC filter was deployed without any complications. The sheath was removed and pressure was held for approximately 15 minutes without any evidence of active continuous bleeding or hematoma. The patient tolerated the procedure well and was transferred in stable condition to the intensive care unit. US ABD LIMIT, SINGLE ORGAN [**2133-8-14**] 1:12 PM US ABD LIMIT, SINGLE ORGAN Reason: Planned PEG at 2pm today: r/o ascites, position stomach? [**Hospital 93**] MEDICAL CONDITION: 77 year old woman pre PEG REASON FOR THIS EXAMINATION: Planned PEG at 2pm today: r/o ascites, position stomach? INDICATIONS: Patient needs percutaneous gastrostomy tube placed by GI. Assess for ascites and assess location of stomach. FINDIGS: 4-quadrant ultrasound shows no evidence of ascites. The stomach is located in the expected position in the left upper quadrant. The stomach does not appear distended. IMPRESSION: No ascites. Stomach in expected position. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the surgical service at [**Hospital1 18**] on [**7-30**] after being transferred from an OSH. She presented to the OSH with an acute onset of nausea and vomiting and after receiving IV contrast dye for a CT scan became hypotensive requiring resuscitation and intubation. Upon admission to the ER her INR was found to be 10. The CT scan showed a duodenal/jejunal hematoma, blood around the liver, and a left iliac thrombosis. During her resuscitation she received 6 units FFP, and 1 unit PRBC's. Upon admission to [**Hospital1 18**] she received 4 units PRBC's and 2 units of FFP. Her WBC's were also elevated to 30k, she had a prior history of C.Diff but stool cultures done on admission were negative. She was admitted to the SICU at [**Hospital1 18**]. Vancomycin, Levofloxacin, and Flagyl were initiated, she was mechanically ventilated and required invasive hemodynamic monitoring. On HD 2 an IVC Filter was placed without complication. On HD 4 TPN was started and she was extubated. On HD 8 she was transferred to the floor, a Dobbhoff tube was placed and confirmed, and tube feeds were started. Her mental status was difficult to assess secondary to history of dementia; a speech and swallow was performed to evaluate for dysphagia and it was suggested the patient remain on tube feeds until she becomes more awake. Since transfer to the floor she has remained stable and afebrile and discharge planning was initiated. Her family was requesting transfer back to [**Hospital3 16749**] Facility which will require a gastrostomy tube instead of Dobbhoff for tube feeds. A gastrostomy was done on [**8-14**] which the patient tolerated well and tube feeds were resumed on [**8-15**] without problems. Blood cultures have been negative, urine cultures have been negative, and sputum culture on admission grew yeast, gram positive cocci, and gram positive rods. She has +MRSA and received 14 days of treatment with Vancomycin. She will require six months of anti-coagulant therapy with Lovenox for her history of DVT's. Physical therapy has recommended mobility, balance, and transfer training. She was transferred to [**Hospital3 16749**] and Rehabilitation facility on [**8-17**] in stable condition. Medications on Admission: Coumadin Celexa Razadyne Fosamax Discharge Medications: 1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): Through PEG tube. 2. Acetaminophen 160 mg/5 mL Elixir Sig: [**12-22**] teaspoon PO every 4-6 hours as needed for pain: Through PEG. 3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 6 months. 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Through PEG Hold for SBP < 90 HR < 60. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Gastrointestinal bleeding Deep vein thrombosis Discharge Condition: Stable Discharge Instructions: *Increased or persistent pain *Fever > 101.5 *Nausea or vomiting *If PEG tube falls out *If PEG site appears red, if there is drainage, or if tube feeds are unable to get through PEG *Any other symptoms concerning to you No tub baths or swimming Please take all medications as ordered Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, Please call his office to schedule an appointment ([**Telephone/Fax (1) 9011**] Completed by:[**2133-8-17**]

[ "250.00", "401.9", "294.10", "331.0", "733.00", "286.7", "285.1", "008.45", "453.8", "E934.2", "578.9", "518.81", "453.41", "560.89" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.6", "99.04", "99.15", "96.71", "38.7", "38.93", "43.11" ]

icd9pcs

[ [ [] ] ]

10111, 10195

7313, 9569

332, 539

10286, 10295

1898, 3495

10631, 10807

1437, 1455

9652, 10088

6821, 6847

10216, 10265

9595, 9629

10320, 10608

1283, 1309

1470, 1472

261, 294

6876, 7290

567, 1087

1487, 1879

1132, 1259

1325, 1421

68,796

155,761

37749

Discharge summary

report

Admission Date: [**2182-9-7**] Discharge Date: [**2182-9-21**] Date of Birth: [**2132-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: SOB, chest discomfort Major Surgical or Invasive Procedure: Dental - tooth extraction Cardiac surgery - Coronary artery bypass grafting x1 with reverse saphenous vein graft to the marginal branch. 2. Mitral valve repair with a 28-mm Future CG annuloplasty ring. History of Present Illness: 50 year old male with known hypertension, +30 pack year tobacco history reports while vacationing in [**Country 6257**] on [**9-2**] he had an initial episode of chest pain associated with shortness of breath and fatigue while ambulating.He continued to have intermittent episodes of chest discomfort, new onset cough, and returned to MA on [**9-5**]. He presented to MWMC [**9-6**] with worsening dyspnea, cough, and chest pressure when lying down. CXR showed left lower lobe consolidation and he was initially treated for Pneumonia and treated with Azithromycin and Ceftriaxone. EKG changes were evident with an elevated Troponin of 2.77. Echocardiogram was done and showed 4+ Mitral Regurg with a reduced Ejection Fraction.Plavix 600 mg was given at OSH. He was transferred to [**Hospital1 18**] for further cardiac workup. Dr.[**Last Name (STitle) **] was consulted for possible surgical intervention. Past Medical History: Acute myocardial infarction, coronary artery disease, and severe mitral regurgitation Hypertension Social History: -Tobacco history: 20 pack years -ETOH: occasional social -Illicit drugs: no illicits Retired printing machinist Daughter is a nurse Married Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 97.4, 62, 86/55, 99% NRB GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 14cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 1-2/6 blowing holosystolic murmur, best at LUSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar rales. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2182-9-16**] 01:25PM BLOOD WBC-11.1* RBC-3.78* Hgb-11.3* Hct-33.3* MCV-88 MCH-30.0 MCHC-34.0 RDW-14.3 Plt Ct-231 [**2182-9-7**] 08:30PM BLOOD WBC-7.9 RBC-4.04* Hgb-12.2* Hct-36.7* MCV-91 MCH-30.2 MCHC-33.3 RDW-13.9 Plt Ct-167 [**2182-9-15**] 04:02AM BLOOD PT-16.0* PTT-35.8* INR(PT)-1.4* [**2182-9-7**] 08:30PM BLOOD PT-15.3* PTT-28.8 INR(PT)-1.3* [**2182-9-16**] 01:25PM BLOOD Glucose-113* UreaN-22* Creat-0.9 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 [**2182-9-7**] 08:30PM BLOOD Glucose-142* UreaN-18 Creat-1.1 Na-139 K-4.3 Cl-106 HCO3-23 AnGap-14 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84554**]Portable TTE (Complete) Done [**2182-9-11**] at 2:07:59 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 43084**] Institute [**Location (un) 830**], [**Hospital Ward Name **] 4 [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2132-5-14**] Age (years): 50 M Hgt (in): 66 BP (mm Hg): 86/54 Wgt (lb): 180 HR (bpm): 72 BSA (m2): 1.91 m2 Indication: Left ventricular function. Mitral valve disease. ICD-9 Codes: 425.4, 428.0, 786.05, 423.9, 424.0, 424.2 Test Information Date/Time: [**2182-9-11**] at 14:07 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2009W081-0:41 Machine: Vivid [**5-27**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.71 Mitral Valve - E Wave deceleration time: 210 ms 140-250 ms Mitral Valve - [**Last Name (un) **]: 0.40 cm2 TR Gradient (+ RA = PASP): *33 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2182-9-9**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg). LEFT VENTRICLE: Moderately dilated LV cavity. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity is moderately dilated. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) 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 leaflets are mildly thickened. An eccentric directed jet of moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared to the prior study of [**2182-9-9**], findings are similar. Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2182-9-11**] 15:00 ?????? [**2175**] CareGroup IS. All rights reserved. Brief Hospital Course: [**9-13**] Mr.[**Known lastname **] was taken to the operating room and underwent Coronary artery bypass grafting x1 (reverse saphenous vein graft to the marginal branch)/ Mitral valve repair (# 28-mm Future CG annuloplasty ring)with Dr.[**Last Name (STitle) **]. Cross clamp time=57 minutes. Cardiopulmonary bypass grafting= 77 minutes. Please refer to Dr[**Last Name (STitle) **] operative note for further surgical details. He tolerated the procedure well and was transferred intubated and sedated to the CVICU in critical but stable condition. He awoke neurologically intact and was extubated postoperative night. Neosynephrine was weaned off. All lines and drains were discontinued in a timely fashion. Aspirin/statin/Beta-blocker/diuresis initiated along with aggressive pulmonary hygiene. He continued to progress and was transferred to the step down unit on POD#3. Physical therapy was consulted for evaluation of increased mobility and strength. Pt did have b/l pleural effussions. These were tapped without sequele. He is to go home on Lasix. His post x ray was much improved. The remainder of his postoperative course was essentially uneventful. On POD# he was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: Norvasc 5mg PO daily ASA 81mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs* Refills:*2* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. 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:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: -Coronary artery bypass grafting x1 with reverse saphenous vein graft to the marginal branch. -Mitral valve repair with a 28-mm Future CG annuloplasty ring. -Acute myocardial infarction -coronary artery disease -severe mitral regurgitation -HTN -chronic back pain -b/l pleural effussions Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: . Please call your doctor or return to the hospital if you develop fever, chest pain, difficulty breathing, palpitations, lightheadedness, other symptoms that concern you. 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, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] (PCP) in 1 week Dr.[**Last Name (STitle) **] for postop and wound check in 3 weeks at [**Hospital3 80253**] #[**Telephone/Fax (1) 6256**] Please call for appointments Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2182-9-21**]

[ "458.29", "305.1", "428.21", "724.5", "414.01", "486", "997.39", "285.9", "E878.2", "410.91", "424.0", "511.9", "338.29", "428.0", "521.00" ]

icd9cm

[ [ [] ] ]

[ "39.64", "88.54", "36.11", "34.91", "88.73", "39.61", "23.19", "88.72", "88.56", "37.23", "35.12" ]

icd9pcs

[ [ [] ] ]

10462, 10521

7716, 9005

342, 555

10854, 10861

2785, 6532

11708, 12068

1790, 1905

9094, 10439

10542, 10833

9031, 9071

10885, 11685

6581, 7693

1920, 2766

281, 304

583, 1491

1513, 1614

1630, 1774

58,781

163,389

45874

Discharge summary

report

Admission Date: [**2167-12-21**] Discharge Date: [**2168-1-1**] Date of Birth: [**2101-5-5**] Sex: F Service: SURGERY Allergies: Codeine / Phenergan / Quinolones / Oxycodone / Enalapril Attending:[**First Name3 (LF) 2777**] Chief Complaint: Left heel ulceration Major Surgical or Invasive Procedure: [**2167-12-22**] Left femoral and external iliac endarterectomy and bovine pericardial patch angioplasty, left external iliac artery stent placement; left superficial femoral artery (SFA) angioplasty; left SFA stent; left lower extremity arteriogram; exploration of left anterior tibial artery History of Present Illness: This is a 66-year-old woman with a gangrenous ulcer of the left heel and diffuse disease of the left lower extremity arterial system. Attempts had been made at percutaneous intervention but the SFA occlusion was not able to be cannulated. She also had bulky plaque within the common femoral artery and a diffusely diseased SFA. She had anterior tibial runoff with a mild to moderate stenosis in the proximal anterior tibial artery. The patient had previously undergone a right femoral endarterectomy and patch angioplasty for severe ischemic rest pain and a gangrenous ulcer of the right foot. The patient has diffuse cardiac disease and had severe hypotension at the completion of that procedure necessitating chest compressions and epinephrine bolus and epinephrine drip. Because of the severity of the patient's disease and the severity of the cardiac disease, the extreme risk of the procedure, all of which made her procedure exceed the abilities of the available residents, I requested a vascular surgery attending as co-surgeon to speed the process and minimize the duration of anesthetic, maximize the chance for successful revascularization. We chose revascularization over amputation as we felt this would have similar risks as well as the patient's strong desire to maintain limb salvage. Past Medical History: 1. s/p cadaveric renal transplant in [**2160**], baseline Cr 1.7 2. Type 2 diabetes mellitus complicated by neuropathy, retinopathy, nephropathy 3. Diastolic Congestive Heart Failure (LVEF 60% in [**2-/2167**]) 4. Atrial fibrillation - diagnosed in [**2166-6-27**]. S/p cardioversions x2 unsuccessful. On Warfarin. 5. Hypertension 6. Hyperlipidemia 7. Peripheral vascular disease with no claudication 8. [**Country **] stenosis 9. Cholelithiasis 10. Hypothyroidism on replacement 11. Chronic anemia (baseline thought to be approx 27) 12. GERD 13. s/p appy 14. s/p eye surgery [**72**]. gout Social History: Lives with husband, [**Name (NI) **] parent has daughter. Used to be secretary. Mother died recently. Smoking: 5py, quit at age 20yrs EtOH: occasional IVDU: denies Family History: Gestational diabetes (both daughters), no htn, no heart disease. Father had [**Name2 (NI) 40342**] and skin cancer. Aunt had lung cancer. Physical Exam: PHYSICAL EXAM Vital Signs: Temp: 98.1 RR: 18 Pulse: 66 BP: 141/45 Neuro/Psych: Oriented x3, Affect Normal, NAD. Skin: Abnormal: Dry gangrene L heel, R toes and heel. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses. Rectal: Not Examined. Extremities: No femoral bruit/thrill, No RLE edema, No [**Name2 (NI) **] Edema, No varicosities, abnormal: Dry blackened RLE 2nd-4th great toe and heel ulcers (healing), dry blackened [**Name2 (NI) **] posterior heel ulcer. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. DP: D. PT: D. Other: Wwp. [**Name2 (NI) **] Femoral: P. DP: D. PT: N. Other: Cool foot, blue great toe. DESCRIPTION OF WOUND: RLE - healing 2nd-4th toe black dry ulcers [**Name2 (NI) **] - black, dry posterior heel ulcer Pertinent Results: [**2167-12-31**] 08:00AM BLOOD WBC-4.7 RBC-2.99* Hgb-8.8* Hct-28.4* MCV-95 MCH-29.3 MCHC-31.0 RDW-18.6* Plt Ct-206 [**2168-1-1**] 05:55AM BLOOD PT-37.6* INR(PT)-3.9* [**2167-12-31**] 08:00AM BLOOD Glucose-239* UreaN-25* Creat-2.9* Na-134 K-4.8 Cl-97 HCO3-28 AnGap-14 [**2167-12-31**] 08:00AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.0 [**2167-12-23**] 06:37AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026 URINE Blood-NEG Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-5.0 Leuks-SM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE Epi-[**5-5**] TransE-[**1-29**] [**2167-12-23**] 6:37 am URINE Source: Catheter. URINE CULTURE (Final [**2167-12-24**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: [**12-21**]: Pt admitted for ischemic pain and heel ulcers, Renal consult for HD, IV antibiotics for heel ulcers. Heparin drip for ischemia [**12-22**]: Left femoral and external iliac endarterectomy and bovine pericardial patch angioplasty, left external iliac artery stent placement; left superficial femoral artery (SFA) angioplasty; left SFA stent; left lower extremity arteriogram; exploration of left anterior tibial artery. AT not suitable for bypass - unclampable and too calcified for suturing. therefore we proceeded with femoral endarterectomy an dSFA PTA/stenting. Given her hypotension at the time of her prior procedure that was worsened with neo we used epinepherine at completion of this procedure with good results. She was kept on a low dose epinepherine drip and taken to the pacu then icu on epi drip. Had HD, epo at HD for anemia, cont cellcept for immunosuppression. [**12-23**]: Pt on epi for BP control, weaned over night. Diet advanced. Pt also showed some fluid overload. Diastolic CHF acute on chronic. Required 02. Coumadin started. INR followed. [**12-24**]: Had HD, epo at HD for anemia, cont cellcept for immunosuppression. Hypotension resolved. Podiatry Consulted for heel. Foot film, betadine dressing changes. Pt put on home meds. PT consult. FXR: There is irregularity of the bases of the fourth and fifth metatarsals and early osteomyelitis cannot be completely excluded. [**12-25**]: O2 weaned [**12-26**]: Had HD, epo at HD for anemia. Pt hypertensive. Antihypertensives titrated up. Neurology consulted for [**Month/Year (2) **] leg weakness. Clinical neuro examination tonight is limited secondary to LE wounds, pain in LE but she can give split second maximum effort in L IP nonetheless. DTRs are hypoactive symmetrically. There is decrease vibration sense distally, c/w sensory polyneuropathy. PT encouraged. Nothing more to do. [**12-27**]: pt stable, continued PT, case management cosulted. Transfered to VICU. [**12-28**]: Had HD, epo at HD for anemia. Pt still hypertensive. On clonidine, hydralazine, coreg. Pt transfered to floor. Case management consulted for rehab. [**12-29**] - [**1-1**] [**Hospital 25403**] rehab, Coumadin, Antihypertensives, HD, Vanco for heel. Serous drainage from groin wound - no erythema or purulence. Pt gets rehab bed Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA Q6, AMLODIPINE 5mg QD, CALCITRIOL 0.25 QD, CALCIUM ACETATE 667 mg 2tabs TID prn, CARVEDILOL 6.25 mg [**Hospital1 **], CLONIDINE 0.3 mg Tablet - 2 tab TID, PLAVIX 75 md QD, COLCHICINE 0.6 mg QD, DIAZEPAM 2.5mg QD, EPOETIN ALFA 4,000 (Wednesday- Friday), VYTORIN 10-80 QD, Lasix 60mg QD, HYDRALAZINE 25 mg TID, Novolog SSI, LEVEMIR 30 units QHS, Imdur 30 mg QD, LACTULOSE - 10 gram/15 mL Solution - 2 tb by mouth once a day, LEVOTHYROXINE - 88 mcg QD, CELLCEPT [**Pager number **] mg [**Hospital1 **], PROTONIX 40 mg [**Hospital1 **], PREDNISONE 5mg QD, TACROLIMUS -1.5mg [**Hospital1 **], WARFARIN 5mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 mg, Colace 100mg [**Hospital1 **], Senna, CALCITRIOL 0.25 mcg Capsule QD Discharge Medications: 1. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): untill ambulatory. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Insulin Fingerstick QACHS, HS, QAM Insulin SC Fixed Dose Orders Bedtime Glargine 20 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 5 Units 5 Units 5 Units 5 Units 251-300 mg/dL 8 Units 8 Units 8 Units 8 Units > 300 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital 15273**] Healthcare Center Discharge Diagnosis: Nonhealing Left heel ulceration PMH: Renal transplant in [**2160**] DM2 Diastolic Congestive Heart Failure (LVEF 60% in [**2-/2167**]) Atrial Fibb Hypertension Hypothyroidism Gout . 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: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**12-30**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2168-1-6**] 2:15 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-2-9**] 9:40 Completed by:[**2168-1-1**]

[ "272.4", "285.9", "440.24", "403.91", "250.50", "530.81", "250.70", "V45.11", "357.2", "428.0", "428.33", "250.60", "244.9", "427.31", "362.01", "250.40", "585.6", "996.81" ]

icd9cm

[ [ [] ] ]

[ "00.42", "39.50", "39.95", "88.48", "38.16", "00.40", "38.18", "39.90", "00.47" ]

icd9pcs

[ [ [] ] ]

9561, 9626

4617, 6934

336, 632

9852, 9852

3798, 4594

12939, 13271

2776, 2916

7743, 9538

9647, 9831

6960, 7720

10029, 12417

12443, 12916

2931, 3779

276, 298

660, 1963

9866, 10005

1985, 2578

2594, 2760

18,734

183,140

48391

Discharge summary

report

Admission Date: [**2118-3-24**] Discharge Date: [**2118-4-1**] Date of Birth: [**2056-5-13**] Sex: F Service: SURGERY Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 473**] Chief Complaint: Pancreatic cystic neoplasm. Major Surgical or Invasive Procedure: subtotal Pancreatectomy with Splenectomy Lysis Of Adhesions Open Wedge Liver Biopsy Small Bowel Resection History of Present Illness: Mrs. [**Known lastname 14893**] is a 61-year-old woman with multiple medical problems, one of which is chronic abdominal pain. She had some type of surgery for a cystic lesion in her pancreas several years ago which I think was on the basis of an incorrect diagnosis as a pancreatic pseudocyst. She has persisted with this cystic neoplasm in her central pancreas which indicates that a pancreatic pseudocyst was not an accurate diagnosis. Although we have followed her pseudocyst serially with imaging and found that it has not changed in its size or anatomical configuration, it is clearly obstructing the outflow from the left pancreas where the pancreatic duct is dilated. We have no other reason for her abdominal pain. She has had numerous issues in the past few months, perhaps the most significant of which was coronary artery disease necessitating coronary artery bypass grafting. She also is morbidly obese and has had multiple prior abdominal operations. As an attempt to eradicate her pain, I recommended resection of this pancreatic cystic neoplasm. Past Medical History: :anxiety, HOCM, cystic pancreatic mass, chronic pain, asthma, HTN, SVT with stress/anxiety, hyperthyroid, hiatal hernia, arthritis, [**Doctor First Name **] . PSx: CABG [**12-29**] ,Roux-en-Y cystojejunostomy Physical Exam: VSS - 63, 136/78, 97%, 250 lbs. Gen: pleasant, A+O x 3 CV: RR, S1, S2 Chest: CTA bilat. Abd: Obese, soft, nontender, nondistended. Ext: +2 pulses bilat. Pertinent Results: [**2118-3-29**] 06:45AM BLOOD WBC-9.2 RBC-3.46* Hgb-10.1* Hct-30.6* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.7* Plt Ct-264 [**2118-3-29**] 06:45AM BLOOD Glucose-122* UreaN-9 Creat-0.5 Na-141 K-3.6 Cl-103 HCO3-33* AnGap-9 [**2118-3-29**] 06:45AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 . SPECIMEN SUBMITTED: LIVER BX, SMALL BOWEL, DISTAL PANCREAS AND SPLEEN, BOWEL, PANCREATIC CYSTIC TUMOR. Procedure date Tissue received Report Date Diagnosed by [**2118-3-24**] [**2118-3-24**] [**2118-3-31**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mrr?????? DIAGNOSIS: 1. Pancreas and duodenum, partial pancreaticoduodenectomy (A-R): 1. Microcystic serous cystadenoma, 4.6 x 4.4 x 2.4 cm, completely-excised. 2. Pancreatic intraepithelial neoplasia 1. 3. Six lymph nodes, no malignancy identified. 4. Unremarkable duodenum. 2. Distal pancreas and spleen, distal pancreatico splenectomy (S-V): 1. Pancreatic intraepithelial neoplasia 1. 2. Chronic pancreatitis. 3. Benign spleen with focal hemorrhage. 4. Six lymph nodes, no malignancy identified. 3. Small bowel (W-Y): No diagnostic abnormalities recognized. 4. :Bowel" (Z-AA): Small bowel, no diagnostic abnormalities recognized. 5. Liver, wedge biopsy (AB): 1. Moderate microvesicular steatosis including approximately 30% of liver parenchyma (score 1). 2. Rare lobular inflammatory foci including neutrophils (score 2). 3. Scattered balloon cells (score 1). 4. Focal minimal central lobular fibrosis seen on trichrome stain (stage 1). 5. Iron stain shows mild iron deposition in Kupffer cells. . Cardiology Report ECHO Study Date of [**2118-3-24**] Conclusions: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thicknesses and cavity size are normal. There is no left ventricular outflow obstruction at rest or with Valsalva. There was no change in the left ventricular outflow tract gradient with Valsalva maneuver. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**11-23**]+) mitral regurgitation is seen. There is no pericardial effusion. . Brief Hospital Course: She was admitted on [**2118-3-24**] and went to the OR for: 1. Subtotal (80%) pancreatectomy with splenectomy. 2. Small bowel resection. 3. Mobilization of splenic flexure of colon. 4. Extensive lysis of adhesions. 5. Open wedge liver biopsy. Post-op Hypovolemia: She received two 500cc fluid boluses overnight in the SICU for hypotension and low urine output. Her urine output remained at 20-40cc/hr in the SICU. On POD 3, she received IV Lasix and had a good response with increased urine output. She was now back on her home Lasix dose and her peripheral edema was improving. GI/Abd: Her abdomen was tender and her dressing was intact over the incision. She had a NGT, was NPO with IVF. Her wicks were removed on POD 2. she had minimal drainage from the left side of her wound. There was no erythema or infection. The staples were left in place and will be removed at her follow-up appointment. The NGT was removed on POD 3. She was started on sips on POD 4. Her diet was slowly advanced over the next few days. She complained of gas pains, that resolved with a suppository and bowel movement. She was able to tolerate regular diet at time of discharge. She was ambulating and safe to go home. Pain: She was having considerable pain post-operatively. She was followed by the pain team. Given the pt's hx of chronic pain and chronic opioid use (was on Percocet (7.5mg), Vicodin, opana at home), she had increased requirements on pain medications. Since she seemed to be having trouble using the PCA, per the pain service was started on a Duragesic patch of 100mcg q 72 hrs. She may also use the Dilaudid PCA as an adjunct to that. She seemed to be pretty sedated and having confusion. The patch and PCA were stopped and she was ordered for Toradol. Toradol controlled her pain. Resp: She remained on the Ventilator overnight in the SICU. She was extubated the next day at 1300. She was initially tachypneic, and with asthma at baseline. We were able to successfully wean her off the O2 and she had no respiratory issues. Neuro: She was weepy and very anxious and confused with visual hallucinations and at times argumentative.. She received Ativan and was frequently reoriented. She received Haldol x 2 the night of [**4-4**] with good effect. Vaccines: she received Vaccines x 3 on POD 3. Medications on Admission: wellbutrin 300mg AM, lasix 40 AM, ,fosamax, vitamin D 5000 AM, B6, ASA, Kcl 60 AM; synthroid 200mcg PM, T3 21mg PM, toprol XL 100 PM, effexor 300 PM, prilosec 40 PM, lipitor 80 PM, Ativan 2mg HS, risperdal 1 HS, ambien 1 HS, metolazone 5 PRN, fiorinal PRN, advair 250/50 PRN, albuterol PRN, T3 for HA, vicodin PRN, percocet PRN, theophyilline PRN Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: Twice/day for 5 days, then resume once/day dose. 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for 2 weeks. Disp:*35 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Pancreatic Cystic Mass Post-op Delerium Discharge Condition: Good. Incision C/D/I with minimal clear pink drainage from left side of wound. Pain controlled A+O x 3 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, 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. Take Lasix 40mg 2x/day for 5 days, then resume 1x/day dose. . Continue to ambulate several times per day. . You may shower and wash your incision. Pat dry and keep clean and dry. Monitor for signs of infection. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment. Completed by:[**2118-4-1**]

[ "571.8", "276.52", "278.01", "401.9", "577.1", "V45.81", "425.1", "244.9", "493.90", "211.6" ]

icd9cm

[ [ [] ] ]

[ "41.5", "50.12", "52.53", "38.93", "45.62" ]

icd9pcs

[ [ [] ] ]

7665, 7768

4542, 6850

300, 408

7852, 7957

1920, 4519

9284, 9445

7247, 7642

7789, 7831

6876, 7224

7981, 9261

1747, 1901

232, 262

436, 1499

1522, 1732

53,411

160,754

12460

Discharge summary

report

Admission Date: [**2196-11-14**] Discharge Date: [**2196-11-25**] Date of Birth: [**2138-12-11**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: fever and headache Major Surgical or Invasive Procedure: [**11-14**] Removal of Ommaya reservoir [**11-14**] Placement of External Ventricular Drain History of Present Illness: 57 yo F with metastatic small cell lung CA s/p ommaya placement on [**2196-11-11**]. Pt noted fever to 100.2 at home on [**11-12**], defervesced, then fever to 100.6 on [**11-13**]. She noted on Saturday she had some neck stiffness which has resolved. She noted nausea and vomiting on Sunday after taking oxycodone. She now c/o mild HA, no nausea/vomiting, no neck pain, no visual disturbances. Pt was given vancomycin at OSH after failed LP attempt. Past Medical History: Met. NSC Lung CA HL Depression, Anxiety migraines Social History: Divorced, currently in a relationship. Has 2 daughters and 3 grandchildren. Living w/ one of her daughters. They have been very supportive. HABITS: She smoked one pack and one-half a day for 15 years. She quit ~[**2179**]. 2 drinks/night. no drug use. Occasional walking but no formal exercise. Family History: non-contributory Physical Exam: O: T: 100.0 BP: 133/76 HR: 67 R 16 O2Sats 96% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2mm bilat EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and year. 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, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-8**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Incision C/D/I, no erythema No nuchal rigidity. *** PE upon discharge non-focal exam except for short term memory loss. incision- [**Month/Day (1) 2729**] intact, well healing. Pertinent Results: ADMISSION LABS: [**2196-11-14**] 01:30AM SED RATE-70* [**2196-11-14**] 01:30AM PT-14.4* PTT-23.2 INR(PT)-1.2* [**2196-11-14**] 01:30AM PLT COUNT-230 [**2196-11-14**] 01:30AM NEUTS-83.5* LYMPHS-14.0* MONOS-1.5* EOS-0.7 BASOS-0.2 [**2196-11-14**] 01:30AM WBC-5.7 RBC-3.21* HGB-11.0* HCT-32.3* MCV-101* MCH-34.3* MCHC-34.2 RDW-16.9* [**2196-11-14**] 01:30AM ALT(SGPT)-64* AST(SGOT)-56* ALK PHOS-157* TOT BILI-0.8 [**2196-11-14**] 01:30AM GLUCOSE-107* UREA N-7 CREAT-0.5 SODIUM-133 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-12 [**2196-11-14**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-187 RBC-16* POLYS-85 LYMPHS-7 MONOS-7 ATYPS-1 [**2196-11-14**] 05:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-20 GLUCOSE-74 DISCHARGE LABS: IMAGING: CT Head [**11-14**]: IMPRESSION: No acute intracranial process CT HEad [**11-16**]: Pneumocephalus is noted status post exchange of Ommaya reservoir for EVD. There is, however, no intracranial hemorrhage or other acute intracranial process identified CT head [**11-19**]: IMPRESSION: Status post EVD removal with minimal increase in size of the lateral ventricles. No midline shift, no hemorrhage. CT Head [**11-22**]: Within this limitation, no evidence of acute intracranial process. No interval change since [**2196-11-19**]. MRI is more sensitive for the detection of subtle ischemic events and should be considered in the correct clinical setting and if there is no contraindication to its use. LENI's [**11-23**]: No DVT Brief Hospital Course: Pt admitted to neurosurgery service on [**2196-11-14**] and underwent removal of infected R frontal omaya resevoir after gram stain should 3+ GPC and CSF showed 187 WBC. Pt tolerated this procedure very well with no complications and her post operative exam remained intact. Infectious disease team was consulted and felt vancomycin 1g q12 and ceftazadime 2g q8 was an appropriate antibiotic regimen until final cultures could be obtained. She tolerated the EVD well, and her ICPs remained low. The EVD was elevated to 20, and she continued to tolerate this. On [**11-16**], her EVD was clamped. She tolerated it well for the duration of the morning,but by the afternoon her ICPs climbed to the high 20s/low 30s and she developed a severe HA. The drain was subsequently opened. New CSF cultures be sent per ID recommendations. Again on [**11-17**], drain clamping was reattempted. She again tolerated it for approximately 2 hours, but gradually developed a severe HA. She had no mental status or exam changes. The decision was made again to open the drain. New blood and urine cx were sent per ID's recs. On [**11-18**] she was febrile to 101.6 in the morning and she was cultured including CSF. Also her drain was clamped again. This time, she tolerated clamping for 12 hours and the EVD was removed. The post-EVD-pull CT revealed no evidence of hemorrhage or hematoma. On [**11-20**] her vancomycin level was elevated at 26 and her a.m dose was held. Her WBC continued to trending down. ID had recommended treatment with neupogen for neutropenic precautions and in discussion with oncology team 480mcg daily was started. Her CBC with diff will be checked daily and treatment will continue based on this. On [**11-21**] the patient was neurologically well. Her WBC trended up to 9.3. She was seen by ID who made final recommendations of 1 week of vancomycin. She was cleared for discharge home at this time with follow up in 1 month. However, because she does not have insurance, she could not have services at home to help with the antibiotic infusions. Therefore the plan was made for her to remain in the hospital until [**11-25**] when her Vancomycin infusion is completed. her most recent CSF culture was also made final as no growth. On [**11-22**] her Vancomycin was decreased, as her level was 23.3. In the afternoon, she developed an acute onset of expressive and receptive aphasia, as well as a R facial droop. A stat head CT was unremarkable. It was determined that the patient had an acute focal seizure. Her Keppra was increased to 750mg [**Hospital1 **], and neurology was consulted to make further recommendations. On [**11-23**] her aphasia and right sided facial droop had resolved and no other seizure activity had been noted. The neurology service was contact[**Name (NI) **] and the patient was initiated on seizure medication per neurology recommendation. On this day she had LENI;s which were negative for DVT. On [**11-24**] her exam remained stable as she prepared to be discharged on friday. Her blood cultures from [**11-20**] have shown no growth to date as well and she will discontinue her Vancomycin on Friday at time of discharge. On [**11-24**] she was deemed fit for discharge to home without services and was sent home with instructions for follow-up Medications on Admission: zolpidem, oxycodone, lorazepam, omeprazole, Discharge Medications: 1. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: Fever CSF infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after [**Month/Year (2) 2729**] have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam) for antiseizure medicine, you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ?????? You have [**Month/Year (2) 2729**] that need to be removed on Monday at your follow up appointment. If there are problems with this please have them call us at [**Telephone/Fax (1) 1669**]. ?????? You have an appointment in the Brain [**Hospital 341**] Clinic on [**2196-11-28**] @ 9:30 AM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ?????? You need a follow up appt with either your PCP or oncologist for later this week to check on your blood levels. Completed by:[**2196-11-25**]

[ "288.00", "320.3", "198.4", "780.39", "401.9", "198.3", "780.60", "E878.1", "198.5", "272.4", "300.4", "162.9", "331.4", "E930.5", "272.0", "V15.82", "996.63" ]

icd9cm

[ [ [] ] ]

[ "02.43", "02.39", "01.10" ]

icd9pcs

[ [ [] ] ]

8623, 8629

4355, 7661

341, 435

8693, 8693

2851, 2851

10422, 11198

1327, 1345

7756, 8600

8650, 8672

7687, 7733

8844, 10399

3590, 4332

1360, 1611

283, 303

463, 921

1863, 2832

2868, 3573

8708, 8820

943, 994

1010, 1311

30,393

120,355

53636

Discharge summary

report

[** **] Date: [**2143-2-28**] Discharge Date: [**2143-3-3**] Date of Birth: [**2056-10-15**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Dilaudid / Gleevec Attending:[**Doctor First Name 2080**] Chief Complaint: Left leg and hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 86 year old male with CML and CAD s/p stenting, afib on warfarin who presented to the ED with atraumatic left hip pain x 6 along with brusing along left thigh x2 days. Per the patient he saw his PCP 2 days ago and had an xray which was unremarkable. He had a planned for MRI for AVN, however today developed worsening pain and bruising. The patient also notes dyspnea with exertion which he has at baseline but has worsened over last few days. The patient denies CP/lightheadedness/palpations. Pt was seen by his PCP today who was concerned for DVT/PE and referred him to the ED. . In the ED initial VS were 97.8 80 91/47 22 96%RA. He was noted to be pale with a large ecchymosis of posterior left thigh at hip. His HCT 19.3 from 47 on [**2143-2-20**]. INR was reported to be 14 initially but then lab said it was in error it was repeated and was 12. PTT 47.7. In the ED his SBP ranged from 70-90s. He received 1L NS. Got CTA of abd and LE to r/o RP , saw large hematoma of gluteus and vastus lateralis no active extravasation. Had negative LLE US for DVT. IV vitK and 2 U FFP, 2U were ordered and being given on transport. Surgery consulted preemptively in the ED in case patient develops compartment syndrome, compartments noted to be soft. . On arrival to the MICU, patient's vital signs were 98.3F 87 93/32 15 100%2LNC. Patient endorsed chronic pain at his lower extremities from venous stasis ulcers. Mild pain at left hip. No chest pain/SOB/dizziness. He does endorse decreased PO intake for the last week due to dry mouth and bland taste which he associates with his hydroxyurea, though he notes this dosing has not changed recently. He denies any new medications or recent changes in current medications. . Review of systems: (+) Per HPI , has noted some constipation over last week responsive to stool softeners. Also occasional difficulty starting urination stream though has been able to void. Denies bloody stools or bleeding. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, 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. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: NSTEMI in [**2132**], STEMI in [**2137**] CHB and bradycardia/asystole requiring temp pacemaker in cath lab -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: [**2132**] bare metal stent of proximal and mid left anterior descending (4.0x13 and 4.0x18 Velocity) as well as 2.5x23 mm Velocity BMS to the OM1 -status post ST elevation MI in [**2137**] (100% thrombotic mRCA occlusion) for which mid RCA was direct stented with a 3.5x12mm stent 3. OTHER PAST MEDICAL HISTORY: -Chronic myelogenous leukemia -chronic venous stasis since approximately [**2118**] with ulcers -right eye blindness status post traumatic injury Social History: Has worked in the music industry his entire life, including conducting in the BSO, composing, teaching, and producing music. He has never smoked. He has [**Last Name (un) 110164**] 3 drinks/week. No illicit drugs. He lives by himself, has a secretary who visits him 5x a week. Walks without assistance. Family History: No history of cancers including leukemia/lymphoma. No CAD in the family. Father died at age [**Age over 90 **] from choking on food. Physical Exam: [**Age over 90 **] EXAM: Vitals:98.3F 87 93/32 15 100%2LNC General: Alert, oriented x3 , no acute distress HEENT: Pale Sclera, MMM, oropharynx clear, EOMI, PERRL, right eye s/p enucleation 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, mildly distended, bowel sounds present, no organomegaly Rectal: dark brown stool, heme positive GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Venous stasis ulcerations at LLE. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Vitals: T97.2F HR116 (100s-140s) BP90-110/60s-70s 18 97% on RA General: Alert, oriented x3 , no acute distress HEENT: Pale Sclera, MMM, oropharynx clear, EOMI, PERRL, right eye s/p enucleation Neck: supple, JVP not elevated, no LAD CV: Tachycardic, irregular, normal S1 + S2, III/VI high pitched holosystolic murmur loudest at apex, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, distended, bowel sounds present, no organomegaly Ext: L thigh w/ palpable hematoma and ecchymosis tracking into groin and down to knee with superimposed ecchymosis; [**1-27**]+ peripheral edema in L leg from feet to distal thigh, then 1+ edema up thigh; 3+ pedal edema in R foot, 1+ edema in RLE to knee; 2+ pulses; intact ROM in b/l knees, hips and ankles; no TTP of L knee Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. Pertinent Results: [**Month/Day (3) **] Labs: [**2143-2-28**] 06:43PM BLOOD WBC-23.3*# RBC-1.76*# Hgb-5.6*# Hct-19.3*# MCV-110* MCH-32.0 MCHC-29.2* RDW-24.6* Plt Ct-283# [**2143-2-28**] 06:43PM BLOOD Neuts-68 Bands-0 Lymphs-6* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-5* Hyperse-15* NRBC-12* [**2143-2-28**] 10:20PM BLOOD PT-116.4* PTT-47.3* INR(PT)-12.0* [**2143-2-28**] 06:43PM BLOOD Glucose-135* UreaN-79* Creat-1.3* Na-136 K-4.8 Cl-102 HCO3-17* AnGap-22* [**2143-2-28**] 06:43PM BLOOD cTropnT-0.05* . Left Lower Extremity US ([**2143-2-28**]): Grayscale and Doppler son[**Name (NI) **] of the left common femoral, superficial femoral, deep femoral and popliteal veins were performed. There is normal compressibility, flow and augmentation throughout. The calf veins were not visualized due to extensive soft tissue edema. In the region of the bruise along the medial aspect of the left thigh, there is diffuse subcutaneous soft tissue swelling, without a focal hematoma. IMPRESSION: No DVT in the left lower extremity. The calf veins were not visualized. Subcutaneous edema. . CXR ([**2143-2-28**]): Small bilateral pleural effusions. Bibasilar opacities may represent combination of effusion and atelectasis, although underlying early consolidation cannot be excluded. 1.3-cm nodular opacity projecting over the right lung may represent nipple shadow, this can be confirmed with repeat with nipple markers. Stable cardiomediastinal silhouette. Calcified left hilar node again seen. . CT Abdomen and Pelvis With and Without Contrast ([**2143-2-28**]): 1. Moderate to large hematoma involving the left gluteus medius and vastus lateralis and the subcutaneous soft tissues of the left proximal and mid-thigh without evidence of active extravasation. 3. 2.9 x 2.6 cm partially visualized right popliteal artery aneurysm. 4. Right retrocrural and retroperitoneal lymphadenopathy of unclear clinical significance. Correlate with history of malignancy/clinical history and follow-up. DISCHARGE LABS: [**2143-3-3**] 07:55AM BLOOD WBC-20.7* RBC-3.16* Hgb-9.8* Hct-32.2* MCV-102*# MCH-31.0 MCHC-30.3* RDW-24.7* Plt Ct-224 [**2143-3-3**] 07:55AM BLOOD Neuts-87* Bands-3 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-8* [**2143-3-3**] 07:55AM BLOOD PT-15.7* INR(PT)-1.5* [**2143-3-3**] 07:55AM BLOOD Glucose-205* UreaN-34* Creat-0.9 Na-140 K-3.8 Cl-109* HCO3-22 AnGap-13 [**2143-3-3**] 07:55AM BLOOD Calcium-8.0* Phos-1.8* Mg-2.5 Brief Hospital Course: 86 year old male with CML and CAD s/p stenting, afib on warfarin with who p/w anemia and left thigh/buttock hematoma. #) Anemia/Spontaneous L Thigh Hematoma: Patient's severe anemia with 28 point HCT decrease in 8 days was attributed to his large atraumatic hematoma. Patient likely had been slowly bleeding for several days given the time course of his symptoms. His anticoagulation status certainly contributed to this with his significantly elevated INR of 12. He also has heme positive stool, though denied any dark or bloody stools. Patient was given IV vit K, FFP x 1 and 1U pRBCs in the ED. There was no active extravasation on the CTA. He was seen by surgery to assess for compartment syndrome, which he had no signs of. Patient received 4 U PRBC total and HCT increased appropriately and remained stable and patient was transferred to the floor. Hct remained stable on the floor and anticoagulation continued to be held, until the patient left against medical advice. #) Coagulopathy/Elevated INR. Patient p/w INR of 12 in the setting of warfarin use which per pt's PCP patient restarted on his own and was not being monitored for. He had previously been on dabigatran but switched to warfarin w/o informing his providers [**12-27**] cost issues. Patient was given FFP and vitamin K with improvement of his INR. At the time when the patient left against medical advice his INR had trended down to 1.5. His CHADS2 score is 2 suggesting that he would benefit from continued anticoagulation when his bleed stabilizes- per discussion with Dr. [**Last Name (STitle) 2903**] he will try to obtain prior authorization for dabigatran given his adverse event with warfarin. The patient left AMA prior to restarting his anticoagulation (see below). #) Hypotension: Patient intially presented w/ hypotension which was attributed to his active bleed. His bleed was managed as above w/ transfusions. He did show signs of mild end organ damage w/ [**Last Name (un) **] which resolved with 4 units pRBCs and 2L IVF (see below for discussion of troponins) but did not require any pressor support. His anti-hypertensives were held and his blood pressure stabilized in the 90-100 range systolically. This persistent relative hypotension in the setting of a stable hct was attributed to intravascular volume depletion as the patient developed significant LE edema as well as poor forward output in the setting of his frequent AF w/ rapid rates as high as 140s. The patient left against medical adivce before these problems could be optimally managed (see below). #) Elevated Cardiac Enzymes: Elevated trop in the setting of severe anemia on [**Last Name (un) **]. EKG was reassuring w/o any acute ischemic changes. His troponin leak was attributed to demand ischemia in the setting of severe anemia. Trops were trended and no signficant elevation. #) Dyspnea on exertion. Likley [**12-27**] to his severe anemia. See treatment above. His dyspnea resolved with HCT improvement. #) [**Last Name (un) **]: As above, creatinine was 1.3 on [**Last Name (un) **] from baseline 1.1. This was attributed to his blood loss and trended back to baseline with transfusions and IVF. #) acute on chronic systolic CHF: Patient w/ EF of 40-45% in [**2141**] with moderate to severe MR. [**First Name (Titles) **] [**Last Name (Titles) **], lasix was held in setting of bleed as was his toprol XL. He was put on metoprolol tartrate with attempts to uptitrate as below. By day of discharge, patient was showing signs of significant volume overload w/ [**1-27**]+ LE edema, though his lungs were relatively clear. Patient left AMA (see below) before diuretics could be restarted. #) Leukocytosis/CML. Patient w/ elevated wbc up from 9 last week with hypersegmented neutrophils and 68 neutrophils. Pt with a hx of CML, though this could be a stress response. His hydroxyurea was continued and his outpatient oncologist was notified of this [**Month/Day (3) **]. Patient did not show signs of active infection. This will require follow up in the outpatient setting. #) Afib, uncontrolled: Patient was tachycardic in the 100s and would shoot up to the 130s-140s with excitation or movement. Rate control was attempted with metoprolol though it was difficult to uptitrate in the setting of his relative hypotension. His anticoagulation was held as above. Patient left AMA before his AF could be better controlled (see below). #) HLD: Patient's simvastatin was initially held in MICU, but then restarted prior to discharge at half dose (40 mg daily) given black box warning against simvastatin 80 mg. #) Disposition: Patient insisted on leaving on [**3-3**] as he had had "slept 2 hours" the entire time he had been in the hospital and was not comfortable here. Extensive discussions were held on the importance of him remaining in the hospital to manage his various issues, but the patient continued to express his desire to leave. Dr. [**Last Name (STitle) 2903**], his PCP, [**Name10 (NameIs) **] [**Name (NI) 653**] and also tried to convince the patient to stay in the hospital, but the patient declined (see OMR note for further details). The risks of his leaving including further bleed, MI, stroke, fall and fracture, fatal arrhythmia were discussed and the patient demonstrated capacity in understanding these issues. He was seen by physical therapy who felt he would be safe at home with his existing 24 hour care and he was ultimately discharged against medical advice to his home. Dr. [**Last Name (STitle) 2903**] will be seeing the patient on the evening of discharge in his home to further optimize his medications, including coming up with a plan for anticoagulation. He will also arrange for nursing services at home including home PT. The patient was informed of warning signs (see discharge instructions). # FULL CODE Medications on [**Last Name (STitle) **]: ALLOPURINOL - 300 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day Take [**11-26**] tab daily for total of 150mg daily Warfarin 5mg qday (Of note patient had been on pradaxa until 2 mo ago but switched to warfarin due to cost of medication) FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth twice a day HYDROXYUREA - 500 mg Capsule - 2 Capsule(s) by mouth once per day or as directed METOPROLOL SUCCINATE [TOPROL XL] - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day MUPIROCIN - 2 % Ointment - apply to lower leg open areas daily or as needed OXYCODONE - 15mg q4-6 hrs as needed for pain RAMIPRIL - 2.5 mg Capsule - 1 Capsule(s) by mouth daily SILVER SULFADIAZINE - 1 % Cream - apply to wound twice a day SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. allopurinol 300 mg Tablet Sig: [**11-26**] Tablet PO once a day. 5. silver sulfadiazine Topical 6. oxycodone Oral Discharge Disposition: Home Discharge Diagnosis: Primary: Hematoma in setting of supratherapeutic INR Secondary: Atrial fibrillation Coronary artery disease Congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the medical ICU with low blood pressures due to a bleed in your thigh. Your INR was found to be high so your coumadin was stopped and you were transfused blood and clotting factors. You were managed on the medical floor but your heart rates were fast and your blood pressures continued to be borderline. Your leg became more swollen and we were concerned about your risk for a fall. You decided to leave against our medical advice. Your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] was notified and is aware that you are leaving the hospital against medical advice. You are aware that you risk recurrent bleed, heart attack, stroke, fall, and fracture if you leave the hospital. Dr. [**Last Name (STitle) 2903**] will see you at home this evening . In the meantime, please DO NOT RESTART your coumadin. Other changes to your medications include: - STOP LASIX - STOP RAMIPRIL - CHANGE SIMVASTATIN DOSE TO 40 MG We have made no other changes to your medications. Please elevated your legs and minimize movement around the house to reduce of falls. Monitor your legs for increased swelling or pain and if these symptoms occur please return to the hospital. We wish you all the best. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2903**] this evening at your home as planned. He will arrange for further follow up. Please keep your previously scheduled appointments. Department: VASCULAR SURGERY When: WEDNESDAY [**2143-3-13**] at 1 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: WEDNESDAY [**2143-3-13**] at 2:00 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: WEDNESDAY [**2143-3-13**] at 2:30 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2143-3-5**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15147, 15153

8036, 10605

314, 320

15331, 15331

5586, 7554

16817, 17764

3740, 3876

14718, 15124

15174, 15310

15514, 16794

7571, 8013

3891, 4627

2783, 3223

4643, 5567

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10622, 14695

253, 276

348, 2064

15346, 15490

3254, 3402

2711, 2763

3418, 3724

3,379

142,774

6798

Discharge summary

report

Admission Date: [**2162-5-26**] Discharge Date: [**2162-5-29**] Date of Birth: [**2130-3-28**] Sex: F Service: MEDICINE Allergies: Haldol / Sulfa (Sulfonamide Antibiotics) / Bactrim / Iodine / Ciprofloxacin Attending:[**First Name3 (LF) 896**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Ms. [**Known lastname 25769**] is a 32 year old female with a PMH significant for schizoaffective disorder, DM 2, PE who presents with chest pain. She reports that today she was resting and started to feel pleuritic chest pain. She also noticed that her legs were hurting. The pt reports that she has a h/o DVT and she was concerned that she might have developed a DVT since she has felt very fatigued lately and has not been very mobile. Denies any cough, wheezing, palpitations, f/c, diarrhea, nausea or vomiting. In the [**Hospital1 18**] ED, inital VS 98 95 124/76 22 100%. Cardiac biomarkers were negative, CXR that was unremarkable. The pt is unable to have a CTA due to allergy, so in the ED they were originally planning to do MRI to evaluate for PE, but the pt was too large for the MRI scanner. The pt was then admitted for V/Q scan. Currently, the patient is states that she has persistent chest pain when she inspires. Denies any current SOB, palpitations. Review of systems: As above, otherwise negative. Past Medical History: - Possible schizoaffective disorder and borderline personality disorder with over 100 hospital admissions at a variety of local and psychiatric hospitals per prior chart notes. - Hypertension. - Hypercholesterolemia. - Type 2 diabetes and some atypical chest pain with normal cardiac cath at the [**Hospital1 756**] in [**2158**]. - Obesity. - Right lower extremity DVT, [**2158**] admitted to [**Hospital1 112**] treated with coumadin (x1 month, held per pt given anemia). - Post traumatic stress disorder. - Upper extremity DVT - Abdominal abscess/cellulitis Social History: She lives with her brother and currently is unemployed. She does not smoke or drink alcohol and there is no other history of illicit drug use. Family History: DM and CAD in multiple family members. Physical Exam: ADMISSION: VS: T98, 126/66, 82, 18, 100%3L Gen: Morbidly obese female in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM. CV: Distant heart sounds, normal S1+S2. Pulm: CTAB Abd: Soft, non tender, non distended. BS+. Ext: No c/c/e. Neuro: A+Ox3, speech fluent, 5/5 strength in upper and lower extremities. DISCHARGE: VS: 96.9 134/76 84 18 100% on 3L Gen: Morbidly obese female in NAD, tearful at times HEENT: Perrl, eomi, sclerae anicteric. MMM. CV: Very distant heart sounds, normal S1+S2, no mrg appreciated Pulm: CTAB with distant heart sounds, no wheezing Abd: Obese, soft, mild ttp over umbilicial hernia. Pannus with area of indurant and slightly that is TTP, no overlying erythema. Ext: warm, well perfused, 1+ pitting edema to the mid calf Neuro: A+Ox3, speech fluent, 5/5 strength in upper and lower extremities. Pertinent Results: IMAGING: [**2162-5-26**] VQ SCAN: Mild, matched heterogeneity of perfusion and ventilation. Very low likelihood ratio for recent pulmonary embolism. [**2162-5-26**] Left Upper Extremity Ultrasound: No evidence of left upper extremity deep venous thrombus. [**2162-5-26**] Bilateral Lower Extremity Ultrasound: Slightly limited exam, with poor assessment of the right calf veins. No evidence of DVT, however, in either lower extremity. LABS: - CBC: WBC-7.5 HGB-10.5* HCT-31.3* MCV-80* PLT COUNT-313 - COAGS: PT-12.5 PTT-84.6* INR(PT)-1.1 - cTropnT-<0.01 x3 - CHEM 7: GLUCOSE-156* UREA N-14 CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-22 - D-DIMER-261 - UA: URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Brief Hospital Course: 32 year old female with a PMH significant for schizoaffective disorder, DM 2, DVT who presented with pleuritic chest pain initially concerning for pulmonary embolus which was ruled out by VQ scan. Had an episode of unresponsiveness with completely normal vital signs and had brief MICU stay. Likely cause felt to be deep sleep # Unresponsiveness: Nurse found patient to be unresponsive for a minute. Pulse, blood pressure, oxygen saturation and ABG all within normal limits. She awoke without intervention. She was observed in the MICU. Episode felt ot be a deep sleep as patient had not been using her CPAP and had not been sleeping well. # Atypical chest pain: Initially concerning for pulmonary embolism given pleuritic component and history of DVT and was initially treated with heparin drip. VQ scan done (patient too heavy for CT or MRI) showing very low probaility of PE. Ruled out for MI. Heparin drip discontinued on day prior to discharge. Discharged on tylenol as needed and tramadol as needed. # Left Arm Pain: Upper arm was slightly firm and tender. Ultrasound negative for clot and pain improved. Discharged on tylenol as needed and tramadol as needed. # Metrorrhagia: Experience heavy menstrual flow in setting of heparin drip which resolved with discontinuation of heparin. Hematocrit remained stable. # Anemia: At baseline. Microcytic. Received iron infusions as out patient. # Depression: Was tearful at times, denied suicidality. Social work counseled. Continued home medications. # Non-insulin dependent Diabtes: Continued home metformin. # Hyperlipidemia: Continued simvastatin. # Hypertension: Continued home anti-hypertensives Medications on Admission: Ropinirole 0.25 mg Tab twice a day Lexapro 20 mg Tab-2 Tablet(s) by mouth once a day Aspirin 81 mg Chewable Tab- 1 Tablet(s) by mouth DAILY (Daily) Acetaminophen 500 mg Tab-1 Tablet(s) by mouth every four (4) hours as needed for pain Ativan 0.5 mg Tab- Tablet(s) by mouth at bedtime as needed for insomnia Atenolol 25 mg Tab-1 Tablet(s) by mouth once a day Albuterol Sulfate HFA 90 mcg/Actuation Aerosol Inhaler- [**2-14**] HFA(s) inhaled every six (6) hours as needed for SOB, wheezing Enalapril Maleate 2.5 mg Tab-1 Tablet(s) by mouth once a day Simvastatin 40 mg Tab-1 Tablet(s) by mouth at bedtime Omeprazole 20 mg Cap, Delayed Release-1 Capsule(s) by mouth once a day Cyclobenzaprine 10 mg Tab-1 Tablet(s) by mouth once a day Imodium A-D 2 mg Tab-1 Tablet(s) by mouth twice a day Zolpidem 10 mg Tab-1 Tablet(s) by mouth at bedtime as needed for insomnia Oxycodone 5 mg Tab-1 Tablet(s) by mouth every eight (8) hours as needed for pain Gabapentin 300 mg Cap-1 Capsule(s) by mouth twice a day Lamotrigine 100 mg Tab-1 Tablet(s) by mouth QPM (once a day (in the evening)) Lamictal ODT 100 mg Tab-1 Tablet(s) by mouth QAM (once a day (in the morning)) Glucophage 500 mg Tab-1 Tablet(s) by mouth twice a day Flovent HFA 110 mcg/Actuation Aerosol Inhaler-2 Aerosol(s) inhaled twice a day Provera -- Unknown Strength- 1 Tablet(s) Once Daily trazodone 100 mg Tab Oral-2 Tablet(s) , at bedtime *iron infusions Unknown sig Discharge Medications: 1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze, SOB. 7. enalapril maleate 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO twice a day. 13. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 10 doses. Disp:*10 Tablet(s)* Refills:*0* 15. Provera Oral 16. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. 17. iron sucrose Intravenous Discharge Disposition: Home Discharge Diagnosis: Atypical Chest Pain Obesity Diabetes Depression 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 chest and left arm pain that was concerning for a clot in your lung. Imaging showed there was no clot in the lung, arm or legs. It is unclear what your chest pain is from, but it was better controlled on oral pain medication. The following medication changes were made: ADDED: Tramadol, take one tablet every 6 hours as needed for pain. Be cautious as this medication can cause drowsiness. It can also interact with some of your other medications, so if you have any concerning symptoms, please stop taking it and call your doctor. No other medication changes were made, you should continue all your home medications as were previously directed. You were also seen by social work who gave you information about your family member becoming a PCA. It was a pleasure meeting you and participating in your care. Followup Instructions: Please follow up with your PCP within the next several weeks.

[ "401.9", "285.9", "327.23", "272.0", "786.59", "278.01", "311", "626.2", "250.00" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

8375, 8381

3897, 5576

346, 353

8473, 8473

3093, 3874

9503, 9568

2196, 2236

7045, 8352

8402, 8452

5602, 7022

8624, 9480

2251, 3074

1400, 1432

296, 308

409, 1381

8488, 8600

1454, 2018

2034, 2180

27,295

159,584

24149

Discharge summary

report

Admission Date: [**2162-12-11**] Discharge Date: [**2162-12-17**] Date of Birth: [**2096-2-4**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Sulfa (Sulfonamides) / Danazol / Ceftriaxone / Ampicillin Attending:[**First Name3 (LF) 613**] Chief Complaint: Altered mental status, fever Major Surgical or Invasive Procedure: - Intubation - Lumbar Puncture History of Present Illness: Patient is a 66 year old female with lupus who presented to the emergency room with altered mental status and fever. She was in her usual state of health until the night prior to admission at which time she developed chills and later confusion. . Patient receives most of her care in [**Location (un) 61361**], [**State 8449**], and was in town visiting when she developed the symptoms noted by her husband. [**Name (NI) **] also noted some possible gait instability. . Review of systems was negative for any sick contacts, fevers, [**Name2 (NI) **], N/V/D/C. Her husband dose report prior episodes of confusion years past with CNS lupus involvement. Past Medical History: - SLE: Diagnosed by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 9241**] ([**University/College 33150**]). No renal involvement. Symptoms included arthralgias and thrombocytopenia, requiring steroids. Also has a history of CNS involvement (altered mental status, fevers). She has been in remission for 15 years, then had hemolytic anemia. Medications include Imuran and steroid taper. - Hypothyroidism s/p goiter resection 35 years ago - Osteoporosis - Shingles with neuralgia - Anxiety Social History: Patient is married, lives in [**Location 61361**], [**State 8449**]. Remote smoking and alcohol history. Family History: Non-contributory Physical Exam: Upon arrival to floor: VS T 98.8 BP 98/60, HR 46, RR 18, Oxy sat 100% on RA GEN: NAD, comfortable, resting in bed, husband at bedside, pleasant [**Name (NI) 4459**]: [**Name (NI) 2994**], EOMI, anicteric, MMM, fleshy nodule at roof of mouth, no erythema or evidence of infection NECK: Supple, no JVD, bandage in place at site of prior RIJ line RESP: Clear to ascultation bilaterally CV: RR, S1, S2, no m/g/r ABD: ND, NT, +BS, no HSM or masses EXT: No c/c/e, warm, good pulses, erythema over right arm where tape was in place SKIN: No other rashes or lesions, no jaundice NEURO: A&Ox3, CNs grossly intact, no focal motor or sensory deficits PSYCH: Pleasant Pertinent Results: [**2162-12-11**] 11:20PM TYPE-ART TEMP-36.9 PO2-152* PCO2-27* PH-7.48* TOTAL CO2-21 BASE XS--1 [**2162-12-11**] 11:20PM GLUCOSE-131* LACTATE-1.0 [**2162-12-11**] 07:02PM LACTATE-1.6 [**2162-12-11**] 06:46PM GLUCOSE-182* UREA N-10 CREAT-0.7 SODIUM-145 POTASSIUM-3.8 CHLORIDE-116* TOTAL CO2-18* ANION GAP-15 [**2162-12-11**] 06:55PM GLUCOSE-193* UREA N-9 CREAT-0.7 SODIUM-143 POTASSIUM-3.5 CHLORIDE-118* TOTAL CO2-16* ANION GAP-13 [**2162-12-11**] 06:46PM CALCIUM-6.6* PHOSPHATE-2.8 MAGNESIUM-1.1* [**2162-12-11**] 05:02PM TYPE-ART TEMP-37.6 PO2-73* PCO2-36 PH-7.37 TOTAL CO2-22 BASE XS--3 INTUBATED-NOT INTUBA [**2162-12-11**] 04:21PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2162-12-11**] 04:21PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2162-12-11**] 04:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2162-12-11**] 03:18PM LACTATE-0.7 [**2162-12-11**] 12:48PM LACTATE-2.0 [**2162-12-11**] 12:40PM GLUCOSE-95 UREA N-13 CREAT-1.2* SODIUM-143 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-31 ANION GAP-15 [**2162-12-11**] 12:40PM estGFR-Using this [**2162-12-11**] 12:40PM ALT(SGPT)-42* AST(SGOT)-43* ALK PHOS-53 AMYLASE-105* [**2162-12-11**] 12:40PM LIPASE-43 [**2162-12-11**] 12:40PM ALBUMIN-3.8 CALCIUM-9.8 PHOSPHATE-2.1* MAGNESIUM-1.4* [**2162-12-11**] 12:40PM TSH-1.9 [**2162-12-11**] 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2162-12-11**] 12:40PM WBC-10.2 RBC-4.33 HGB-14.7 HCT-42.2 MCV-98 MCH-33.9* MCHC-34.7 RDW-14.7 [**2162-12-11**] 12:40PM NEUTS-94.9* BANDS-0 LYMPHS-1.0* MONOS-3.8 EOS-0.2 BASOS-0.2 [**2162-12-11**] 12:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2162-12-11**] 12:40PM PLT SMR-NORMAL PLT COUNT-245 [**2162-12-11**] 12:40PM PT-16.4* PTT-35.8* INR(PT)-1.5* . CT Torso [**12-11**]: IMPRESSION: 1. No evidence of PE. 2. Peribronchovascular ground glass opacity within the anterior right upper lobe may represent aspiration pneumonia. Bilateral small pleural effusions and lower lobe consolidation, likely atelectasis. 4. Endotracheal tube and NG tube in acceptable position. 5. Small amount of ascites. CT Head [**12-11**]: IMPRESSION: 1. No hemorrhage or edema. 2. Increased mucosal thickening in the ethmoid sinuses. MRI Head [**12-12**]: IMPRESSION: Several bilateral white matter T2 hyperintensity foci, predominantly in the corona radiata, most likely representing chronic microvascular infarctions. However, given clinical history, another diagnostic consideration does include CNS lupus. Chest X-Ray [**12-13**]: PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: There is interval improvement in the previously identified right mid lung opacities. Bibasilar atelectasis remains. No new pulmonary infiltrates are identified. The heart size and mediastinal contours are normal. The pleural surfaces are smooth. ET tube is 8 cm above the carina, at the superior aspect of the clavicles and unchanged from the last two days. A right IJ central venous catheter is again seen in the mid SVC, and an NG tube is seen in the stomach and courses out of view inferiorly. IMPRESSION: Interval improvement in right mid lung opacities. Bibasilar atelectasis remains. ET tube is 8 cm above the carina. No new pulmonary infiltrates identified. Brief Hospital Course: In the emergency room, she was found to have an unsteady gait and confusion. Her initial vital signs were T 101.4, HR 129, BP 143/73, RR 18, and 96% on room air. A head CT was completed and was unremarkable. A chest x-ray was without any significant findings except for a possible right middle lobe pneumonia. A lumbar puncture was attempted three times, but was unsuccessful initially. Patient received one dose of intranvenous vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone due to concerns over an unsteady gait and confusion. Labs including an urine analysis, serum urine and toxicology screen, and TSH were within normal limits. There was a mild transaminitis noted. A lactate was drawn that was initially 2.0, which came down to 0.7. A bedside echo did not reveal any effusion. . The patient was admitted to the MICU for further monitoring. While there, she was intubated and briefly on pressors. She was successfully extubated and did well. She was initially continued on acyclovir until her HSV PCR returned negative. Rheumatology and neurology were both consulted and assisted with her management. The differential considered for her presentation was broad and included sepsis, aseptic or bacterial meningitis, or lupus cerebritis, among other causes. She did have a history of known CNS involvement of her lupus in the past, with reported similar symptoms. All of her cultures (CSF, urine, blood, sputum, stool, including for PCP, [**Name10 (NameIs) **], [**Name Initial (NameIs) **]. difficile) demonstrated no growth. Her antibiotics and antivirals were discontinued once all results were negative. Given the concern over lupus cerebritis, she was treated with intravenous dexamethasone, then hydorcourt, and finally on an oral prednisone taper. There was a question of a possible reaction to cephalosporins given in the emergency, so those were avoided. . There was not overwhelming laboratory support of CNS involvement of her lupus, but this was considered to be the most likely source of her symptoms, other than the acute stress of an infection such as pneumonia. It was also felt that, after additional history was obtained, the patient may have missed some doses of her steroids in the setting of being chronically steroid-dependent that lead to her symptoms. . The patient's mental status returned to baseline, and, per her and her husband's preference, her follow up was to occur with her outpatient [**Name Initial (NameIs) 10368**] in [**Location (un) 61361**] as well as with contacts her husband had in the area. She was discharged on a prednisone taper, as well as atovaquone for treatment of her lupus. . Other issues managed during her stay included: - Anemia: Patient had mild anemia during her stay with negative hemolysis labs. There was felt to be some degree of dilutional effect from fluids received in the intensive care setting. - LFT elevations: Patient had a mild transaminitis, with an elevated INR to 1.5 at admission. The etiology of this was unclear, possibly related to medications or viral syndrome. She was instructed to have her liver function tests monitored on an outpatient setting. - Hypothyroidism: Her home dose of levothyroxine was thought to 12.5 mcg, so this was continued. A TSH was 1.9 in the emergency room. - Anxiety, insomnia: Her home medications of benzodiazepam agents were initially held given her altered mental status. - Neuralgia: Patient's home dose of lyrica was continued once her mental status returned to baseline. - Physical therapy evaluated the patient, and she was cleared for a safe discharge. She was discharged home with plans being made for close outpatient follow up. Medications on Admission: Prednisone 12 mg daily (tapering down recently) Imuran 150 mg daily Synthroid, unknown dose Lyrica 100 mg TID for neuralgia Bisphosphonates Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Please continue your home dose. 2. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO q8hours (). 3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Please taper as directed by your [**Location (un) 10368**]. . Disp:*60 Tablet(s)* Refills:*2* 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qHS PRN: As needed at night for insomnia, anxiety. 5. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily): Please discuss with your [**Location (un) 10368**] whether to continue this medication while on prednisone. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Altered mental status Secondary Diagnoses: - Lupus - Hypothyroidism - Osteoporosis - Recent diagnosis of shingles Discharge Condition: Stable, ambulating without difficulty and cleared by physical therapy. Tolerating regular diet, afebrile. Discharge Instructions: You were admitted due to symptoms of confusion, changes in mental status, and fevers. You were intubated due to concern over securing your airway, and briefly treated with medications to support your blood pressure. You also received several antibiotics which were stopped when all of your culture data came back negative. Increased doses of steroids were also used in the event that your diagnosis of Lupus was contributing. A lumbar puncture was also completed. You were monitored on the regular floor and seen by physical therapy. . Please follow up at your scheduled appointments with your primary care physician, [**Name10 (NameIs) **] rheumatologists. You were discharged on 40 mg of Prednisone daily, and should taper down this medication as advised by your [**Name10 (NameIs) 10368**]. . Please contact your primary care physician, [**Name10 (NameIs) 10368**], or go to the emergency room if you experience fevers (greater than 101), confusion, numbness or weakness of extremities, difficulty speaking, chest pain, shortness of breath, dizziness, or other concerning symptoms. Followup Instructions: Please follow up with your primary care physician and [**Name10 (NameIs) 10368**] as scheduled over the next few weeks. You will need to discuss tapering of your steroids (currently at 40 mg of Prednisone), as well as the events of your recent hospitalization. Your Imuran was stopped, and atovaquone was continued until your [**Name10 (NameIs) 10368**] decides otherwise. . You should also discuss risks and benefits of initiating aspirin therapy. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "244.0", "276.0", "285.9", "780.6", "E930.9", "790.4", "053.19", "710.0", "733.00", "293.0", "300.00", "V58.65", "995.0", "780.52", "276.2", "079.99" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "03.31", "38.93", "33.24", "96.71" ]

icd9pcs

[ [ [] ] ]

10420, 10426

5904, 9577

363, 396

10605, 10713

2441, 5881

11846, 12419

1732, 1750

9767, 10397

10447, 10447

9603, 9744

10737, 11823

1765, 2422

10511, 10584

295, 325

424, 1076

10466, 10490

1098, 1594

1610, 1716

44,375

171,207

42263

Discharge summary

report

Admission Date: [**2152-9-26**] Discharge Date: [**2152-10-1**] Date of Birth: [**2082-2-6**] Sex: F Service: SURGERY Allergies: aspirin / Codeine Attending:[**First Name3 (LF) 3223**] Chief Complaint: bleeding from stoma Major Surgical or Invasive Procedure: Endoscopic clipping of anastomotic ulcers History of Present Illness: Mrs. [**Known lastname 91607**] is a 70 year-old female s/p multiple abdominal operations (see PSH below) for ischemic colitis transferred from [**Hospital **] Hospital for an acute GI bleed while on heparin and Coumadin. Briefly, she is s/p lap chole [**2152-7-4**] and lap SBR/LOA [**2152-7-22**] who presented to [**Hospital **] Hospital on [**2152-8-14**] with vague abdominal pain. Her abdominal pain continued to worsen and she developed signs of peritonitis with a CT scan showing ischemic colitis and pneumatosis. She underwent an exploratory laparotomy, resection ischemic/necrotic small bowel, debridement of necrotic rectum, sigmoid and descending colon with temporary abdominal closure on [**2152-8-22**]. Prior to her planned take back for a second look, she developed sudden left lower extremity ischemia which required a left femoral artery embolectomy on [**2152-8-24**] and following her embolectomy, she was started on a heparin drip. Her planned 2nd look was performed on [**2152-8-25**] where she underwent a washout, repair of pelvic floor hernia with Stratus mesh, mucous fistula creation, temporary closure of abdomen, rigid proctosigmoidoscopy. A final operation was performed on [**2152-8-28**] where a washout, creation of ileal colonic anastomosis (side-to-side hand-sewn two layer), and closure of abdomen with Stratus mesh (10x25cm) via complex closure was performed. She had a delayed return of bowel function and was started on TPN with her starting to take POs in mid-[**Month (only) 359**] and recently started on Coumadin She was doing well until [**9-23**] when she started to have melena from her ostomy. Her INR at that time was approximately 2.0. She continued to have melena from her ostomy and her aspirin, heparin and Coumadin were held with an INR of 2.6 on [**2152-9-25**] down to 2.2 on [**2152-9-26**]. She underwent a upper GI endoscopy which revealed no active bleeding source. Her ostomy output continued to remain dark with a decreasing hematocrit down to 22.5 on [**2152-9-19**]. She was transfused 2 units of PRBC with an increase in hematocrit to 28.9. She has been stable for the previous 24 hours (28.4,29.3,29.5,28.6) but has continued to have dark burgundy output from her ostomy with an INR of 1.6. She underwent a tagged RBC scan this evening which localized to the right upper quadrant and received 1 unit of FFP and 2 units of plateets. She was subsequently transferred to [**Hospital1 18**] for possible angioembolization. Currently, she reports that she has minimal incisional pain. She has had no nausea or vomiting. She was previously DNR/DNI but currently reports that her code status has been changed to FULL code. Past Medical History: cervical cancer s/p radiation to pelvis 34 years ago, GERD, TAAA/AAA (4.2cm), ECHO [**8-23**] (EF 55-60%, mild mitral regurg), pSBO, HTN, Last colonoscopy [**4-12**] failed [**1-5**] sigmoid stricture -[**2152-7-4**] lap chole for gangrenous cholecystitis -[**2152-7-22**] lap LOA/SBR for adhesions/pSBO -[**2152-8-22**] exlap, cystoscopy with bilateral ureteral stents, resection ischemic/necrotic small bowel, debridement of necrotic rectum, sigmoid and descending colon with temporary abdominal closure -[**2152-8-24**] Left femoral exploration CFA embolectomy -[**2152-8-25**] 2nd look exlap/washout, repair of pelvic floor hernia with Stratus mesh (16x20cm), mucous fistula creation, temporary closure of abdomen, rigid proctosigmoidoscopy -[**2152-8-28**] 3rd look exlap/washout, creation of ileal colonic anastomosis side-to-side hand-sewn two layer), closure of abdomen with Stratus mesh (10x25cm) via complex closure. Social History: Previously lived at home in [**Hospital1 **]. Smoked until [**4-12**], 40 pack year history. Denies EtOH or recreational drugs. Family History: Colorectal cancer Physical Exam: Admssion: GEN: Alert and oriented x3, No acute distress HEENT: No scleral icterus, mucus membranes moist CV: Regular rate and rhythm, No Murmurs/rubs/gallops PULM: Clear to auscultation bilaterally ABD: Soft, nondistended, appropriately Tender to palpation around incision, no rebound or guarding, normoactive bowel sounds, no palpable masses. VAC dressing in place and functioning, wound healing well with no signs of infection. Ostomy with burgundy output. DRE: normal tone, no gross or occult blood. Ext: No LE edema, LE warm and well perfused, distal pulses palpable bilaterally. Dsicharge: GEN: Alert and oriented x3, No acute distress HEENT: No scleral icterus, mucus membranes moist CV: Regular rate and rhythm, No Murmurs/rubs/gallops PULM: Clear to auscultation bilaterally ABD: Soft, nondistended, appropriately Tender to palpation around incision, no rebound or guarding, normoactive bowel sounds, no palpable masses. VAC dressing in place and functioning, wound healing well with no signs of infection. Ostomy with brown stool colored output. Ext: No LE edema, LE warm and well perfused, distal pulses palpable bilaterally. Pertinent Results: [**2152-10-1**] Hct 33.0 [**2152-9-30**] 32.9* [**2152-9-29**] 32.4* [**2152-9-27**] 34.3* [**2152-9-27**] 34.9 [**2152-9-27**] 26.4* [**2152-9-27**] 28.8* PTT has been [**2152-10-1**] 04:54AM BLOOD PT-14.3* PTT-62.6* INR(PT)-1.2* [**2152-9-30**] 09:00AM BLOOD PTT-69.3* [**2152-9-30**] 03:02AM BLOOD PTT-62.9* CTA abd/pelvis [**2152-9-27**] 1. Extensive atherosclerotic disease as described above including mild celiac axis stenosis, right common femoral artery stenosis, infrarenal abdominal aortic aneurysm, focal aneurysmal dilatation of the left iliac artery. 2. Probable chronic infarct involving the spleen. 3. No active extravasation. 4. Postoperative changes within the pelvis including areas of expected bowel wall thickening, predominantly small bowel, left lower quadrant colostomy, Hartmann's pouch, well-delineated and thick walled small fluid collection which is unchanged from the prior exam and is not amenable to CT-guided or ultrasound-guided drainage. 5. Apparent open midline incision, small right-sided fat-containing spigelian hernia which appears uncomplicated. Small Bowel Enteroscopy [**2152-9-28**] Normal mucosa in the esophagus Normal mucosa in the stomach Normal mucosa in the duodenum Normal mucosa in the proximal jejunum Otherwise normal EGD to third part of the duodenum Colonoscopy report [**2152-9-28**] Polyp on the Ileo-cecal valve, biopsy was obtained. Endomucosal resection was not attempted given recent GI bleed. (biopsy, endoclip) Ulcer in the colon, with large clot that was removed and clips placed. Additional clip was placed over another anastomotic ulcer. This was the likely source of the patient's bleeding. Suture material at the anastomotic site at the ileo-cecal valve Otherwise normal colonoscopy Brief Hospital Course: The patient was admitted to the ACS service on [**2152-9-26**]. On the morning of [**9-27**], the patient began to have copious amount of melena from her ostomy site. Her HCT dropped from 29 to 26 overnight and blood transfusion was started. The patient remained hemodynamically stable the entire time. She was transferred to the ICU on the morning of [**9-27**] for concern of ongoing bleeding. Interventional radiology was consulted and recommended CTA of the abdomen and pelvis, which showed no active bleeding. Patient received two units of blood total and HCT stabilized at 34. GI was consulted and performed colonoscopy on [**9-28**]. This showed larger ulcer at anastamosis site and this was clipped. A polyp was also seen at the ileocecal junction and this was biopsied. OSH attending was called regarding transfer back to [**Hospital **] hospital, but attending requested that patient be re-stabilized on her heparin gtt before transferring back. The patient was transferred to the floor on [**9-28**] and became therapuetic on heparin gtt on [**2152-9-30**] at 0300 and has remained therapuetic since then running at heparin drip of 1200 units/hour. She was continued on TPN until [**2152-9-30**] in the evening as she was tolerating regular diet, although PO intake was limited. She did not have bleeeding from ostomy site since [**2152-9-28**] after the clipping procedure and has had stable hematocrit since then, as it was checked daily. Her wound vac was changed on Friday [**2152-9-29**] last a nd her abdominal wound had good granulation tissue. Vascular surgery was consulted at the request of Dr. [**Last Name (STitle) 91608**] and agreed that the patient needed long term anticoagulation of heparin with a bridge to coumadin and thought that there was no prophylactic surgical intervention at this time to prevent further atheroembolisms. Patient was started on coumadin bridge [**2152-10-1**] with 5mg Coumadin and continued on heparin drip. Medications on Admission: Miconazole 2% topical, pantoprazole 40 mg IV BID, Florastor 250 mg PO BID, Sucralfate 1gm PO AC+HS, Dilaudid 0.5-1 mg Q6H PRN, Tylenol 1000mg IV Q6H PRN, Duoneb Q4H while awake, Haldol 2mg IV Q4H PRN, Zofran 4 mg IV Q6H, Percocet 1 Q4H PRN, Compazine 10 mg IV Q6H, racemic epinephrine 0.ml INH Q30M PRN Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 5. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day). 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea. 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for Anxiety. 10. haloperidol lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for agitation/anxiety. 11. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). 12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 **] Discharge Diagnosis: Bleeding anastomotic ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] for evaluation of your bleeding through your ostomy bag. You were evaluated by Interventional Radiology and a CT angiogram of your abdomen and pelvis was ordered which showed no area of active bleeding. Gastroenterology was consulted and performed colonoscopy procedure to find source of bleeding, and they were successful in controlling the bleeding. Since that time you have been your red blood cell count has been stable and you ahve been continued on anticoagulation with a heparin drip. Vascular surgery were also consulted to comment on your anticoagulation and agreed that you needed long term anticoagulation with coumadin, which was started on [**2152-10-1**]. You are being transferred back to [**Hospital **] Hospital at your request and the request of Dr. [**Last Name (STitle) **] at [**Hospital **] Hospital. Should you need our services again please do not hesitate to contact us, our number is below. Your eventual discharge instructions will be [**First Name8 (NamePattern2) **] [**Hospital **] Hospital. Followup Instructions: Please call the Acute Care Surgery Service if you need to contact any of the team who cared for you at [**Hospital1 18**]. The contact number is [**Telephone/Fax (1) 600**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2152-10-1**]

[ "569.82", "211.3", "V15.82", "707.25", "997.49", "707.03", "269.9", "E878.2", "V12.51", "V58.61", "285.9", "530.81", "780.52", "998.11", "V44.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.43", "99.15", "45.13", "45.25" ]

icd9pcs

[ [ [] ] ]

10917, 10987

7162, 9127

296, 340

11058, 11058

5381, 7139

12286, 12619

4184, 4204

9480, 10894

11008, 11037

9153, 9457

11196, 12263

4219, 5362

237, 258

368, 3068

11073, 11172

3090, 4020

4036, 4168

28,078

122,847

8782

Discharge summary

report

Admission Date: [**2106-4-28**] Discharge Date: [**2106-4-28**] Date of Birth: [**2026-3-29**] Sex: F Service: NEUROSURGERY Allergies: Ciprofloxacin Hcl / Bactrim / Nsaids / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2724**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 80 F transferred from [**Hospital3 628**], intubated, with a massive R. SDH with herniation. She was in her usual state of health at her nursing home until approximately [**2028**] when she reportedly fell out of her wheel chair reaching for a sewing needle. This was unwitnessed. She was placed back into bed and then at 2100 found unresponsive. Brought to [**Location (un) 620**] ED and intubated. INR 1.8 and given Vitamin K and Factor IX. She is on coumadin, plavix, and ASA. Past Medical History: PMHx: 1. Dysequilbrium/vertigo, felt to be cervical by Dr. [**Last Name (STitle) **] 2. Status post coiling of right PCA aneurysm in [**2098**] after small subarachnoid hemorrhage . Presented at that time with unsteady gait, dysequilibrium, and diplopia. States her gait never improved status post coiling. 3. Gait disorder. Followed in past by [**Doctor Last Name **] and [**Doctor Last Name **]. No change in gait or mental status testing status post large volume LP in past. Did have improvement after wearing of soft cervical collar at night. 4. Cervical spondylosis with MRI in past showing C5/C6 disc with indentation on thecal sac. 5. Stress and urge incontinence. Followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] past. 6. Hypercholesterolemia 7. Hypertension 8. Hypothyroidism 9. COPD 10. G8P5 11. Status post appendectomy 12. Status post hysterectomy 13. Status post breast surgery [**12**]. Depression 15. Anxiety Social History: Homemaker. 5 kids. Widowed in [**2097**]. Living in [**Hospital3 **]. Smoker of 1ppd x 40-50 years. At baseline, spend most of her time in a wheelchair. Family History: Parents deceased in their 80s due to their old age, but mother also with multiple strokes. Physical Exam: PHYSICAL EXAM: O: T: 96.5 BP: 126/68 HR: 61 R:18 O2Sats: 100% on AC Gen: Intubated, C-collar in place HEENT: Pupils: fixed at 9mm b/l, dilated, unreactive to light; small laceration L. forehead; c-collar in place Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: GCS 4 (intubated); Unresponsive to voice. No movement of UE's to pain. Decorticate posturing of LE to painful stimulation. Minimal movement of feet spontaneously but not following commands. Cranial Nerves: I: Not tested II: Pupils equal, fixed and dilated to 9mm and nonreactive to light bilaterally. Corneal reflexes are absent. III, IV, VI: No doll's eye reflex VII: not tested VIII: not tested IX, X: no gag reflex [**Doctor First Name 81**]: not tested XII: not tested Motor/Sensation: Does not open eyes. No movement of UE's. Decorticate posturing of LE's to pain. Pertinent Results: CT: 2.6 cm R. SDH with 1.7 cm subfalcine herniation, completely effacing the R. ventricle. Supracellar cisterns are obliterated. Midbrain is elongated. Labs: WBC 13, HCT 31, PLTS 279, PT 15.6, PTT 27, INR 1.4, Na 141, K 3.6, Cl 101, HCO3 30, BUN 15, Cr 0.7, Cluc 156 At [**Location (un) 620**]: INR 1.8, PTT 36.4 Brief Hospital Course: She was admitted to neurosurgical service. After long discussion with her son and daughter, they understand the extent of her injury and wish to make her comfort measures only. She was extubated and expired approximately 15 minutes after extubation. Medications on Admission: Medications prior to admission: synthroid, spireva, plavix, simvastatin, ASA, coumadin, B12, sertraline, nifedipine, detrol HCTZ, percocet Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: R SDH Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2106-4-28**]

[ "272.0", "852.21", "V58.61", "401.9", "496", "E884.3" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

3867, 3876

3396, 3649

329, 336

3926, 3936

3058, 3373

3989, 4025

2007, 2099

3838, 3844

3897, 3905

3675, 3675

3960, 3966

2129, 2451

3707, 3815

285, 291

364, 850

2673, 3039

2466, 2657

872, 1820

1836, 1991

21,460

179,115

51262

Discharge summary

report

Admission Date: [**2144-7-23**] Discharge Date: [**2144-7-27**] Date of Birth: [**2095-4-26**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy. History of Present Illness: This is a 49 y.o. female w/ history of two liver transplants for hemochromatosis and EtOH (first in [**2136**], second following hepatic artery thrombosus in [**2137**]) and ESRD on TuThSa dialysis, who was transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**7-23**] with abdominal pain and hematemesis. The morning of admission, the patient had been feeling weak with DOE. She then went to her dialysis appointment where she had worsening of the Sx and decided to go to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. In triage at [**Hospital1 **], the patient unexpectedly vomited a large volume of blood. At that time, she was transfused 2 units, Pantoprazole drip was started and she was transferred to [**Hospital1 18**]. Past Medical History: - h/o hypoxic respiratory failure and hypotension in [**3-/2144**] for altered mental status and ? PE, s/p intubation complicated by VAP - possible PE, now on coumadin - ESRD [**3-4**] hypotension in [**3-/2144**] - ETOH cirrhosis s/p OTL [**2137-12-7**], s/p OTL [**2136-6-4**] - renal insufficiency (due to cyclosporine: baseline cr 1.4) - hemochromatosis - HTN - CAD s/p MI - asthma - h/o cyclosporine toxicity - history of antiphospholipid syndrome with myopathy and neuropathy . Social History: Lives with husband. - Tobacco: smokes [**4-3**] pack per day - Alcohol: drinks EtOH rarely, [**2-2**] glass of wine a week - Illicits: Denies Family History: Father with [**Name2 (NI) **] ca and DVT Physical Exam: On admission: General: Cachectic, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at L>R bases, clearing above, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender but greatest in the lower quadrants. No organomegaly. No rebound or guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, trace symmetric edema Neuro: CNII-XII intact, moving all extremities, gait not assessed. On discharge: VS: 98.0 1121/67 60 16 97% General: Walking around room, in no acute distress HEENT: Laceration over left eyebrow with 3 sutures in place, sclera anicteric, MMM, oropharynx clear Neck: supple, JVD not elevated, no LAD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender but greatest in the lower quadrants. No organomegaly. No rebound or guarding. Ext: warm, well perfused, 2+ pulses Neuro: A&Ox3 Pertinent Results: Labs at admission: [**2144-7-23**] 12:00PM BLOOD WBC-7.6# RBC-2.71* Hgb-8.1* Hct-23.8* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.0* Plt Ct-268 [**2144-7-23**] 12:00PM BLOOD PT-16.2* PTT-25.9 [**Month/Day/Year 263**](PT)-1.4* [**2144-7-23**] 12:00PM BLOOD UreaN-91* Creat-4.6* Na-136 K-5.5* Cl-104 HCO3-18* AnGap-20 [**2144-7-23**] 12:00PM BLOOD ALT-7 AST-15 AlkPhos-117* TotBili-0.4 [**2144-7-24**] 02:59AM BLOOD Cortsol-4.9 [**2144-7-23**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2144-7-23**] 08:12PM BLOOD Lactate-1.2 Studies: EGD [**7-24**]: Varices at the fundus. Erythema, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy. Otherwise normal EGD to second part of the duodenum RUQ U/S: IMPRESSION: Normal hepatic echotexture with patent vessels. Trace free fluid. Splenomegaly to at least 13 cm. CXR: FINDINGS: Right-sided internal jugular dialysis catheter terminates with tip in the right atrium. The lungs demonstrate bibasilar atelectasis and scarring in the left upper lobe. There is no pleural effusion or pneumothorax. The heart is normal in size. Normal cardiomediastinal silhouette. EKG: Regular. P wave axis is abnormal. Normal QRS. Echo: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 55-60%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate ([**2-2**]+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**2-2**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 49 year old woman with EtOH cirrhosis s/p two liver transplants ([**2136**] and [**2137**]), ESRD on TuThSa HD here with hemodynamically significant upper GI bleed and abdominal pain. Now with improved abdominal pain and no further episodes of UGI bleed/melena. #Upper GI bleed: Patient with history of liver disease and is s/p two liver txpts. She reports having an EGD performed approximately 2 years ago for reasons unrelated to her liver disease that did not show varices. She presented [**7-23**] following an episode of hematemis at OSH. She received 1 unit of blood at OSH and then an addional 2 units here. She was also started on a PPI drip in the ED and a 7 day course of ciprofloxacin. She was initially transferred to the MICU, where her HCT remained stable following transfusion. An EGD on [**7-24**] revealed non-bleeding varices at the fundus and portal hypertensive gastropathy. Transferred to [**Hospital Ward Name 121**] 10 in stable condition on [**7-25**]. On the floor she remained stable without further bleeding. #Hypotenstion: The patient has chronically low blood pressures in the 70-90s systolic. She describes even lower BPs during dialysis. The patient denies any symptoms related to her low BP. In the MICU, the patient was started on midodrine and an AM cortisol was checked that revealed a level of 4.9, indicating likely adrenal insufficiency. She was started on high-dose hydrocortisone. The following day, a repeat AM cortisol was perfomed >12 hours after the prior steroid dose, and the level was 21.3. The steroids were stopped and the patient's BP remained >90 systolic for the remainder of her inpatient stay. She will be discharged on midodrine. #Abdominal pain: The patient developed abdominal pain following her episodes of hematemesis. Likely related to spasming during vomiting but also considered ischemia related to low BP. Lactate was measured to be 1.2 on admission and climbed to 5.5 during her hospital stay. Unclear etiology, but may be related to hypotension/ischemia vs. inability to clear lactate due to ESRD and skipped dialysis sessions while inpatient. The patient's abdominal pain resolved largely by the end of the first hospital day. She was continued on her home doses of oxycontin. #ESRD: The patient developed ESRD during her prior admission in early [**2144**]. On 3x weekly dialysis. She was dialysed as an inpatient on [**2144-7-27**]. #Fall: The patient frequently left the floor for extended periods of time during her inpatient stay. Often left to smoke despite counseling. During one trip on the night of [**7-25**], the patient tripped and fell causing a laceration above her left eye that required 3 sutures by surgery and a Head CT. The head CT did not reveal any ICH. She will require suture removal by her PCP on [**Name9 (PRE) 2974**], [**7-31**]. #Liver transplant: Continued cellcept and sirolimus. No active issues. #Possible PE: The patient was started on warfarin x3 months during her last admission due to a possible PE. She reported being on warfarin at home at admission although was subtherepeuticwith [**Name9 (PRE) 263**] 1.3. As an inpatient, coumadin was held in the setting of recent UGI bleed. She will be discharged off coumadin. Also stopped ASA given recent bleed. #Chronic pain/fibromyalgia: has chronic, neuropathic pain throughout her body. We continued her home dose of oxycontin (60mg QAM, 40mg QPM) and her lyrica. Medications on Admission: - diazepam 5mg PO TID PRN - mycophenolate mofetil 500mg [**Hospital1 **] - oxycontin 40mg [**Hospital1 **] - oxycontin 20mg [**Hospital1 **] - Lyrica 50mg daily - simvastatin 20mg daily - sirolimus 2mg daily - warfarin 3mg daily - zaleplon 5mg QHS - ascorbic acid 500mg [**Hospital1 **] - Aspirin 81mg daily - ferrous sulfate 325mg daily - folic acid 0.4mg daily Discharge Medications: 1. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). 2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. ciprofloxacin 500 mg Tablet Sig: 0.5 Tablet PO Q24H (every 24 hours) for 2 days. Disp:*3 Tablet(s)* Refills:*0* 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. zaleplon 5 mg Capsule Sig: One (1) Capsule PO at bedtime. 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 12. folic acid 1 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 every twenty-four(24) hours. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper gastrointestinal bleed End-stage renal disease on hemodialysis 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 after a bleed from the stomach. You underwent an upper endoscopy that showed varices in the stomach, although no evidence of active bleeding. You received several transfusions of red blood cells and one cycle of dialysis, and you remained stable afterwards with no further bleeding. The following changes were made to your medicines. - ADDED midodrine 5 mg three times daily. - ADDED pantoprazole 40 mg once daily for stomach acid suppression. - ADDED ciprofloxacin 250 mg once daily to take for three more days. - STOPPED warfarin. - STOPPED aspirin. Please discuss with your liver doctor at your clinic appointment on Wednesday before restarting. - STOPPED diazepam due to low blood pressure. Please discuss with your primary care physician before restarting. There were no other changes to your medicines. Please note your follow-up appointments below. Your sutures should be removed at your primary care visit appointment this coming Friday. Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [**2144-7-29**] at 9:40 AM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital **] MEDICAL GROUP Where: [**Street Address(2) 3375**], [**Location (un) **], MA With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8682**] [**Telephone/Fax (1) 133**] When: FRIDAY [**2144-7-31**] at 8:15 AM Completed by:[**2144-7-27**]

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icd9cm

[ [ [] ] ]

[ "08.81", "45.13", "39.95" ]

icd9pcs

[ [ [] ] ]

10114, 10120

5019, 8470

318, 347

10252, 10252

2972, 4996

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1848, 1891

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10141, 10141

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45868

Discharge summary

report

Admission Date: [**2111-8-3**] Discharge Date: [**2111-8-6**] Date of Birth: [**2029-3-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: Abdominal aortic aneurysm. Major Surgical or Invasive Procedure: [**2111-8-3**] 1. Total percutaneous endovascular aortic aneurysm repair. 2. Zenith main body 32-82, ipsilateral limb on the right 14- 73, left limb 18-73 with 10-71 extender. 3. Bilateral ultrasound guidance for femoral access. History of Present Illness: The patient is a an 82-year-old male with a complex infrarenal aortic aneurysm with marginal anatomy for endovascular repair. He is not an open surgical candidate. He presents for endovascular repair. Past Medical History: Renal cell carcinoma s/p a nephrectomy [**2085**] Dural infiltration of a metastatic renal cell carcinoma s/p laminectomy at C2-3 for decompression of metastatic renal cell carcinoma on [**2107-10-18**], also s/p upper cervical spine irradiation that was completed on [**2107-12-7**] CAD s/p MI per patient Chronic renal insufficiency, baseline Cr 1.2-1.6 BPH Social History: Patient lives in [**Location (un) 55**] with wife of 60 years. Smokes 1ppd x 60 years, drinks 1-2 drinks of vodka (1 oz) daily, no other drugs. Has 4 children, lots of grandchildren, 2 great-grandchildren. Family History: Non-contributory Physical Exam: a/o nad grossly intact cta rrr pos bs kyphotic palp distal pulses Pertinent Results: [**2111-8-5**] 05:35AM BLOOD WBC-7.1 RBC-2.94* Hgb-10.1* Hct-30.2* MCV-103* MCH-34.5* MCHC-33.6 RDW-14.1 Plt Ct-116* [**2111-8-5**] 05:35AM BLOOD Plt Ct-116* [**2111-8-5**] 05:35AM BLOOD Glucose-135* UreaN-25* Creat-1.6* Na-134 K-3.9 Cl-101 HCO3-24 AnGap-13 [**2111-8-4**] 04:30AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.4 Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname 2922**] A. was admitted on [**8-3**] with AAA. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a EVAR He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. SHe was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. To note pt did have a slight increase in creatine, hydrated. Stable on DC. Did have low grade temps. Thought to be an inflammatory responce to the thromboses AAA post EVAR. CX, UA, CXR negative. Medications on Admission: ATORVASTATIN CALCIUM 20mg QD, Carbidopa-Levodopa 25 mg-100 mg [**Hospital1 **], finesteride ? dose, Metoprolol Succinate 25 mg ([**12-15**] tab) [**Hospital1 **], Tamsulosin 0.4 mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: AAA (preop) PMH: metastatic renal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-14**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-17**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-9-1**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-9-1**] 11:30 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2112-4-15**] 9:30 Completed by:[**2111-8-6**]

[ "V10.52", "788.99", "412", "600.00", "198.5", "V45.89", "414.01", "585.9", "427.31", "441.4" ]

icd9cm

[ [ [] ] ]

[ "39.71", "88.42", "88.47" ]

icd9pcs

[ [ [] ] ]

4119, 4125

1896, 3267

339, 574

4211, 4211

1550, 1873

6945, 7458

1431, 1449

3552, 4096

4146, 4190

3293, 3529

4362, 6365

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1464, 1531

273, 301

602, 805

4226, 4338

827, 1189

1205, 1415

3,793

157,997

22787+57321+57322

Discharge summary

report+addendum+addendum

Admission Date: [**2163-6-27**] Discharge Date: [**2163-7-3**] Date of Birth: [**2091-1-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: aortic valve replacement (19mm tissue) [**2163-6-27**] History of Present Illness: 72 yo deaf woman with PMH significant for hypertension, hyperlipidemia, aortic stenosis, and carotid disease s/p [**Country **] [**Country **] [**2158**] with increasing dyspnea and syncope. She presents today for preoperative catheterization and cardiac surgery evaluation. Past Medical History: Coronary artery disease, no prior MI. Hyperlipidemia Hypertension Hypothyroidism Deafness Carpal tunnel syndrome Past surgical history: Status post hysterectomy Social History: She is deaf and lives with her son. She communicates with ASL. She does drink a few glasses of wine per week. She is an active smoker and smokes [**1-15**] pack per day x 49 years. She is employed as a housekeeper. Is active in all of her ADLs. Family History: Colon cancer in her mother. Brother with myocardial infarction at age 58. Father with myocardial infarction. Physical Exam: Pulse:61 Resp:16 O2 sat:95% RA B/P Right:186/80 Left:173/68 Height:5'1" Weight:140 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [] Heart: RRR [x] Irregular [] Murmur: 2-3/6 systolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Patient is deaf otherwise-Grossly intact, non focal Pulses: Femoral Right:2+ Left:cath site DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: soft radiated murmur Left: soft radiated murmur Pertinent Results: [**2163-7-2**] 04:55AM BLOOD WBC-6.6 RBC-3.42* Hgb-10.3* Hct-31.7* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.7 Plt Ct-125* [**2163-6-30**] 01:23AM BLOOD PT-15.0* PTT-31.0 INR(PT)-1.3* [**2163-7-2**] 04:55AM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-141 K-4.0 Cl-102 HCO3-33* AnGap-10 The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. 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 to 35 cm from the incisors. The aortic valve leaflets are moderately thickened. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post bypass The patient is on a Neosynephrine drip There is now a well seated 19 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Bioprosthetic valve in place There is a mean gradient of 26 mm across the valve,the new valve area is 0.9 There is no paravalvular regurgitation The LV function is preserved @ >55% The aorta has no dissection flaps post decannulation Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2163-6-27**] where the patient underwent aortic valve replacement (19mm tissue). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: Levothyroxine 75mcg po daily Lovastatin 40g po BID ASA 81 mg po daily Plavix 75 mg po daily- stopped 2 weeks, will stop 1 week prior to surgery **uses 1 inhaler, but does not know name Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*qs * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: HTN,Hyperlipidemia,AS,SVT,PVD s/p [**Country **] [**Country **] [**2-/2158**],Benign thyroid nodule s/p hemithyroidectomy,COPD,Chronic bronchitis, Degenerative disc disease,s/p Carpal tunnel release,s/p cataract surgery bilateral,s/p hysterectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with ultram Incisions: Sternal - healing well, no erythema or drainage 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 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 **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**] [**2163-7-28**] at 1:45pm Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 58937**] in [**1-15**] weeks Cardiologist Dr. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 8725**] in [**1-15**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2163-7-3**] Name: [**Known lastname **],[**Known firstname 4377**] A. Unit No: [**Numeric Identifier 10860**] Admission Date: [**2163-6-27**] Discharge Date: [**2163-7-3**] Date of Birth: [**2091-1-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Mrs. [**Known lastname **] was initially confused/agitated immediately following extubation. Narcotics and sedatives were held, and this cleared. By the time of discharge on [**2163-7-3**], the patient was A&O x 3. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2163-8-15**] Name: [**Known lastname **],[**Known firstname 4377**] A. Unit No: [**Numeric Identifier 10860**] Admission Date: [**2163-6-27**] Discharge Date: [**2163-7-3**] Date of Birth: [**2091-1-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Mrs. [**Known lastname **] was acutely confused/agitated immediately following extubation. Narcotics and sedatives were held, and this cleared. By the time of discharge on [**2163-7-3**], the patient was A&O x 3. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2163-8-23**]

[ "443.9", "287.5", "285.9", "293.0", "427.89", "305.1", "389.9", "424.1", "401.9", "272.4", "491.20" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

9239, 9416

3183, 4340

328, 385

6206, 6363

2045, 3160

7202, 8406

1154, 1265

4576, 5837

5936, 6185

4366, 4553

6387, 7179

849, 875

1280, 2026

281, 290

413, 690

712, 826

891, 1138

8,427

158,235

51531

Discharge summary

report

Admission Date: [**2141-10-12**] Discharge Date: [**2141-10-19**] Date of Birth: [**2078-1-10**] Sex: M Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: The patient has been followed for his abdominal aneurysm and reported onset of abdominal and back pain. Patient is now admitted for elective abdominal aortic aneurysm repair and iliac aneurysm repair on the left. ALLERGIES: No known drug allergies. MEDICATIONS: Coumadin 5 mg daily, Pepcid 20 mg b.i.d., Lipitor 10 mg daily, Lopressor 25 mg b.i.d. PAST MEDICAL HISTORY: Ischemic heart disease, stable angina, status post angioplasty in [**2131**], cardiac stress [**2141-7-21**] showed a fixed inferior septal defect with an ejection fraction of 50%, dyspnea with one flight of stairs. History of hiatal hernia. History of right index finger ischemia secondary to embolus source - unknown. Status post tissue Plasminogen Activator. SOCIAL HISTORY: Significant for current use of tobacco within the last month. Patient smokes one to two packs per day for 40 years. Does admit to alcohol 2 to 3 drinks per day. PHYSICAL EXAMINATION: General appearance: Is in no acute distress. Head, eyes, ears, nose and throat examination without bruits. Heart is regular rate and rhythm without murmur. Lungs with mild wheezing diffusely bilaterally. The abdomen is soft, nontender. There are no palpable masses or bruits, no organomegaly. Extremities: Left leg with edema. All distal pulses are palpable. Toes and fingers are pink, warm and brisk capillary refill. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2141-10-12**] and underwent abdominal aortic repair with an 18 x 9 graft and right iliac repair and a left femoral graft. Patient tolerated the procedure and was transferred intubated to the post anesthesia care unit. He remained intubated secondary to bilateral lower lobe collapse. His postoperative hematocrit was 32.0. He remained on Neo-Synephrine drip, maintained his blood pressure greater than 120. Epidural was placed for analgesic control intraoperatively. Patient remained in the post anesthesia care unit overnight intubated and was transferred to the surgical intensive care unit for continued ventilatory support. Blood gases were 7.37, 32, 67, 23 and - 2. Patient still continued to require Neo-Synephrine for vasopressor support. Patient was extubated on postoperative day 2. Hematocrit remained stable at 30.1. He had palpable dorsalis pedis and posterior tibial pulses bilaterally. He was transferred from the thoracic intensive care to Far 9 nursing floor for continued postoperative care. Patient was started on levofloxacin for positive sputum culture which he received for a total of 5 days. His epidural was discontinued. Ambulation was begun. Patient's diet was progressed as tolerated. On postoperative day 4 physical therapy was requested to see the patient for evaluation of discharge planning. Patient was seen by social service for history of tobacco abuse and patient was amenable to starting a smoking cessation program and nicotine patch 14 mg q day was started. Patient was instructed on the imperative importance of no smoking while wearing the patch. The remaining hospital course was unremarkable and patient was discharged when medically stable. DISCHARGE MEDICATIONS: Warfarin 5 mg q.h.s., acetaminophen 325 to 650 mg q 4 to 6 hours p.r.n., nicotine patch 14 mg daily, oxycodone/acetaminophen tablets 1 to 2 q 4 to 6 hours p.r.n. for pain, metoprolol 25 mg b.i.d. emodin 20 mg b.i.d., levofloxacin 500 mg q 24 hours for a total of 5 days. This was started on [**2141-10-15**] and should continue to [**2141-10-20**]. Opprobrium bromide nebulizer q 6 hours, albuterol .083% nebulizer q 6 hours p.r.n. Patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time. [**Month (only) 116**] ambulate essential distances. DISCHARGE DIAGNOSES: Abdominal aortic aneurysm with right iliac extension status post repair. History of smoking. Postoperative bilateral basilar lung collapse, resolved. Postoperative hypotension requiring vasopressor support, resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2141-10-17**] 12:39:30 T: [**2141-10-17**] 13:23:10 Job#: [**Job Number 106833**]

[ "518.0", "V45.82", "414.8", "414.01", "458.29", "413.9", "441.4", "997.3" ]

icd9cm

[ [ [] ] ]

[ "39.56", "38.44" ]

icd9pcs

[ [ [] ] ]

3954, 4446

3364, 3932

1592, 3340

1154, 1574

156, 184

213, 566

589, 952

969, 1131

40,911

153,650

3897

Discharge summary

report

Admission Date: [**2122-6-30**] Discharge Date: [**2122-7-7**] Date of Birth: [**2055-10-31**] Sex: M Service: MEDICINE Allergies: vancomycin Attending:[**First Name3 (LF) 2387**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Right heart catheterization History of Present Illness: 66M patient of Dr. [**Last Name (STitle) **], who presented to the [**Hospital1 **] ED today c/o poor UOP for 3 days. He states that his weight this morning was 192 which is high for him and he states that he has been as low as 172. Weights in our system are difficult to follow, and the patient has readings of many He notes that he has had a normal bowel movement this morning and has never noticed red blood around stool, red blood in the toilet bowl, or black-tarry stools. He explicitly denies CP, or an increase in his baseline shortness of breath. He states this morning he was getting light-headed with changes in position, however this has resolved at this time. . Of note he was changed from lasix to torsemide [**6-24**] but the patient feels this didnt work as well as his lasix and that he has been gaining weight. He states he took two doses of his old lasix yesterday without effect. . In the ED his initial vitals were 97.6 70 88/52 16 100% and given his low MAPs, he received 2 units of pRBCs, and 2L IVF. With that His systolics were noted to be in the low 100's. A foley cathter was placed and returned 50cc of uirne. Rectal exam revealed bright red blood. 2 peripheral 18G IVs were placed. The patient briefly endorsed respiratory distress, and cxr was checked revealing a mild increase in interstitial edema and 160mg of IV lasix were given with 100cc of UOP and resolution of symptoms. . For unclear reasons, the patient was given Zosyn and vancomycin. Durring the infusion of vancomycin he developed hives on his arm and the infusion was stopped. . On arrival to the floor the patient is clear, not complaining of any dyspnea, and feels very comfortable. Past Medical History: 1. Severe CAD s/p 4vCABG [**2107**] 2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**] - Generator change and pocket revision in [**2120-1-14**] to right side of chest secondary to pain 3. Ischemic cardiomypoathy / systolic CHF, EF 25% 4. Peripheral vascular disease s/p bilateral femoral-popliteal bypass 5. multiple lower extremity catheterizations 6. Diabetes Type II - followed at [**Last Name (un) **] 7. Obstructive sleep apnea 8. Gout 9. Asthma 10. Mild sigmoid colonic thickening on recent CT-Abd/Plv, colonoscopy showing sessile polyps, biopsy will have to happen off plavix 11. Esophagitis, gastritis, peptic ulcer disease 12. Afib/flutter s/p TTE cardioversion [**1-/2121**], ablation. Social History: -Tobacco history: quit [**2107**], prior 70 pack year history -ETOH: quit [**2107**], prior heavy use -Illicit drugs: denies any history Married, lives at home with wife. [**Name (NI) 3003**] to his admission to rehab he lived at home with his wife. [**Name (NI) **] walks with a cane. He does not drink or smoke. Family History: There is no family history of premature coronary artery disease or sudden death. Mother with kidney problems. Father died of unknown causes. + h/o stomach cancer. Diabetes is prevalent throughout the family. Physical Exam: Admission physical exam: VS: T=96.2 BP=80/51(57) HR=69 RR=16 O2 sat=95% on 3L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera mildly icteric. PERRL, EOMI. Conjunctiva were pale, Dry mucosa. No xanthalesma. NECK: Supple with JVP of 3 above the clavicle at 30 degrees. CARDIAC: Midline scar, RR, normal at least two murmurs one early peaking heard best in the pulmonic area, one holosystolic heard best over the mitral area. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Mild crackles at the bases clearing with deeping breaths, diffuse inspiratory wheezes doing the same. ABDOMEN: Distended Soft, NTND. No HSM or tenderness. No fluid wave, Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: stasis dermatitis, no pitting edema, bilateral scars of saphenous harvest. Right: Radial [**Name (NI) 17394**] DP (-) PT [**Name (NI) **] [**Name (NI) 2325**]: Radial [**Name (NI) 17394**] DP [**Name (NI) 17394**] PT [**Name (NI) 17394**] Discharge physical exam: Pertinent Results: Admission labs: WBC 5.6 Hgb 7.4 Hct 25.1 Plts 269 PT 22.8 PTT 47.4 INR 2.1 Na 133 K 4.6 Cl 101 HCO3 22 BUN 76 Cr 2.9 Gluc 234 ALT 18 AST 23 LDH 339 Alk phos 161 T bili 0.3 ALbumin 3.0 lactate 1.6 Trop-T 0.04 pro-BNP 2247 Iron 21 Ferritin 20 TIBC 343 Pertinent studies: CT abdomen/pelvis without contrast ([**2122-6-30**]): 1. Trace perihepatic fluid noted tracking along the right paracolic gutter as well as trace retroperitoneal fluid and a small amount of simple pelvic fluid. Overall this is nons-specfic and may be related to IV hydration status. 2. [**Doctor First Name **] mesentery noted in the upper part of the abdomen, a nonspecific finding though new compared to prior studies. Follow up in 6 months is advised. 3. Bilateral small pleural effusions, right greater than left. 4. Right lower lobe 5mm pulmonary nodule. Recommend non-emergent chest CT to assess for other possible pulmonary nodules and establish frequency of surveillance. 5. Extensive vascular calcifications. TTE ([**2122-7-1**]): The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the interventricular septum and anterior wall (LVEF= 20-25 %). The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the prior study dated [**2122-1-8**] (images reviewed), the degree of mitral regurgitation is slightly worse. Pulmonary pressures are higher. LVEF is similar. Renal ultrasound ([**2122-7-1**]): FINDINGS: The right kidney measures 9.8 cm and the left kidney measures 10.1 cm. There is no hydronephrosis. No cyst or stone or solid mass is seen in either kidney. IMPRESSION: No hydronephrosis. . Cardiac catheterization ([**2122-7-3**]): Response to inhaled NO PVR 3.9 to 1.3 C/I 3.5 to 3.9 PCWP 34 to 42 Discharge labs ([**2122-7-7**]): WBC 5.7 Hgb 8.9 Hct 28.2 Plts 220 PT 14.6 PTT 30.5 INR 1.3 Na 137 K 4.3 Cl 100 HCO3 25 BUN 67 Cr 2.0 Gluc 116 Brief Hospital Course: 66M with CAD s/p CABG, VF arrest s/p AICD, ischemic CMP (EF 20-25%), AF/flutter s/p ablation with recent admission for acute systolic CHF with aggressive diuresis admitted with hypotension and [**Last Name (un) **]. . # Hypotension: Suspect hypovolemic shock in the setting of GI bleeding vs. efficatious response to torsemide. The patient responded well to volume. Symptoms not consistent with cardiogenic shock given his excellent oxygenation, very mild insterstitial marking, and baseline pro-BNP. In addition, echocardiogram performed on HD1 was not consistent with cardiogenic shock. The patient did not meet any SIRS criteria currently as he was without fever, leukocytosis, tachycardia or tachypnea throughout admission. Pt was fluid/volume responsive in the ED with pressures rising into the low 100's systolic after 2uPRBC and 2L IVF. He received a total of 4UPRBC and pressures improved. Metoprolol, torsemide and flomax were held initially. Metoprolol and torsemide were restarted on HD4 as blood pressures were stable and patient began to appear volume overloaded with increased weight, fluid wave in abdomen, elevated JVP and lower extremity edema. Patient responded to PO torsemide. He was discharged on torsemide 100mg in the AM and 50mg in PM. His weight was 189 lbs at the time of discharge. Patient's ideal weight is likely closer to 183 lbs. . #Right>Left heart failure- Patient's ongoing signs of lower extremity edema, abdominal distension and elevated JVP on exam indicating right>left sided failure. On HD3, patient was taken for right heart catheterization to determine acute vasoreactivity to nitric oxide. The right heart catherization showed elevated pulmonary pressures with good response to NO. The patient was therefore started on sildenafil. Most likely etiology of pulmonary arterial hypertension is underlying obstructive sleep apnea. Patient was continued on home CPAP while sleeping. He was instructed to be compliant with CPAP. Patient was discharged on sildenafil. . # ARF - Low FeUrea reflected current clinical suspicion that patient had pre-renal azotemia, whether the etiology is poor forward flow or dehydration. Following rehydration, creatinine remained elevated. Urine sediment did not show signs of ATN. Renal ultrasound showed no signs of hydronephrosis. Lisinopril and torsemide were held initially. Creatinine began to trend downward. His home lisinopril was restarted and his torsemide was restarted. Creatine continued to trend down and was 2.0 at the time of discharge. . # GI bleed - Patient with no obvious predilection to bleeding on upper and lower endoscopy in '[**20**]. He does have diverticulosis which is the most likely source of bleeding. It is unclear if this is his primary issue or a complication of decreased clearance of his dabigatran. On initial exam, patient had bright red blood per rectum on digital exam. He continued to have blood streaked stools intermittently, but hematocrit remained stable following initial transfuion. GI was consulted and felt that patient should be prepped for colonoscopy pending resolution of acute renal failure. However, as ARF improved, patient became volume overloaded and the decision was made to diurese patient over hydrating for bowel prep. The patient will follow-up with GI for colonoscopy as an outpatient. His home pradaxa was not restarted given recent bleed. He was discharged on protonix. . #. Chronic Systolic CHF: Patient had no signs of volume overload at the time of admission. Echocardiogram performed on HD1 showed higher pulmonary pressures and worse MR in comparison to prior TTE performed in [**2121-12-16**]. Torsemide was held initially, and restarted on HD4 as patient began to show signs of volume overload. Patient diuresed well on po torsemide and was 189 lbs at the time of discharge. His ideal weight is likely 183lbs. Patient was instructed to call Dr. [**Last Name (STitle) **] if he had a weight gain of >3lbs. . #. CAD s/p 4V CABG: Patient was without chest pain or EKG changes at the time of admission. He was continued on atorvastatin and aspirin. Toprol and lisinopril were held initially as above in the setting of hypotension. These medications were restarted on HD 4 with maintenance of blood pressue. The patients diuretics were also initally held but restarted when the patients weight began to increase as above. . #. Atrial Fibrillation/Flutter s/p Ablation: HR control excellent. Dabigatran was held in the setting of [**Last Name (un) **] and GI bleed. At the time of discharge his PTT and INR were trending downward. . #IDDM: Patient's blood sugar was well controlled with insulin sliding scale throughout admission. . # Neuropathy: Patient was continued on home pregabalin 75 mg PO BID throughout admission. . #. Gout: No acute flare during admission. Allopurinol and colchicine were held initially in the setting of [**Last Name (un) **]. Allopurinol was restarted at half home dose. Colchicine was restarted at home dose. . #Transitional Issues: - CT abd/pelvis revealed RLL 5mm pulmonary nodule. Recommend non-emergent chest CT to assess for other possible pulmonary nodules and establish frequency of surveillance. Also [**Doctor First Name 9189**] mesentery noted in the upper part of the abdomen, a nonspecific finding though new compared to prior studies. Follow up in 6 months is advised. - Close GI follow-up for colonoscopy. Pt did not have a date for the colonoscopy at discharge but will be contact[**Name (NI) **] at home by the gastroenterology department. - Patient was full code throughout admission. Medications on Admission: ALLOPURINOL - 300 mg daily ATORVASTATIN [LIPITOR] - 40 mg Tablet by mouth once a day COLCHICINE [COLCRYS] - 0.6 mg every other day DABIGATRAN ETEXILATE [PRADAXA] 75 mg Capsule [**Hospital1 **] Torsemide - 100 mg Tablet daily HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth 4 times a day as needed INSULIN GLARGINE [LANTUS]60 units sc once a day am INSULIN LISPRO [HUMALOG]15 units three times a day METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily PREGABALIN [LYRICA] - 75 mg Capsule - one Capsule(s) by mouth twice a day Tamsulosin 0.4 Lisinopril 5mg daily Discharge Medications: 1. Outpatient Lab Work Please check Chem-7 and CBC on Thursday [**7-9**] with results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3642**] 2. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day: please take one half tablet at 1600. . Disp:*60 Tablet(s)* Refills:*2* 4. prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. insulin glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. 10. insulin lispro 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous three times a day: 10 minutes before meals. . 11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. MoviPrep 100-7.5-2.691 gram Powder in Packet Sig: One (1) packet PO as directed the evening before your colonoscopy for 1 doses. Disp:*1 packet* Refills:*0* 13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other day. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Acute On Chronic Systolic congestive heart failure Lower gastrointestinal bleed Acute on chronic kidney failure Pulmonary 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: You had bleeding from your lower intestines, likely this is due to hemorrhoids. We were unable to do a colonoscopy to check the site of the bleeding so a colonoscopy will be scheduled in [**1-16**] weeks to check this. Your blood counts have been stable and the bleeding seems to have stopped. You had an acute exacerbation of your congestive heart failure and needed high doses of diuretics to take off the extra fluid. We are sending you home on an increased dose of the diuretics. Your weight at discharge is 189 pounds. Your ideal weight is probably about 183 pounds. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. It is very important that you follow a low sodium diet at home as well. Your kidney function had worsened when you were admitted to the hospital, they are better now but need to be followed closely after you go home. We have scheduled your follow up appointments close together after you go home. . We made the following changes to your medicines: 1. Increase the torsemide to 100 mg in the morning and 50 mg in the afternoon 2. Start taking sildenafil to lower the pressures in your lungs and help your heart work better 3. Discontinue Pradaxa 4. Decrease allopurinol to 150 mg once a day 5. Decrease prednisone to 2.5 mg daily 6. Start taking protonix to prevent bleeding in your stomach Followup Instructions: You will be contact[**Name (NI) **] by the gastroenterology department to schedule a colonoscopy in about 3 weeks. . Department: RHEUMATOLOGY When: WEDNESDAY [**2122-7-23**] at 11:00 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: FRIDAY [**2122-7-10**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital3 249**] When: FRIDAY [**2122-7-13**] at 1:45 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3642**] [**Location (un) 10877**], [**Street Address(1) **] MA

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icd9cm

[ [ [] ] ]

[ "88.72", "37.21" ]

icd9pcs

[ [ [] ] ]

14937, 14985

7057, 12068

299, 328

15164, 15164

4379, 4379

16764, 17767

3127, 3337

13357, 14914

15006, 15143

12687, 13334

15347, 16741

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356, 2046

4395, 7034

15179, 15323

2068, 2777

2793, 3111

4360, 4360

19,213

140,312

52406+52407

Discharge summary

report+report

Admission Date: [**2202-11-2**] Discharge Date: [**2202-11-5**] Date of Birth: [**2168-10-6**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old female with type 1 diabetes, gastroparesis, chronic renal insufficiency and neuropathy, and a history of multiple admissions for diabetic ketoacidosis presenting with 24 hours of nausea and vomiting. This is a recurrent issue for her secondary to gastroparesis. She took her by mouth Phenergan at home with no affect. She also had a mental status change. She denied abdominal pain, cough, or dysuria. She did complain of fevers and chills at home. After examining the patient it was noted that there was a new right foot ulceration draining foul-smelling pus. The patient then admitted to spilling hot grease on this area approximately one week ago which she was self-treating with dressing changes. PAST MEDICAL HISTORY: 1. Type 1 diabetes (complicated by neuropathy, gastroparesis, chronic renal insufficiency, and multiple episodes of diabetic ketoacidosis). 2. Hypertension. 3. Left ventricular hypertrophy. 4. Hypertriglyceridemia. 5. Recurrent urinary tract infection from perirectal abscess. 6. Microcytic anemia. 7. History of [**Doctor First Name **]-[**Doctor Last Name **] tear. MEDICATIONS ON ADMISSION: 1. Metoprolol 25 mg by mouth three times per day. 2. Lisinopril 30 mg by mouth once per day. 3. Protonix 40 mg by mouth once per day. 4. Lantus 20 units subcutaneously at hour of sleep. 5. Humalog sliding-scale with meals. 6. Multivitamin. 7. Sublingual nitroglycerin as needed. ALLERGIES: COMPAZINE, ASPIRIN, CODEINE, ERYTHROMYCIN, and BEEF/PORK INSULIN. PHYSICAL EXAMINATION ON PRESENTATION: Examination revealed the patient's temperature was 97.2 degrees Fahrenheit, her heart rate was 107, her blood pressure was 142/100, her respiratory rate was 18, and her oxygen saturation was 100% on room air. The patient was lying in bed asleep but arousable. She answered a few questions with "yes" or "no." The sclerae were anicteric. The pupils were equal, round, and reactive to light. The oropharynx was clear. The mucous membranes were dry. There was an nasogastric tube in place. The neck was supple. No carotid bruits. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed tachycardia with a regular rhythm. There was a [**3-7**] holosystolic murmur heard throughout the precordium. The abdomen was soft and nontender. There were normal active bowel sounds. There was a suprapubic surgical scar. Extremity examination revealed numerous scars. Dorsalis pedis pulses were 2+. The feet were warm. Right second web space with deep ulceration draining pus. The second toe on the right with black/dry gangrene. There was a right plantar ulceration with granulation but deep to the muscle. Neurologic examination revealed the patient was sleepy but arousable. She moved all extremities. She followed commands. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed the patient's white blood cell count was 13.9, her hematocrit was 29.9, and her platelets were 579. Chemistry revealed her sodium was 143, potassium was 3.5, chloride was 106, bicarbonate was 17, blood urea nitrogen was 53, creatinine was 2.6 (baseline of 1.5 to 2), and her blood glucose was 114. Small acetone. Urinalysis revealed trace ketones. Negative for a urinary tract infection. PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative. KUB revealed minimal bowel gas. An electrocardiogram revealed sinus tachycardia. No ST-T wave abnormalities. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit for management of her diabetic ketoacidosis which was likely precipitated by her new right foot ulceration. 1. DIABETIC KETOACIDOSIS ISSUES: The patient was managed initially on an insulin drip which was then supplemented with D5 half normal saline until the anion gap closed. Her electrolytes were repleted as needed. The patient was also aggressively hydrated, and Unasyn was given for her foot ulceration. On hospital day two, the patient's anion gap had closed to 8. The patient was converted to subcutaneous insulin. Her nausea progressively improved. Her Glargine insulin was increased to 22 units subcutaneously once per day to improve her glucose control. She was followed during this hospitalization by the [**Last Name (un) **] Service, and at the time of discharge her glucose levels were controlled adequately. She was to follow up as an outpatient with [**Last Name (un) **]. 2. RIGHT FOOT ULCERATION ISSUES: The patient apparently got this foot ulceration one week prior to admission from a grease burn, and it progressively worsened at home. The Podiatry Service was consulted, and the patient was started on Unasyn. The Podiatry Service did not feel like the wound needed debridement at this time, and it was treated conservatively with dressing changes and antibiotics to allow granulation of the wound. At the time of discharge, the patient was converted from intravenous Unasyn to by mouth Augmentin and was to follow up in the [**Hospital **] Clinic as an outpatient. 3. RENAL ISSUES: The patient's creatinine remained persistently elevated at 3.1; which was up from her baseline of 1.5 to 2. This was thought to be secondary to newly started ACE inhibitor. The ACE inhibitor was discontinued, and the patient's creatinine was stable 3.1 at the time of discharge. The patient was to follow up in two days in the [**Hospital6 733**] clinic for a repeat creatinine draw. Her electrolytes were stable at the time of discharge. 4. HYPERTENSION ISSUES: The patient's hypertension was controlled on her home regiment throughout her hospital course. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Acute renal failure. 3. Type 1 diabetes. 4. Infected right foot ulceration. 5. Chronic renal insufficiency. 6. Hypertension. 7. Asthma. MEDICATIONS ON DISCHARGE: 1. Metoprolol 25 mg by mouth three times per day. 2. Glargine insulin 22 units subcutaneously at hour of sleep. 3. Humalog sliding-scale at meals. 4. Augmentin one tablet by mouth four times per day (times at least two to three weeks in duration, though readdress duration during outpatient appointment with Podiatry). 5. Protonix 40 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: Follow-up appointments were made for the patient in the [**Hospital6 733**] Clinic for [**2202-11-8**] and in the [**Hospital **] Clinic on [**2202-11-9**] and in the [**Hospital **] Clinic for [**2202-11-19**]. DISCHARGE STATUS: The patient was discharged home on [**2202-11-5**]. CONDITION AT DISCHARGE: Condition on discharge was good. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 17848**] MEDQUIST36 D: [**2202-12-24**] 11:47 T: [**2202-12-25**] 01:17 JOB#: [**Job Number 108300**] Admission Date: [**2202-11-2**] Discharge Date: [**2202-11-5**] Date of Birth: [**2168-10-6**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: 34-year-old female with type 1 diabetes, gastroparesis, chronic renal insufficiency, neuropathy, history of multiple admissions for diabetic ketoacidosis most recently in [**9-/2202**] INCOMPLETE REPORT...DICTATOR HUNG UP. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 17848**] MEDQUIST36 D: [**2202-12-24**] 00:49 T: [**2202-12-24**] 15:38 JOB#: [**Job Number 108301**]

[ "578.0", "401.9", "584.9", "958.3", "707.15", "250.11", "493.90", "250.61", "276.5" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5852, 6025

6051, 6417

1327, 3647

6451, 6746

3682, 5831

6761, 7187

7216, 7694

925, 1301

61,539

106,755

39075

Discharge summary

report

Admission Date: [**2109-1-2**] Discharge Date: [**2109-1-5**] Date of Birth: [**2077-9-11**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1257**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: 31 year old previously healthy male was seen at the office of his PCP today for complaint of melena (black stools), lightheadedness and mild ?coffee ground emesis. Patient states he woke up on Sunday at 3am and had an episode of dark brown emesis; given that he had just had BBQ for dinner, he was unsure of the significance. The following morning, he had a solid black, foul smelling, formed but slightly soft bowel movement. He did not have any abdominal cramping but did have some discomfort, so he started taking Pepto Bismo. The patient proceeded to have two more episodes of tarry black stools on Tuesday morning prior to going to his PCP's office. Throughout Tuesday, he felt light headed and short of breath with mild chest pressure when exerting himself (ex: walking up stairs to his apartment). Labs at his PCP's office showed hemoglobin 7.6 and hematocrit 22.6. Patient was advised to come to the ER for further work-up and management. Of note, patient denies significant alcohol, NSAID, coffee consumption; also denies significant retching with episode of emesis on Sunday or significant history of GERD. . In the ED, patient was tachycardic to 110 although abdominal exam was benign; patient was complaining of exertional chest pressure/shortness of breath but cardiac enzymes were negative X1. On rectal exam, no bright red blood or tarry stools were found in the rectal vault but patient was guaiac positive. NG lavage was performed which yielded coffee ground emesis that would not clear after 400cc, no bright red emesis was noted. Patient was given 1L intravenous fluid boluses and transfused 2 units of pRBC, type and crossed for 4 units. Two 18 gauge peripheral IVs were placed and intravenous PPI started. GI was informed of the patient and plans to do EGD in the morning unless the patient is still tachycardic. VS upon transfer: were afebrile, heart rate 102, BP126/65, RR20, 100%RA. . Upon arrival to the ICU, patient was resting comfortably in bed. He denies current light headedness, chest pressure or shortness of breath. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, rhinorrhea or congestion. Denies coughor wheezing. Denies chest pain, palpitations, or weakness. Denies nausea, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Past Medical History: Bilateral ankle fractures Social History: Social History: Third year law student at [**University/College 86617**]T - Denies A - [**1-24**] drinks every other weekend D - Denies illicit drug use Family History: Diabetes Mellitus, no history of Peptic Ulcer Disease or malignancies . Physical Exam: Vitals: T: Afebrile BP: 156/84 P: 109 R: 18 O2: 98% RA General: Alert, oriented, no acute distress, well-nourished 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 Pertinent Results: Admission labs: [**2109-1-1**] 10:05PM BLOOD WBC-11.4* RBC-2.21* Hgb-6.2* Hct-18.5* MCV-84 MCH-27.6 MCHC-33.0 RDW-15.9* Plt Ct-235 [**2109-1-1**] 10:05PM BLOOD Neuts-76* Bands-0 Lymphs-17* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4* [**2109-1-1**] 10:05PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2109-1-1**] 10:05PM BLOOD PT-13.5* PTT-25.0 INR(PT)-1.2* [**2109-1-1**] 10:05PM BLOOD Ret Man-4.7* [**2109-1-1**] 10:05PM BLOOD Glucose-109* UreaN-24* Creat-1.0 Na-137 K-4.2 Cl-105 HCO3-26 AnGap-10 [**2109-1-1**] 10:05PM BLOOD ALT-22 AST-24 LD(LDH)-176 CK(CPK)-92 AlkPhos-28* TotBili-0.2 [**2109-1-1**] 10:05PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2109-1-1**] 10:05PM BLOOD Lipase-47 [**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135 [**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1 Hapto-105 Ferritn-98 TRF-222 [**2109-1-1**] 10:24PM BLOOD Glucose-108* Na-138 K-3.9 Cl-104 calHCO3-25 [**2109-1-1**] 11:12PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019 [**2109-1-1**] 11:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**1-2**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2109-1-4**]): POSITIVE BY EIA. (Reference Range-Negative). [**1-1**] ECG: Sinus tachycardia. Slight ST-T wave changes are non-specific and may be within normal limits. No previous tracing available for comparison. [**1-2**] EGD: Old hematin was seen in the stomach. There was a very small ulcer noted in her antrum with small clot overlying it. This was likely the source of GI bleeding. There were also several small erosions noted in the antrum as well as gastritis. Erythema in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum [**2109-1-5**] 02:13AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.4* Hct-31.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-17.8* Plt Ct-211 [**2109-1-5**] 02:13AM BLOOD Glucose-92 UreaN-12 Creat-1.2 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [**2109-1-4**] 05:10AM BLOOD ALT-18 AST-20 AlkPhos-32* TotBili-1.2 [**2109-1-5**] 02:13AM BLOOD Calcium-8.9 Phos-4.8*# Mg-2.2 [**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1 Hapto-105 Ferritn-98 TRF-222 [**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135 [**2109-1-2**] 09:25AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2109-1-1**] 10:05PM BLOOD Ret Man-4.7* [**2109-1-3**] 09:47AM BLOOD Hgb A-PENDING Hgb S-PND Hgb C-PND Brief Hospital Course: # Melena - Patient presented with melena and Hct of 18. He received IVF and blood transfusions support as was admitted to the MICU. An emergent EGD was performed and this revealed an antral ulcer, as above. The patient denied alcohol or recent NSAID use. Adequate type and screen and IV access were maintained. He was also started on IV PPI boluses/gtt. Overnight, the patient's Hct had decreased to 22.6, and the GI fellow was paged. Urgent EGD was not felt to be necessary, as the patient's NG lavage was negative for gross hemorrhage. Once the patient was stable and Hct was also stable he was started on a clear diet and advanced to regular. IV PPI was changed to PO after 3 days of therapy. H Pylori serology was sent and resulted in a positive test. He was started on clarithromycin and metronidazole (allergic to penicillin) and given a prescription to finish a 2 week course of triple therapy. He received a total of 6 PRBC transfusions. . # Anemia - The patient had an active GI bleed as above, but it was unclear what his baseline hematocrit is. Hemoglobin electropheresis was sent, but these are still pending and should be followed up by his PCP. [**Name10 (NameIs) **] panel and hemolysis labs were WNL and this was all felt to be secondary to GI bleed. . # Substernal chest pressure - Believed to be mild demand ischemia in setting of GI bleed. EKG and cardiac enzymes within normal limits. The patient was followed on telemetry. . # Leukocytosis - Mild, likely demargination in the setting of recent GI bleeding, this resolved after treatement for acute GIB. . # Code: The patient was full code for the duration of the admission Medications on Admission: Occasional Centrum, Advil ~1X/week (up to 4 tabs Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 13 days. Disp:*26 Tablet(s)* Refills:*0* 2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 13 days. Disp:*52 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Upper GI ulcer bleed H. pylori Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted because you were having blood in your stool and found to be severe anemia due to blood loss. We transfused a total of 6 units of blood. We did an upper endoscopy and found you had an ulcer that looked like it had recently bled. You were started on medications to decrease the acid in your stomach. You were also found to have a bacteria in you stomach called H. Pylori that can cause ulcers. You were started on antibiotics for this and should finish a 2 week course of these. Medication changes: START: Pantoprazole 40 mg twice a day START: Metronidazole 500 mg twice a day for 13 days START: Clarithromycing 500 mg twice a day for 13 days Followup Instructions: Appointment #1 MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Internal Medicine-Primary Care Date/ Time: Location: [**Street Address(2) 75332**], [**Location (un) 86**] Ma Phone number: [**Telephone/Fax (1) 644**] Special instructions for patient: The office will call you with an appointment for your hospitalization. If you do not here from the office in 2 business days please call them. Thanks. Appointment #2 MD: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 26390**] Specialty: Gastroenterology Date/ Time: [**2109-1-10**] 12:40pm Location: [**Location (un) 4363**], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 2296**]

[ "535.50", "785.0", "285.1", "531.40", "041.86", "786.50", "276.52" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

8285, 8291

6096, 7741

277, 295

8366, 8366

3568, 3568

9196, 9903

2919, 2993

7840, 8262

8312, 8345

7767, 7817

8511, 9007

3008, 3549

2393, 2682

9027, 9173

231, 239

323, 2374

3584, 6073

8380, 8487

2704, 2731

2763, 2902

6,566

175,682

20675

Discharge summary

report

Admission Date: [**2187-7-10**] Discharge Date: [**2187-7-13**] Date of Birth: [**2137-3-14**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Abdominal wall bleeding s/p pericentesis of abdominal ascites Major Surgical or Invasive Procedure: Paracentesis [**2187-7-10**] History of Present Illness: 50 yo male with history of cirrhosis secondary to Hepatitis C and ETOH abuse presented for routine paracentesis for diuretic resistant abdominal ascites. Pt has no history of variceal bleeds, hepatic encephalopathy, or jaundice. The patient had never been treated for his Hepatitis. Past Medical History: CAD with stent Anemia ETOH abuse Hepatitis C Liver cirrhosis/End stage liver disease Social History: Currently unemployed Lives with wife, a healthcare proxy Lives in [**Location 21318**] Has not used drugs x 15 years No ETOH since [**6-14**] [**1-12**] pack of cigarrettes/day Family History: non-contributory Physical Exam: T 99.5 BP 108/64 72 14 96% RA General: awake, somewhat frail, pleasant HEENT: Dry mucous membranes, mildly icteric sclera, mildly dark pink mucous, membranes in the mouth/tongue, OP clear Lungs: minimal crackles in left base CVS: RRR Abdomen: distended, nontender with + BS, flat and tympanic abdominal sounds (fluid, gas?) 5x5 umbilical hernia, retractable, LE: +1 PE wih minimal venous stasis, +2 DP, no lesions, Pertinent Results: [**2187-7-12**] 06:15AM BLOOD WBC-6.6 RBC-3.34* Hgb-10.5* Hct-30.6* MCV-91 MCH-31.4 MCHC-34.4 RDW-15.8* Plt Ct-82* [**2187-7-11**] 03:35PM BLOOD WBC-6.2 RBC-3.26* Hgb-10.2* Hct-29.4* MCV-90 MCH-31.4 MCHC-34.8 RDW-16.4* Plt Ct-72* [**2187-7-11**] 05:43AM BLOOD WBC-5.9 RBC-3.14* Hgb-9.6* Hct-28.6* MCV-91 MCH-30.5 MCHC-33.6 RDW-16.3* Plt Ct-94* [**2187-7-10**] 09:01PM BLOOD Hct-27.9* [**2187-7-10**] 02:25PM BLOOD Hct-25.8* [**2187-7-10**] 10:55AM BLOOD WBC-7.8 RBC-2.64* Hgb-8.6* Hct-24.3* MCV-92 MCH-32.7* MCHC-35.5* RDW-15.9* Plt Ct-94* [**2187-7-10**] 10:00AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.5* Hct-24.4* MCV-92 MCH-31.8 MCHC-34.6 RDW-15.9* Plt Ct-106* [**2187-7-10**] 08:10AM BLOOD WBC-9.1 RBC-3.43* Hgb-11.0* Hct-31.8* MCV-93 MCH-32.2* MCHC-34.7 RDW-15.9* Plt Ct-114* [**2187-7-10**] 08:10AM BLOOD Neuts-67.3 Lymphs-16.6* Monos-12.0* Eos-3.5 Baso-0.6 [**2187-7-12**] 06:15AM BLOOD Plt Ct-82* [**2187-7-12**] 06:15AM BLOOD PT-16.3* PTT-39.6* INR(PT)-1.8 [**2187-7-11**] 03:35PM BLOOD Plt Ct-72* [**2187-7-11**] 03:35PM BLOOD PT-15.3* PTT-37.1* INR(PT)-1.5 [**2187-7-11**] 05:43AM BLOOD Plt Ct-94* [**2187-7-11**] 05:43AM BLOOD PT-14.9* PTT-37.0* INR(PT)-1.5 [**2187-7-10**] 09:39PM BLOOD PT-15.1* PTT-38.9* INR(PT)-1.5 [**2187-7-10**] 02:25PM BLOOD PT-15.7* PTT-42.4* INR(PT)-1.6 [**2187-7-10**] 10:55AM BLOOD Plt Ct-94* [**2187-7-10**] 10:00AM BLOOD Plt Ct-106* [**2187-7-10**] 08:10AM BLOOD Plt Ct-114* [**2187-7-10**] 08:10AM BLOOD PT-16.7* INR(PT)-1.9 [**2187-7-11**] 05:43AM BLOOD Glucose-116* UreaN-23* Creat-1.1 Na-132* K-4.6 Cl-99 HCO3-24 AnGap-14 [**2187-7-10**] 09:01PM BLOOD Glucose-140* UreaN-27* Creat-1.4* Na-129* K-5.2* Cl-98 HCO3-23 AnGap-13 [**2187-7-10**] 08:10AM BLOOD Glucose-115* UreaN-34* Creat-2.0*# Na-127* K-5.5* Cl-95* HCO3-24 AnGap-14 [**2187-7-10**] 08:10AM BLOOD ALT-20 AST-43* AlkPhos-77 TotBili-4.7* [**2187-7-11**] 05:43AM BLOOD Calcium-8.8 [**2187-7-10**] 09:01PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1 [**2187-7-10**] 02:25PM BLOOD Calcium-8.7 [**2187-7-10**] 08:10AM BLOOD Albumin-2.8* Calcium-8.9 Phos-4.3 [**2187-7-13**] 09:25AM BLOOD WBC-7.5 RBC-3.56* Hgb-11.0* Hct-32.7* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.8* Plt Ct-85* Brief Hospital Course: Pt is a 50 yo man with cirrhosis secondary to HCV and ETOH abuse and baseline anemia who had an abdominal bleed after a routine pericentesis to remove ascitic fluid, s/p transfusions, now stable. 1.Abdominal bleed: most likely secondary to hitting a vessel during pericentesis. Pt has been transfused multiple times and given fluids in an effort to address his falling hematocrit/bleed. Now that pt is stable, will start to diurese/remove fluid that has accumulated in his abdomen. Pt notes that abdominal size is close to, but not as large as his abdomen prior to getting his pericentesis. Pt seen by Liver and received another paracentesis for abdominal ascites on [**7-12**] without complications. Pt is to be dc'd with follow up with Dr. [**Last Name (STitle) 497**] on [**7-19**]. 2.Anemia: pt transfused with FFP, currently 28.6 Hesitant to transfuse now due to increasing accumulation of fluid in the abdomen and the sequelae of SOB and discomfort. Will follow and check crit in AM- Vitals stable, if crit decreased, will transfuse. Currently stable. 3.FEN: Pt to get meal tonight. DC NPO. Cont bowel regimen. No protonix due to low platelets. 4.Cirrhosis: continue lactulose. 5.Pain/Headache. Cont. oxycodone for pain until follow up. 6.Cough: Pt with productive cough, yellowish grey sputum. Possible etiologies are URI considering slightly elevated temperature, Chronic bronchitis exacerbation considering pt??????s smoking history. Pt??????s CXR negative for consolidation. Will monitor for fevers, worsening cough. Cont. guanefesin-codeine for cough and cipro 500 mg qd x 7 days and follow up with Dr. [**Last Name (STitle) 497**] if cough persists. Medications on Admission: Medications on admission Oxycodone 5 mg po BID Lasix 20 mg qd Spironolactone 100 mg qd nadolol 20 mg qd Caltrate 600 mg [**Hospital1 **] Mycelex 1 x 5/day lactulose 30 mg TID Discharge Medications: 1. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*1 ML(s)* Refills:*0* 5. Phytonadione 5 mg Tablet Sig: 1-2 Tablets PO QD (once a day) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for headache. Disp:*25 Tablet(s)* Refills:*0* 7. Ciprofloxacin HCl 500 mg Tablet Sig: One (1) Tablet PO QD (once a day) as needed for cough for 7 days. Disp:*6 Tablet(s)* Refills:*0* 8. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. ESLD 2. Abdominal bleed after therapeutic paracentesis on [**2187-7-7**] 3. Anemia 4. bronchitis Discharge Condition: Fever to 100.5 on day of discharge, no localizing symptoms, tolerating pos, ambulating Discharge Instructions: 1. Please follow up at the [**Date Range **] unit on [**7-29**] for your next paracentesis. 2. Take all your medications, including the antibiotics for the cough 3. If you experience fevers, chills, increasingly severe cough, nausea, vomiting, or a tender abdomen that causes you pain, come to the emergency department at once. 4. Take oxycodone for your headaches, 5-10 mg (1-2 tablets) by mouth every 6 hours. 5. Take the cough syrup, but if you continue to cough by your appointment with Dr. [**Last Name (STitle) 497**], be sure to be examined and worked up for something more serious. 6. You need to stay on a strict 1.5 L diet. If you have questions, talk to Dr. [**Last Name (STitle) 497**] at your appointment. Followup Instructions: 1 follow up: Provider: [**Name10 (NameIs) 454**],TEN DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2187-7-19**] 11:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "070.51", "285.9", "276.1", "571.2", "998.11", "E870.5", "998.2", "789.5", "491.9" ]

icd9cm

[ [ [] ] ]

[ "99.07", "54.91", "99.04" ]

icd9pcs

[ [ [] ] ]

6430, 6436

3695, 5361

379, 409

6580, 6668

1515, 3672

7435, 7437

1040, 1058

5587, 6407

6457, 6559

5387, 5564

6692, 7412

1073, 1496

7449, 7741

278, 341

437, 721

743, 830

846, 1024

357

145,674

29356

Discharge summary

report

Admission Date: [**2198-8-2**] Discharge Date: [**2198-10-26**] Date of Birth: [**2135-3-22**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7573**] Chief Complaint: Status epilepticus in setting of severe metabolic derangement in setting of liver failure due to NASH and HCC, with prolonged multifactorial encephalopathy (post-ictal, non-convulsive status, metabolic derangements) and a protracted hospital course in light of the above, as well as several complications as outlined extensively under "Brief Hospital Course". Major Surgical or Invasive Procedure: Continuous Venous Venous Hemodialysis. Intubation x 1. Continuous EEG monitoring. History of Present Illness: 63yo man with cirrhosis, DM, HTN, and seizures diagnosed in [**11/2197**] presents with seizures as a transfer from an OSH. History is per his wife, as he is currently seizing. She reports he was in his USOH until this evening, when returning from dinner he had a seizure with left head deviation and left arm shaking. EMS brought him to [**Hospital3 10310**] Hospital at 8pm. At [**2200**], a "focal seizure" was noted, with extremities lifted and gaze deviation to the left; he was resonding to verbal commands at that time. He was given ativan 2mg IV x 1, after which he was reportedly "confused", following commands incorrectly. At 2105, he was still noted to be confused, with "gaze to right". At 2200, he was noted to have occasional right gaze deviation. He had labs, which were notable for NH3 of 139, and had a negative head CT. He was given lactulose at 0040 and transferred to [**Hospital1 18**]. He arrived around 2am, reportedly "awake, confused, looking to right, grip weak on right." When seen by the resident just before 4am, she saw him raise his right arm, then have right head and eye deviation, lasting one minute and spontaneously resolving. During the next five minutes, he had intermittent gaze deviation to the right, 2-3x, each approximately 30 seconds. His wife told her this was different from the prior events in that it was the right, not left, and that he had no shaking. Neurology consult was called. ROS per his wife is negative for fevers, chills, cough, abdominal pain, nausea, vomiting, other complaints. He was noted to have his first seizure while in the ICU in [**11-22**]. He was admitted for TIPS procedure and had ammonia level in the 200s at the time. On [**2197-12-14**], he was found to have slight left head deviation with jerking movements of the shoulders and head. He was treated with dilantin (goal 20-25) and then a versed gtt. He was noted to have subclinical seizures on bedside EEG. He was eventually seizure free and was changed to keppra. He has had seizures since only in the context of AED vacation, and was thus restarted on the medications. Of note, MRI had shown bilateral cortical DWI abnormalities thought to be due to hepatic disease vs seizure; these had resolved on repeat MRI one week later. Past Medical History: DM HTN NASH cirrhosis, on transplant list seizures as above hypothyroidism GERD Social History: lives with wife, remote smoking history, no EtOH or drug use Family History: NC Physical Exam: VS: T 97.9, HR 84, BP 152/74, RR 14, SaO2 98%/RA, FS 187 Genl: lying on side, moving purposefully, appears to be seizing (see below) CV: RRR, nl S1, S2, no m/r/g Chest: CTA bilaterally anteriorly Abd: soft, NT, BS+ Ext: warm and dry Neurologic examination: Pt is lying on side, with head and eyes deviated far to the right, and right beating nystagmus. He has rhythmic jerking of his eyebrows, but not his arms or legs. MS: Nonverbal, not following commands, responds to noxious CN: pupils equal and reactive, unable to assess EOM as head tonically deviated to right, but eyes are to the right with right beating nystagmus. ?left facial flattening vs drawing over of face to the right. Motor: hypertonic throughout, no jerking of limbs, moves all extremities antigravity to noxious Sensory: responds to noxious throughout Pertinent Results: Studies: CT - head - [**2198-8-2**] IMPRESSION: 1. There is no evidence of intracranial hemorrhage, mass effect, or large vascular territory infarct. There is no evidence of fracture. 2. There is increase in opacification of the ethmoid air cells. Again seen is opacification of the right maxillary sinus with central hyperintensity. This is likely due to chronic sinusitis changes, however, would recommend work up to rule out fungal infection if clinically warranted. There is no change to the appearance of this sinus compared to prior studies. A left maxillary sinus also has mucosal thickening posteriorly, and there is fluid or mucosal thickening in the left frontal sinus as well. EEG - [**2198-8-2**] IMPRESSION: This is an abnormal portable EEG due to the presence of frequent sharp and sharp and slow wave discharges arising from the left posterior quadrant with maximal frequency of about 1 per Hz in the setting of brief episodes of theta frequency slowing seen in the same region. The findings suggest an area of cortical and subcortical dysfunction along with cortical irritability which may serve as a focus for potential seizure activity. No clear electrographic seizures were noted. EEG - [**2198-8-5**] IMPRESSION: This telemetry captured five pushbutton activations. In addition to the pushbutton activations, routine sampling and spike and seizure detection programs captured multiple episodes of rhythmic, sustained, and prolonged generalized spike and slow wave discharges occurring at a maximal frequency of about 8 Hz, at times associated with eye blinking or left upper extremity jerking and, at other times, without a clear clinical correlate. The majority of these electrographic seizures were captured at the beginning of the recording on the evening of [**2198-8-4**]. These events are consistent with non-convulsive status epilepticus. As the electrographic tracing continued, the tracing evolved into a pattern of burst suppression, albeit with continued intermittent sharp and sharp and wave discharges arising from the left posterior quadrant. This pattern continued overnight until the following morning where there were several episodes of rhythmic monomorphic sharp wave discharges seen in a generalized distribution. While these electrographic findings may be artifactual in nature, we cannot rule out recurrent electrographic seizure activity. EEG - [**2198-8-6**] IMPRESSION: This telemetry captured one pushbutton activation. Routine sampling and spike and seizure detection programs demonstrated several episodes of rhythmic 8 Hz monomorphic blunted sharp wave discharges occurring in a generalized distribution. There is no clear source of artifact associated with these events raising the possibility of persistent electrographic seizure activity. At other times, the recording showed bursts of low amplitude activity admixed with sharply contoured waves arising from the left posterior quadrant and, at times, evolving over the left hemisphere intermixed with periods of background voltage suppression consistent with a burst suppression pattern. CT-torso - [**2198-8-7**] IMPRESSION: 1. Limited evaluation secondary to lack of intravenous contrast administration. New right and left lower lobe collapse compared to [**2198-5-7**]. New small right pleural effusion. Patchy appearance of left lung base raises the suspicion for component of aspiration. Overall findings suspicious for pneumonia. Clinical correlation is recommended. Endotracheal tube and nasogastric tube remain in good position. 2. Small amount of perihepatic fluid. TIPS shunt. No significant amount of abdominal ascites. No evidence of acute abdominal or pelvic pathology within the limitations described.\ CT torso - [**2198-10-23**] " CHEST: The patient is status post tracheostomy tube placement, with the tip terminating at the level of thoracic inlet. There are small mediastinal lymph nodes; however, there is no significant lymphadenopathy. Coronary arteries are calcified. There is no pericardial effusion. Small pericardial nodes are noted; however, measure less than 5 mm. There is trace pleural effusion bilaterally. In the lung window, again note is made of patchy opacities in the dependent portion of lower lobes, decreased since prior study, likely representing residual atelectasis. Somewhat confluent area in the left lower lobe is noted, likely due to a part of resolving atelectasis; however, the attention should be paid to this location at the time of next follow up. There is no endobronchial lesion. ABDOMEN: The patient is status post RF ablation of two lesions in the right lobe of the liver, which demonstrate hypoattenuation relative to liver parenchyma on all the phases. The patient is status post TIPS placement. The visualized portion of portal vein is patent. There is no new focal arterial enhancement. Again, note is made of splenomegaly. Gallbladder is unremarkable without evidence of calcification. Pancreas is somewhat atrophic, without ductal dilatation or focal solid lesion. There is fat replacement of the pancreatic head. There is unchanged fat stranding surrounding the celiac trunk with small nodes. There are enlarged peripancreatic and porta hepatis nodes measuring up to 1.4 cm in short axis, unchanged since prior study. There is no significant ascites. The adrenal glands are within normal limits. The visualized portion of large and small intestines are within normal limits. Bilateral kidneys have surrounding fat stranding with unchanged small hypoattenuating lesion, likely representing cyst, unchanged since prior studies. There is no hydronephrosis. The evaluation of the posterior portion of the abdomen is somewhat limited due to artifact from the arms. PELVIS: There is colonic diverticulosis without evidence of diverticulitis. Note is made of residual fluid in the somewhat dilated rectum. Foley catheter is noted in the urinary bladder. The visualized portions of small intestines are within normal limits, without ascites or lymphadenopathy. There are degenerative changes of thoracolumbar spine; however, there is no suspicious lytic or blastic lesion in skeletal structures. Atherosclerotic changes of the vascular structures are again noted. IMPRESSION: 1. Decreased parenchymal opacities in both lower lobes with residual atelectasis and effusion. Somewhat confluent area near the left lower lobe, likely a part of resolving atelectasis. Attention should be paid to this location at the time of next followup. 2. Post RF ablation of two liver lesions without new arterial enhancement, with severe cirrhosis and splenomegaly. 3. Enlarged porta hepatis and peripancreatic nodes, unchanged. 4. Diverticulosis. " CT-head - [**2198-8-7**] IMPRESSION: Limited evaluation secondary to artifact from overlying metallic devices. No gross acute intracranial hemorrhage. Unchanged multifocal sinus disease as described on [**2198-8-2**]. NOTE ON ATTENDING REVIEW: The study is markedly limited for the evaluation of brain parencyma due to streak artifacts from the several external metallic objects. There is gross midline shift. Other than this, it is extremely difficult to assess the intracranial structures for abnormality. There is new moderate opacification of the sphenoid sinus and the left side of frontal sinus and the marked opacification of ethmoid air cells is worsened. The nasopharynx is opaciifed with a tube, likely nasogastric tube within. This appearance is new. EEG - [**2198-8-8**] IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling and spike and seizure detection programs showed bursts of sharply contoured waveforms occurring in a generalized distribution but also with a leftsided predominance lasting up to one to two seconds in duration and admixed with other periods of voltage suppressed background lasting, at times, up to 10-20 seconds. These findings are consistent with a burst suppression pattern. Superimposed on this pattern, later in the tracing, there is also rhythmic high amplitude low frequency slow wave morphology discharges that are related to artifact from the dialysis machine. There were no prolonged or repetitive discharges. No clinical seizures were noted. [**2198-8-10**] ECHO Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2198-3-29**], regional LV wall motion abnormalities are new, and consequently, LV systolic function is now depressed. [**2198-8-15**] head MRI with and without contrast. CONCLUSION: Negligible interval change in the appearance of the brain compared to the prior study. Particularly in view of the history of status epilepticus, it is of some interest that the present diffusion scan is normal, whereas as a diffusion imaging study from [**2197-12-15**], showed very extensive areas of signal abnormality. The reason for this discrepancy is not clear. ADDENDUM: Multiple paranasal sinuses exhibit mucosal thickening, and likely fluid as well within the mastoid sinuses. Presumably, these findings relate to the intubated status of the patient. [**2198-10-12**] head MRI with and without contrast. 1. No acute intracranial process. 2. Multiple paranasal sinuses exhibit mucosal thickening and some demonstrate air-fluid levels. This may represent sinusitis or post intubation changes [**2198-10-26**] Most recent labs - see attached printout. Brief Hospital Course: The patient was admitted to the ICU for convulsive status epilepticus on [**2198-8-2**]. Routine portable EEG showed frequent and at times periodic lateralized discharges from the left posterior quadrant. On [**2198-8-3**] the patient was taken out of the unit to the step down unit on [**Hospital Ward Name 121**] 5. At that time his exam revealed staring spells with confusion most of the time - excluding an episode of lucidity. He was also not using his R(dominant) hand as much as usual. He was breathing well and did not require intubation. On the evening of [**2198-8-3**] he had a seizure and then three more on the morning of [**2198-8-4**]. Later in the day a nurse noted that he was breathing and was turning "dusky". A code was called. O2 sat was initially 89% (was breathing at this point) and HR regular, 72. The patient again had difficulty breathing and was intubated and started on propofol gtt. He was transferred to the ICU and soon after got 20mg/kg of dilantin. Continuous EEG was set up and revealed non-convulsive status epilepticus. This yielded to burst suppression due to the propofol. At this point his anti-seizure regimen inlcuded Keppra, Neurontin, Dilantin, and propofol. Elevated ammonia/hepatic encephalopathy was thought to be the trigger of the patient's seizures. He was titrated to three bowel movements a day with lactulose and rifaximin. The liver service was consulted. . EEG on [**2198-8-6**] continued to demonstrate isolated occipitally predominant and leftsided predominant spike and wave discharges despite this heavy dose of antiseizure medication. In the afternoon of the same day the patient was noted to have increasing acidosis, elevated lactate and rising CKs which were both attributed to his propofol. Propofol was stopped and the patient was put into a pentobarbital coma. . On [**2198-8-7**] Mr [**Known lastname **] became hypotensive requiring two pressors. Pentobarbital was stopped but he remaind on Keppra, Dilantin and tapering Neurontin. He was empirically started on vancomycin and Zosyn for concern of sepsis. A CT of the abdomen failed reveal a nidus of infection, though the study was limited due to the lack of contrast. The renal service was consulted regarding his acidosis. He was started on CVVH. . Blood cultures from [**2198-8-7**] grew coag negative staph and vancomycin sensitive enterococcus. The infectious diseases service was consulted. Xigris was started to treat the systemic inflammatory response syndrome. . An EEG on [**2198-8-8**] was read by the covering resident as suggestive of insufficient burst suppression and the patient was given a 400mg IV dilantin bolus. . Renal function/acidosis improved on the CVVH and by [**2198-8-9**] it was discontinued. That evening his heart rhythm was noted to go into VTach. Cardiology was emergently consulted. A STAT echo showed hypokinesis of the anterior septum, akinesis of the inferior septum, and severe hypokinesis of the inferior wall. He was started on amiodarone. . By [**2198-8-10**] pressors were weened off and Zosyn was stopped. Vancomycin was continued for a two week course. Of note a definite source of the infection was never identified. . On [**2198-8-11**] the patient was started on a versed gtt and dilantin was started. . Over the next four weeks the patient's renal status would normalize and his fever and infectious issues would resolve confirmed by sterile blood cultures. Over the same period he was maintained on phenobarbital, Keppra, dilantin, and transitioned from the Versed gtt to an Ativan taper. An MRI failed to detect any significant abnormality or change from prior. Physical examination of the patient during this period revealed an unresponsive edematous male with reactive pupils, intact corneal reflexes, intact OCRs, and [**12-22**] response to nail bed pressure intermittently in the LUE and LLE. As the Ativan was tapered the patient's EEG showed an increased quantity of 1hz global paroxysmal epileptiform discharges. As such on [**2198-8-31**] Zonisamide was added to the above regimen. Also during this time, the a tracheostomy was performed. Plans for a PEG tube were thwarted by the patient's overwhelming edema, which was a result of the fluid boluses he recived while hypotensive/septic. Lasix and aldactone were used to diurese approximately 15 liters off the patient. . Since then, he has been gradually weaned off phenobarb with no significant changes in his EEG. Ativan was also slightly tapered and zonegran was slightly increased. Mr. [**Known lastname **] was noted to have intermittent hematuria, therefore Urology was consulted. It was suggested that this was due to trauma from his Foley, and a repeat U/A and UCx were stable. His bag was taped to his leg to stabilize it and he will need OP follow-up for cystoscopy. He also had intermittent episodes of hypotension, therefore his metoprolol was decreased from QID to [**Hospital1 **] and this resolved. Lisinopril was added for renal protection given his DM. . He was transfered to the step down on [**9-20**] for further management. . Hospital Summary from [**9-20**] - [**10-6**] Neuro: pt had his phenobarbital weaned down with improvement in his alertness - opening eyes much more. However, his EEG began to demonstrate more discharges. As a result, his medical regimen was increased with stabilization of his EEG. After several days, his phenobarbital again was weaned to 100 mg PO BID. His Ativan was also weaned and his Zonegran dose was increased. He was also started on Topamax with less frequent discharges on above AED therapy. Topamax increased to 125 [**Hospital1 **] by [**10-6**]. Over the course of the next two weeks, PB was tapered alltogether, as well as his Ativan, both in small decrements. Topamax was increased to 200 mg [**Hospital1 **] and Zonegran to 600 mg daily. His Keppra was maintained at 2250 mg [**Hospital1 **], and his Dilantin at 300 mg TID, the latter with corrected (for low albumin) levels around 30. . Of note, a repeat MRI of the brain on [**10-15**] showed no ischemic changes. . Despite this slow taper, the patient remained deeply encephalopathic, despite the absence of epileptiform abnormalities on EEG, which continued to show an encephalopathic pattern with very low voltage slow background and occasional parasagittal sharp wave discharges, but these were not frequent or rapid enough to suggest ongoing seizures. On exam, he would have his eyes open, but he would not regard, localize sound or regard his examiner, nor blink to threat. He would not grimace nor move his extremities to noxious stimulation, but he would grimace to flexion of his arms, suggesting that perhaps he had distal sensory deficits as well as marked weakness and muscle bulk loss, suggestive of a critical illness polyneuromyopathy. His reflexes were absent, supporting this finding. . Note that 1 week prior to discharge hid improved neurologically on a daily basis: he made eye-contact, would fix and follow a face (non consistently), and would occasionally following midline commands such as sticking out his tongue, and mouthing words like "good-morning". Prior to this, he was basically considered to be in a persistent vegetative state, but thankfully he disproved this prior to discharge to rehab. . Neurologically, our advise is an extreme slow taper of his Ativan, perhaps as slow as -.25 mg per 2 weeks. He should have interval EEGs to assess for continued epileptiform activity. As this patient is complex, in case of questions please do not hesitate to contact the epilepsy fellow regarding his EEG findings, for proper electro-clinical correlation. . CV: Low BPs initially during stay in step down. Metoprolol dose was halved with improvement in his BPs with stable bps on metoprolol 12.5 [**Hospital1 **] and lisinopril. Later, the metoprolol was further decreased due to continued low bloodpressures. . Resp/ID: Requiring prolonged stay in the stepdown unit due to the intensive nursing care needs, the patient kept having marked sputum production. Staph aureus was cultured, and for concern of PNA he was started on Vancomycin, but continued on regimen with continued staph in his sputum. His VRE (rectal swab) showed sparse growth on [**10-13**]. His Vancomycin was discontinued, and he remained afebrile. He continued to produce sputum occasionally blood-tinged, and I refer to the respiratory care sign-out regarding his pulmonary status. A chest CT done just prior to discharge showed "decreased parenchymal opacities in both lower lobes with residual atelectasis and effusion. Somewhat confluent area near the left lower lobe, likely a part of resolving atelectasis. Attention should be paid to this location at the time of next followup". . GI: The patient had stable LTFs and ammonia levels, as long as having daily BMs. he was treated with 60 mL of lactulose QID, titrated to 3 bowel movements per day. He was also on Rifaximin for selective decontamination. Hepatology followed the patient during hospital stay, with advise regarding management of his liver failure, adjusting lactulose and others, metabolic management. Towards the end of his stay, an U/S of his abdomen, a bone-scan and CT torso were obtained - see below. . FEN: Stable electrolytes with only occasional replacement necessary. He had a Dobhoff in place fo several weeks, and an assessment of the amount of ascitis by U/S on [**10-22**] showed no intra-abdominal ascites, making PEG placement possible. His Dobhoff tip was found to be intragastric, and when pushed down further it only resulted in curlingup in the back of his mouth. After withdrawing again, a repeat CXR on [**10-24**] showed the tip to be in the stomach still. Follow-up was recommended. . To assess overall prognosis (re: PEG placement) a bone-scan and CT torso (post-RFA protocol) were obtained on [**10-23**], which showed extensive degenerative joint disease but no progression of his HCC (see details in results-section). Hepatology was then scheduling his PEG placement, but due to logistical issues this could not be done promptly. This should be considered on a day-care basis, unless the patient's level of consciousness allows him a safe swallow, and the enteral feedings prove to be only temporary. . Endo: The continued to have low thyroid function, likely absorption impaired [**1-19**] continuous feeds, so he was changed to IV thyroxine with improvement after gradual upward titration of the dosis. TSH and T4's were checked regularly. . Heme: All lineages decreasing on [**10-5**], hematology was consulted, iron and vitamin studies were normal. Their advise was to D/C Dilantin if clinically possible, but we were not able to do so at this stage. Guiac's were checked regularly as well, all negative. In summary, the pancytopenia was considered secondary to chronic illness with polypharmacy, and a bone marrow biopsy was not performed. CBC's are to be followed. . Musculoskeletal: As outlined under the neurological section, he had marked muscle wasting and areflexia, as well as decreased response to peripheral noxious stimuli, making a critical illness polyneuro-myopathy likely. Of note however, his pain seemed to be exacerbated when his joints were passively moved, ranging from smaller joints in the hand to larger joints as elbow. His bone scan, done to assess for bony metastasis of his HCC, showed diffusely symmetric increased uptake of tracer in all joints, indicating degenerative disease. In the setting of his polyneuro-myopathy, prolonged immobilization despite PT, it is not a suprising finding. However, if the patient is further mobilized, and this continues to be a problem, pain medication should be adapted and a further workup is warranted. . Social: His wife was updated frequently and on a regular basis, during later stages of the admission twice per week on set days of the week. She continued to be understanding, and slowly appeared to accept the persistent vegetative state her husband was in, with no improvement of his neurological exam during the 2nd to last month of his stay. Fortunately, he did improve during the last week of his stay he did suddenly improve, with eye-contact and occasionally following midline commands, and mouthing words like "good-morning". His wife was [**Name2 (NI) 70524**] pleased. Medications on Admission: lactulose 30mg 5x/day rifaximin 400mg tid protonix 40mg [**Hospital1 **] propranolol 10mg tid levothyroxine 175mg daily lantus 64units qhs keprra 1500mg [**Hospital1 **] mycelex 10mg 5x/day "zepia" 10mg daily(?) Discharge Medications: 1. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1) Appl Ophthalmic PRN (as needed). 3. Metoclopramide 5 mg/mL Solution [**Hospital1 **]: One (1) Injection Q6H (every 6 hours). 4. Levothyroxine 200 mcg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection DAILY (Daily). 5. Lorazepam 2 mg/mL Syringe [**Hospital1 **]: 0.75 mg Injection Q6H (every 6 hours). 6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection [**Hospital1 **] (2 times a day). 7. Fluocinolone 0.025 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 9. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-19**] Drops Ophthalmic PRN (as needed). 11. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: One (1) PO Q4-6H () as needed for temp>100.4. 12. Furosemide 40 mg Tablet [**Month/Day (2) **]: 3.5 Tablets PO DAILY (Daily). 13. Lisinopril 5 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily). 14. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO TID (3 times a day). 16. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: Three (3) PO TID (3 times a day): 300 mg TID. 17. Levetiracetam 1,000 mg Tablet [**Month/Day (2) **]: 2250 mg Tablets PO twice a day as needed for seizure. 18. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Sixty (60) ML PO QID (4 times a day): [**Month/Day (2) **] to 3 - 3 bowel movements per day. 19. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 20. Topiramate 100 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a day). 21. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily). 22. Zonisamide 100 mg Capsule [**Month/Day (2) **]: Seven (7) Capsule PO DAILY (Daily). 23. INSULIN STANDING ORDER AND SLIDING SCALE AS PRESRIBED IN NURSING SIGNOUT Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Status epilepticus in setting of severe metabolic derangement in setting of liver failure due to Non Alcoholic Steatotic Hepatitis and Hepato Cellular Carcinoma, with prolonged multifactorial encephalopathy (post-ictal, non-convulsive status, metabolic derangements) and a protracted hospital course in light of the above, as well as several complications as outlined extensively under "Brief Hospital Course". Discharge Condition: Stable, neurologically slowly improving, labs unchanged, afebrile. Discharge Instructions: Please follow up with Dr [**Last Name (STitle) **] as planned, unless you are still at [**Hospital1 **] at that time. Take all your medications as presribed. Followup Instructions: Epilepsy: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 17798**], MD Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2198-11-26**] 9:00 You will be contact[**Name (NI) **] by Hepatology regarding follow-up and possible PEG placement, for details see [**Hospital 7666**] Hospital Course'. Completed by:[**2198-10-26**]

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Discharge summary

report+addendum+addendum

Admission Date: [**2154-7-14**] Discharge Date: Date of Birth: [**2078-5-1**] Sex: M Service: CCU NOTE: For discharge date, please see Addendum. Please see Addendum to Discharge Summary for hospital course starting on [**2154-7-18**] until the time of discharge. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old male who presented to [**Hospital6 33**] with chest pain on [**2154-7-14**] and was transferred to the [**Hospital1 346**] for management of an acute myocardial infarction. He has a history of atrial fibrillation since [**2143**], deep venous thrombosis, and colon cancer. His cardiac risk factors include a remote smoking history, hypercholesterolemia, and a family history of myocardial infarctions. He was in his usual state of health until the morning of [**7-14**] when he developed acute chest pain when getting up at 4 a.m. The pain appeared localized mostly to his back without any radiation. He did not have symptoms of dyspnea. No nausea, and no diaphoresis. He was able to go back to sleep and woke up again at 5 a.m. with severe squeezing chest pain localized to the anterior chest. He rated the pain [**10-31**]; again no radiation, no dyspnea, no nausea, and no diaphoresis were noted. He had never had this type of chest pain before. He also had not experienced any recent changes in exercise tolerance of being able to walk about one flight of stairs (limited by dyspnea and not limited by pain). He did not give any history of orthopnea or paroxysmal nocturnal dyspnea. He does have chronic leg edema which has not changed recently. He was brought to [**Hospital6 33**] where he received four doses of sublingual nitroglycerin which relieved the chest pain temporarily. An electrocardiogram at [**Hospital6 3426**] showed ST elevations in V2 to V6. His cardiologist is Dr. [**Last Name (STitle) 11378**] at [**Hospital6 1708**], but due to an unavailability of beds he was transferred to [**Hospital1 346**] for cardiac catheterization. The initial electrocardiogram at [**Hospital1 190**] showed marked ST elevations in leads I, aVL, and V2 to V6, with reciprocal depressions over the inferior leads, as well as a right bundle-branch block pattern, and left axis deviation. Cardiac catheterization at [**Hospital1 188**] showed total occlusion of the left anterior descending artery after first heart sound, diffuse irregularities in the right coronary artery, but no significant disease in the left main coronary artery and left circumflex. The left anterior descending artery occlusion was successfully stented; however, no reflow resulted. He was admitted to the Coronary Care Unit for management of his acute myocardial infarction. PAST MEDICAL HISTORY: 1. Atrial fibrillation since [**2143**]. 2. Congestive heart failure in the setting of atrial fibrillation. 3. Deep venous thrombosis in [**2134**] and [**2150**] (the latter in the setting of colectomy). 4. Colon cancer, status post colectomy with colostomy in [**2150**]. 5. Arthritis. 6. Hypercholesterolemia. 7. One past episode of hematuria of unclear etiology. 8. Depression. 9. Benign prostatic hyperplasia with transurethral resection of prostate a little more than five years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Medications at home included digoxin 0.25 mg p.o. q.d., Zestril 20 mg p.o. b.i.d., furosemide 40 mg p.o. q.d., Celexa 20 mg p.o. q.d., Lipitor 10 mg p.o. q.d., metoprolol 50 mg p.o. b.i.d., verapamil 240 mg p.o. q.d., naproxen 500 mg p.o. q.d. SOCIAL HISTORY: He is a retired police officer. He lives with his wife in [**Name (NI) 11379**]. He smoked four packs per day for over 10 years, but he quit 40 years ago. He occasionally drinks alcohol. FAMILY HISTORY: His brother died from a myocardial infarction at the age of 56. His father died from "heart disease" at the age of 40. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Coronary Care Unit revealed vital signs with a temperature of 97, blood pressure of 110/60, heart rate of 77, respiratory rate of 16, pulse oximetry 90% on 3 liters nasal cannula. General appearance revealed the patient was tired-appearing but in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. His sclerae were anicteric. He had moist mucous membranes, and no appreciable oral lesions. Neck revealed jugular venous pressure was difficult to assess due to the supine position. No carotid bruits were appreciated. Cardiovascular examination revealed an irregularly irregular rhythm with a [**3-27**] holosystolic murmur at the apex, radiating to the axilla. The lungs had mild diffuse wheezes throughout. The abdomen was soft, nontender, and nondistended, with active bowel sounds. A well-healed midline scar, and a colostomy bag in place on the left side. Extremities revealed 1 to 2+ pitting edema on both legs and chronic venous stasis changes. Good distal pulses. The catheterization site in the right groin were remarkable for dressing soaked with blood. No hematoma or bruits were evident. Neurologic examination revealed the patient was alert and oriented. Cranial nerves II through XII were intact. No drift. Full grip strength. Plantar flexion strength was [**5-26**]. His reflexes were symmetric. His toes were equivocal. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data at the time of admission to the Coronary Care Unit, his hematocrit was 43.4, white blood cell count was 7.9, platelet count was 161. His PT was 16.9, INR of 2, PTT of 23.2. Sodium of 140, potassium of 4.9, chloride of 106, bicarbonate of 22, blood urea nitrogen of 29, creatinine of 0.9, blood glucose of 203. The initial creatine kinase was 114, and the CK/MB was 7, troponin I was less than 0.3. RADIOLOGY/IMAGING: Electrocardiogram performed status post catheterization showed atrial fibrillation with an average ventricular response of 69, marked ST elevations were noted in leads I, aVL, and V2 through V6; suggesting an acute myocardial infarction. There was also a right bundle-branch block pattern and left axis deviation. A chest x-ray from [**Hospital6 33**] showed evidence of congestive heart failure as well as small right-sided pleural effusion. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR: Following catheterization, he was admitted to the [**Hospital1 69**] Coronary Care Unit with a diagnosis of acute myocardial infarction. He was started on aspirin, Plavix, and an 18-hour course Integrilin following catheterization, and metoprolol and nitroglycerin drip for management of chest pain and blood pressure. His Coumadin had been held for catheterization, and he was started on heparin for anticoagulation in the setting of atrial fibrillation. His digoxin, verapamil, Lasix, and Zestril were initially held. He was initially not given an intravenous fluids as his physical examination and outside chest x-ray suggested possible mild fluid overload. An echocardiogram was planned for the next day. Over the course of the first night he had three short episodes of chest pain and nausea which were relieved by nitroglycerin. One of them required 1 mg of morphine. Electrocardiograms at that time with chest pain showed developing Q waves, but no new ST elevations. Serial creatine kinases were drawn which peaked at the second creatine kinase at 5856, the CK/MB was 482, and the MB index was 8.3. The third creatine kinase was 3586, CK/MB of 258, MB index of 7.2. In the morning of [**7-15**], he became hypotensive to a blood pressure of 80/40. He had not yet given consent for a central line. He was given two fluid boluses of 250 cc of normal saline which stabilized his blood pressure. However, over the next few hours he developed considerable respiratory distress requiring increasing concentrations of oxygen and a brief course of BiPAP. A chest x-ray showed evidence of congestive heart failure. He now gave consent for central line, and a right internal jugular line was put in place. He was given a total of 160 mg of intravenous Lasix with great improvement in his respiratory status, and he was able to breathe comfortably on nasal cannula again. His blood pressure remained stable except for one further episode of hypotension in the evening of [**7-15**], for which he was briefly placed on a Levophed drip which was discontinued after two hours. He did not require management with intravenous pressors. An echocardiogram done on [**7-15**] showed extensive left ventricular systolic dysfunction including akinesis of the distal third of the inferior, lateral, and anterior walls as well as the apex, and additional areas of hypokinesis. There was evidence of torn mitral cordis with moderate (2+) eccentric jet of mitral regurgitation directed inferolaterally. Moderate tricuspid regurgitation was also seen. His ejection fraction was 20% to 25%. Note: Based on the American Heart Association recommendations, these findings recommend endocarditis prophylaxis in the future. His blood pressure remained stable, but he still was repeatedly tachycardia into the 100 to 120 range. Over the next two days his metoprolol dose was increased. Captopril and eventually digoxin were added to the regimen for improved blood pressure and rate control. Please see addendum to this Discharge Summary for further cardiovascular course and details on the medications on discharge. 2. PULMONARY: As noted above, the patient developed respiratory distress on [**7-15**], likely secondary to congestive heart failure. He initially required BiPAP but was quickly able to switch back to nasal cannula with improved oxygenation following 160 mg of intravenous Lasix. His respiratory status continued to improve over the next two days. He was given daily intravenous Lasix for continued diuresis and will likely be switched back to his home oral regimen of daily Lasix prior to discharge. Please see addendum for details of his pulmonary course. 3. GENITOURINARY: As noted above, the patient has a history of hematuria even though a full workup has never been initiated. During the initial night of [**7-14**], he developed significant hematuria with clotting in the Foley catheter bag as well as leakage of blood and urine around the Foley catheter. His urine output dropped to 0 secondary to clotting. An attempt was made with a larger Foley which was only briefly successful. Due to the hematuria, the post catheterization Integrilin was stopped after a total of 15 hours instead of the normal 18 hours. The Urology Service was consulted and were able irrigate copious clots with a larger Foley catheter. He was started on continuous bladder irrigation which was stopped after 24 hours, as he had no further hematuria. The Urology Service recommended outpatient workup of the hematuria when he was stable including outpatient cystoscopy. For this, the patient should follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**] (telephone number [**Telephone/Fax (1) 2906**]). 4. ENDOCRINOLOGY: The patient's initial blood glucose on admission was 203. He did not have a known diagnosis of diabetes, but was placed on fingerstick checks and an insulin sliding-scale. He did require an average of 2 units of regular insulin per day. Most of his blood sugars were in the 150 to 170 range. His hemoglobin A1c was checked which was 6.7. This suggested he does potentially recent onset diabetes. Given his cardiac history, he would benefit from glucose control and should probably be started on an oral hypoglycemic [**Doctor Last Name 360**] such as metformin on discharge. Please see details in the addendum. NOTE: Please see addendum to this Discharge Summary for the hospital course beginning on [**2154-7-18**] until the time of discharge for further events of hospital stay; including discharge diagnosis, medications, and followup instructions. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 423**] MEDQUIST36 D: [**2154-7-18**] 18:16 T: [**2154-7-20**] 04:53 JOB#: [**Job Number 11380**] Name: Unit No: [**Numeric Identifier 1595**] Admission Date: [**2154-7-23**] Discharge Date: Date of Birth: Sex: Service: This is a second addendum to the prior discharge summary, which was for the hospital course starting on [**7-14**] and ending [**7-24**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern4) 1596**] MEDQUIST36 D: [**2154-7-23**] 15:34 T: [**2154-7-23**] 15:48 JOB#: [**Job Number 1597**] Name: [**Known lastname 1598**], [**Known firstname **] A. Unit No: [**Numeric Identifier **] Admission Date: [**2154-7-14**] Discharge Date: [**2154-7-24**] Date of Birth: [**2078-5-1**] Sex: M Service: CCU ADDENDUM: This is an addendum to a Discharge Summary dated up to [**2154-7-18**]. HOSPITAL COURSE: Please add: 1. Nonsustained ventricular tachycardia: On [**7-21**], the patient had a 25 beat course of nonsustained ventricular tachycardia which was asymptomatic and not associated with hemodynamic instability, however, non-sustained ventricular tachycardia seven days post myocardial infarction is suspicious for a re-entrant circuit present in the conduction system, which is a poor marker for long-term cardiovascular function and indicates possible risk for sudden death. Therefore, after the patient's INR was corrected to 1.6 with Vitamin K which was given subcutaneously, the patient was taken to the Electrophysiology Service laboratory on [**2154-7-23**], to be evaluated for defibrillation and AICD placement. The patient was taken to the Electrophysiology Service Laboratory and found to be inducible for ventricular tachycardia which indicated that he had a re-entrant circuit and he had an AICD placed successfully without complications. The patient was restarted on Coumadin after the procedure for prophylaxis from cerebrovascular accident as a result of his atrial fibrillation. His INR, however, was subtherapeutic prior to discharge and he was therefore given subcutaneously Lovenox to cover him for atrial fibrillation prophylaxis. This was to be given until his INR became therapeutic which would be in the range of 2.0 to 3.0. 2. Endocrine: The patient's fingerstick blood glucoses remained in the range of 120 to 140 throughout the rest of his hospitalization and he was not started on an oral hypoglycemic [**Doctor Last Name 932**] at this time, however, due to his regularly elevated blood glucoses, he should be considered for an oral hypoglycemic [**Doctor Last Name 932**] to be started on an outpatient basis with proper surveillance of his sugars. It will not be started at this time due to the possibility of medication induced hypoglycemia with a newly started [**Doctor Last Name 932**]. 3. Pressure Ulcers: The patient developed decubitus ulcers on his upper back noticed on [**2154-7-19**]. The ulcers were from the patient's lack of activity despite the fact that he was being ambulated and rehabed by Physical Therapy every day. The patient had difficulty even sitting up in bed and the constant pressure of laying on his back with his large body habitus put him at high risk for developing decubitus ulcers. The ulcers were Grade 2 involving skin breakdown but not involving the underlying dermis. They were not infected at any point and never exhibited purulent exudate. The ulcers were dressed with silver sulfadiazine twice a day with dressing changes twice a day and improved after the 28th with increased activity and the dressings. DISPOSITION: The patient will be discharged to an inpatient Physical Rehabilitation Center for his functionality status post myocardial infarction. The patient reported being able to completely function with all his activities of daily living prior to his myocardial infarction and is currently unable to lift himself up in bed or walk on his own. DISCHARGE MEDICATIONS: 1. Metoprolol 75 mg p.o. twice a day. 2. Furosemide 80 mg p.o. q. day. 3. Lisinopril 20 mg p.o. q. day. 4. Digoxin 0.25 mg p.o. q. day. 5. Neutra-Phos two packets p.o. twice a day. 6. Docusate 100 mg p.o. twice a day p.r.n. constipation. 7. Pantoprazole 40 mg p.o. q. day. 8. Plavix 75 mg p.o. q. day times 25 days. 9. Aspirin 325 mg p.o. q. day. 10 Celexa 20 mg p.o. q. day. CONDITION AT DISCHARGE: Fair. DISPOSITION: The patient is discharged to the [**Hospital 1599**] Rehabilitation Facility. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1600**], M.D. [**MD Number(1) 1601**] Dictated By:[**Last Name (NamePattern1) 1602**] MEDQUIST36 D: [**2154-7-23**] 15:21 T: [**2154-7-23**] 15:35 JOB#: [**Job Number 1603**]

[ "272.0", "427.1", "410.11", "518.5", "458.2", "427.31", "599.7", "707.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "36.06", "36.02", "37.26", "88.53", "38.93", "88.56", "37.22", "37.94" ]

icd9pcs

[ [ [] ] ]

3771, 6350

16909, 17218

16374, 16771

3301, 3546

13302, 16351

6378, 13284

16787, 16888

311, 2714

2736, 3274

3563, 3754

27,799

116,592

34724

Discharge summary

report

Admission Date: [**2180-8-14**] Discharge Date: [**2180-8-18**] Date of Birth: [**2150-5-11**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 13541**] Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None. History of Present Illness: 30 M with long history of EtOH abuse with history of withdrawal seizures, schizophrenia, admit to MICU with EtOH withdrawal. Patient was admitted to [**Hospital1 **] for detox on [**8-11**]. Etoh level on admission was >400. On [**8-13**] noted to have tachycardia and increased BP (baseline 90s-100s now into 140s+). Today patient sent from [**Hospital1 **] for agitation and confusion/disorientation. In ED, vitals were: AF, BP 142/100, HR 101, 98% on RA. Remained hypertensive and tachy during course. Given 4 mg IV ativan and 40 mg IV valium; also banana bag. Placed in 4 points and 1:1 sitter. Serum and urine tox negative. Currently denies auditory hallucinations, reports seeing brother walk by him (+VH). Denies chest pain, abdominal pain, shortness of breath. Denies recent cold symptoms or cough. Does not answer other ROS questions. Denies recent drug use. Thinks last EtOH use was vodka yesterday at 3pm after a 2pm appointment that he cannot further specify about. Past Medical History: 1) EtOH abuse including seizures from withdrawal (reports 3 hospitalizations in last year in [**State 531**]). Detox most recently in [**2180-3-4**] in [**State 531**]. 2) Reported h/o MI due to cocaine abuse per OMR 3) Cocaine abuse 4) Schizophrenia 5) Depression (h/o suicide attempt at age 15) 6) ADHD Social History: Pt. born in [**Country 13622**] Republic and moved to United States at the age of 1. Raised in Bronx, NY and moved 2 months ago to [**Location (un) 86**] where he mother currently lives. Denies tobacco use. +EtOH abuse [began 7 years ago, reports drinking 1 pint vodka/day, last drink [**2180-8-11**]] Polysubstance abuse/recreational drug use (including cocaine and remote use of marijuana, heroin, LSD, crystal meth) Pt. worked as a bar manager from [**2176**]-[**2177**], but has been unemployed for the past year and a half. Patient has seen numerous therapists since the age of twelve. He reports being abused and raped when he was younger. Currently, he has a therapist in [**Location (un) 86**] who has referred him to a psychiatrist. He has not started treatment yet. Family History: He has noticed no history of MI, cancer, or depression in his first degree relatives. There is a history of high cholesterol, hypertension, and alcohol use in his father's side of his family. Physical Exam: Vitals: T: 98.1, BP 147/94, HR 100, R24, 100% RA General/mental status: Thin male, alert and conversant. Speech quiet but understandable. Thought process often very tangential but at times showing awareness of current situation ("I'm at detox, I've seen so many doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**]..."). + VH + paranoia. Neck: supple, no adenopathy. Chest: CTA bilat. Heart: RRR, tachy, no m/r/g appreciated. Abdomen: soft, NT, ND, relaxes abdomen poorly but liver edge palpable. Extrem: warm, no edema Neuro: alert, refuses to answer orientation questions. MAE, grossly intact. Pertinent Results: [**2180-8-14**] 08:45AM BLOOD WBC-5.5# RBC-4.44* Hgb-14.0 Hct-38.2* MCV-86 MCH-31.5 MCHC-36.7* RDW-15.8* Plt Ct-150 [**2180-8-14**] 08:45AM BLOOD Glucose-149* UreaN-7 Creat-0.8 Na-135 K-3.3 Cl-95* HCO3-26 AnGap-17 [**2180-8-14**] 08:45AM BLOOD ALT-218* AST-280* CK(CPK)-375* AlkPhos-107 Amylase-62 TotBili-0.6 CK 375 -> 2549 -> 4031 -> 4280 -> 6277 -> 6220 [**2180-8-14**] 08:45AM BLOOD CK-MB-4 cTropnT-<0.01 [**2180-8-14**] 08:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2180-8-14**] 08:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2180-8-14**] 12:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CXR ([**8-14**]): IMPRESSIONS: No consolidation, but increased opacity at the lung apices may reflect aspiration. Correlation with dedicated PA and lateral CXR is recommended. Brief Hospital Course: # EtOH withdrawal: Last known drink [**8-11**]. Presented with agitation, visual hallucinations, tachycardia, hypertension, consistent with delirium tremens. Also had mild transaminitis that trended down, negative hepatitis serologies. Pt was initially admitted to the MICU [**8-14**] and started on a CIWA protocol with diazepam 15 mg IV Q15-30 min for CIWA >10. He was also started on MVI, thiamine, and folate. Initially, he required a 1:1 sitter, restraints, and haldol for agitation, but this was stopped after 1 day. He received over 200 mg IV diazepam during the first day. He was transferred to the floor on [**8-16**] after a substantial decrease in his benzo requirement. He was continued on PO diazepam prn, but his CIWA was 6 or less on the floor for 2 days. Social work was consulted and recommended inpatient detoxification. # Schizophrenia/Depression/ADHD: He was continued on his outpatient risperidone. By the time of transfer to the wards, he denied hallucinations, suicidal or homicidal ideations. At discharge, he was interacting appropriately and felt optimistic. He will follow up with outpatient psychiatry. - Note to PCP/Psychiatry re: medications. He was previously on Strattera 60mg daily for ADHD, but hasn't taken this in a couple of months. He was discharged with trazodone for insomnia, which he tolerated well during admission. He was not given any ativan on discharge due to low CIWA and risk for abuse. Please assess the need for these medications at his follow-up appointment. # Elevated CK No muscular symptoms or recent trauma. Thought to be in the setting of delirium tremens. He was given aggressive fluids to prevent renal damage, and his BUN and Cr remained normal throughout. His CK had peaked and come down slightly on the day of discharge. Medications on Admission: Risperdal 2 mg HS Ativan 1 mg Q4-6H prn Thiamine 100 mg daily Folate 1 mg daily MVI 1 mg daily Discharge Medications: 1. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 100 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Delirium tremens Alcohol abuse/dependence Schizophrenia Polysubstance abuse Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted to [**Hospital1 18**] due to signs of alcohol withdrawal. You had hallucinations, tremors, elevated heart rate and blood pressure, which is part of a syndrome called delirium tremens. We gave you diazepam and observed you in the ICU. Now that your vitals signs are normal and your mental status has improved, we will discharge you with close follow-up for your alcohol abuse. As we discussed in length during your admission, continuing to drink alcohol will cause progressive damage to many parts of your body, including your liver. We strongly recommend that you seek treatment, either as an inpatient, or through intensive outpatient therapy. We have provided you with information about BEST, a program that can provide you with these resources. Please contact [**Name (NI) **] at BEST as soon as possible to set up a treatment plan: ([**Telephone/Fax (1) 79589**]. Also, please contact your therapist, [**Name (NI) 803**] [**Name (NI) 79590**], at [**Hospital **] [**Hospital **] Health Center on Monday morning to set up an appointment. Phone: ([**Telephone/Fax (1) 79591**]. Please take all of your medications as prescribed and go to all follow-up appointments. We will continue your trazodone that you received here to use if needed at nighttime for insomnia. If you experience any tremors, palpitations, chest pain, agitation, dizziness, headache, hear or see things others do not, experience any thoughts of harm to yourself or others, or have any other concerning symptoms, please seek medical attention or come to the emergency room immediately. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2180-8-24**] 2:00 Psychiatry: [**Hospital1 **] St. Health Center, [**2180-8-30**], 2:30pm, Dr. [**First Name (STitle) **] Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2180-9-21**] 9:20 Please call your therapist [**First Name5 (NamePattern1) 803**] [**Last Name (NamePattern1) 79590**] at [**Hospital1 **], ([**Telephone/Fax (1) 79591**], and [**Doctor First Name **] at BEST, ([**Telephone/Fax (1) 79589**], as instructed above. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**] Completed by:[**2180-8-18**]

[ "401.9", "359.4", "291.0", "412", "571.1", "295.90", "303.91", "311", "345.90", "314.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6484, 6490

4146, 5933

285, 292

6609, 6635

3276, 4123

8262, 8972

2439, 2632

6079, 6461

6511, 6588

5959, 6056

6659, 8239

2647, 2704

230, 247

320, 1301

2719, 3257

1323, 1630

1646, 2423

4,429

179,758

51370

Discharge summary

report

Admission Date: [**2155-12-24**] Discharge Date: [**2155-12-26**] Date of Birth: [**2094-8-31**] Sex: F Service: MEDICINE Allergies: Elavil / Aspirin / Nsaids Attending:[**First Name3 (LF) 99**] Chief Complaint: Anaphylaxis Major Surgical or Invasive Procedure: none History of Present Illness: Mrs [**Known lastname 106520**] is a 61 yo with a PMH significant for chronic hypotension, severe chronic asthma, type 2 diabetes mellitus, and past substance abuse who presented to the ED with suspected anaphylactic shock. She was recently admitted to [**Hospital1 18**] from [**12-15**] until [**12-22**] for low back pain that started three weeks earlier when she sufferred a fall after tripping over the wheels of her walker. Her workup revealed an L5 compression fracture and she was treated with epidural steroid injections by the pain service. She was also started on MS contin and dilaudid for pain control and was discharged to a rehab facility for further treatment of her back pain and for physical therapy. She was doing well at rehab until 5:00 am the morning of admission ([**12-24**]) when she received 2 tablets of dilaudid 2 mg, morphine SR, and ibuprofen for pain control and developed diffuse erythema and puritis. At approximately 8:30 AM, she also complained of difficulty breathing which she described as a tightness in her throat and lungs. Her pulse was 123 and her oxygen saturation on room air was 88%. She was transported to [**Hospital1 18**] ED for evaluation. Of note, she has received dilaudid in the past without any adverse effect. In the ED, her VS were 99.8 116 63/40s 28 97% on a 100% nonrebreather. It was felt that she had suffered an anaphylactic reaction to the dilaudid. She was treated with 125 mg of IV solumedrol, 20 mg IV pepcid, and 50 mg IV benadryl. She also received a total of 4 liters of NS. She had a good BP response to the fluid. Epinephrine was avoided as the pt responded to the other medications and she was tachycardic. Labs were significant for a WBC count of 26.7 (history of chronic leukocytosis) and a UA suggestive of UTI. There was also a concern in the ED for an infiltrate on CXR. The pt was treated with levoquin, vancomycin, and flagyl. She was admitted to the [**Hospital Unit Name 153**] for further observation. ROS: She denies any chest pain, no change in baseline SOB, except for morning of admission, when had a feeling of SOB and "tightness" that was much different and worse than baseline SOB. + gas for few days prior to admission, + nausea and no emesis. + decreased PO intake, last BM 1 dat PTA. no BRBPR, no fevers, chills, myalgias. Past Medical History: 1. Chronic severe asthma- Pt is on long term steroids. 2. Type 2 diabetes mellitus 3. Gait disturbance- Thought to be multifactorial secondary to peripheral neuropathy, steroid induced myopathy, and polyradiculopathy. 4. Hypothyroidism 5. Hypercholesterolemia 6. Depression 7. History of polysusbstance abuse- Pt used ETOH, cocaine, and heroin in the past. She has been clean since [**2140**]. 8. Hepatitis B 9. H/O duodenal ulcer 10. MGUS 11. Iron deficiency anemia 12. Diverticular disease seen on colonsocopy 13. Type II Diabetes 1. Elavil- Caused confusion. Social History: She is an artist. She denies narcotic use in the past 16 years but has h/o abuse. She has been in a [**Hospital1 1501**] since her recent admission. Family History: NC Physical Exam: Wght 80.1 kg T 98.4 BP 92/40 P 57 RR 16 O2 sat 94% 4L NC Gen- Well appearing lady resting in bed. NAD. Alert and oriented. HEENT- NC AT. PERRL. EOMI. Anicteric sclera. Dry mucous membranes. Cardiac- RRR. No m,r,g. Pulm- Diffuse [**Last Name (un) **] expiratory wheezing anteriorly and laterally. Abdomen- Obese. Soft. Diffusely tender. ND. No rebound or gaurding. Positive bowel sounds. Extremities- Warm. No c/c/e. 2+ DP pulses bilaterally. Neuro- CN II-XII intact. 5/5 strength in upper and lower extremities bilaterally. Pertinent Results: Labs: wbc hct plt Na K Cl HCO3 BUN Cr glucose Ca Mg Ph [**12-24**] U/A: Large blood/ positive nitrite/ small leuks/ 26 RBCs/ 20 WBCs/ few bact/ no yeast/ <1 epi Microbiology: [**12-24**] Blood culture: [**12-24**] Urine culture: Recent studies: CXR ([**2155-12-24**]): Moderate cardiomegaly is stable. There may be new atelectasis at the medial aspect of the right lung base but lungs are clear of any focal lesions of concern. A small-to-moderate-sized hiatus hernia is air filled. It could be a loop of small bowel alongside the esophagus. The appearance is unchanged since [**8-18**], [**2152**]. Echo ([**2155-12-16**]): Normal LVEF of >55%. Normal RV chamber size and free wall motion. Mildly thickened aortic valve leaflets. No AS or AR. Normal mitral valve leaflets with trivial MR. 1+ TR. Normal PA systolic pressure. Small pericardial effusion. MRI Lumbar Spine ([**2155-12-15**]): Compression fractures at T10, T12, and L1. There is no evidence of abnormal signal to suggest an acute component. Slight retropulsion of the superior corner of T10 but this does not compromise the cord. There is also some retropulsion of the superior margin of T12 which touches the cord but is not producing high grade canal stenosis. There is a more recent compression fracture of the body of L4 which is new compared to previous exams. There is persistent spondylolisthesis at this level. Oce again a moderacte canal stenosis. There now is bilateral neural foramen stenosis. There is no evidence of focal disc protrusion at any additional level. MRI Cervical Spine ([**2155-12-17**]): Images severely degraded by motion artifact. It is impossible to interpret spinal cord signal intensity. Although the exam is limited, there is no evidence of spinal cord compression. MRI Thoracic Spine ([**2155-12-20**]): T10, T12, and L1 vertebral bodies demostrate compressions as seen on the previous study. No evidence of increased signal seen in these vertebral bodies on inversion recovery images indidicating chronic compressions. There is mild retropulsion at T11-12 level slightly indenting the thecal sac. No evidence of high grade spinal stenosis. Mild retrolisthesis and slight extrinsic indentation on the spinal cord is also seen at T9-10 level. From T1-2 to T8-9 no evidence of disc buldge, herniation, or spinal stenosis seen. Incidental small hemangiomas are noted in T3, T4, and T5 vertebral bodies. Spinal cord shows normal intrinsic signal. Mild disc degenerative changes are seen from T9-10 to L1-2 level. Incidental finding of a large hiatal hernia. Brief Hospital Course: Mrs [**Known lastname 106520**] is a 61 yo with a PMH significant for chronic hypotension, severe chronic asthma, type 2 diabetes mellitus, and past substance abuse, recently discharged to rehab for back pain who was readmitted through the ED with suspected anaphylactic reaction. . 1. Anaphylactic reaction- Pt's presentation to the ED was most consistent with an anaphylactic reaction. However, it is unclear what would have caused this as she had been taking the morphine SR, Dilaudid, and ibuprofen for quite some time. Her symptoms had resolved by the time she reached the ICU, but she was kept for further monitoring and concern for the development of a delayed reaction. Pt was continued on IV Solu-Medrol and Benadryl for 14 hours. Oxygen saturation was monitored closely, and she maintained sats of in range of 93-100%. Benadryl was discontinued on the day after admission. IV steroids were also discontinued and pt was switched to her usual dose of prednisone. Allergy was consulted and felt that the reaction was most likely due to NSAIDs. They felt that the reaction was either a non-specific histamine release in the setting of concurrent NSAID and opiate administration or an NSAID intolerance causing an anaphylactoid reaction. Pt should avoid all NSAIDs in the future, including acetylated salicylates. If pt should need to take aspirin, she should be desensitized on a protocol prior to doing so. According to the allergist, it is safe for her to use non-acetylated salicylates such as Disalcid or choline salicylates. It is also safe for her to continue to use Tylenol, oxycodone and other narcotics. . 2. [**Name (NI) 12007**] Pt's UA is consistent with a UTI with + nit, lek, and WBCs. She also has a leukocytosis. She was treated for three days with ciprofloxacin. Final urine culture showed growth of < 10,000 CFU. . 3. Anion gap- Pt with significant anion gap of 23 on presentation. The etiology of this remains unclear as her lactate level and acute renal failure were not severe enough to account for this. We questioned if she could have had another unknown ingestion; toxicology screen was unrevealing. Gap closed after rehydration and recheck of her electrolytes. The reason for her gap on admission was not clarified. . 4. [**Name (NI) 10271**] Pt's creatinine was elevated to 1.4 from a baseline of 0.7. This was likely prerenal azotemia. After IV hydration serum Cr trended down; Cr was 0.6 on day of discharge. . 5. Type 2 DM- Metformin was held while patient was in the ICU. Her hyperglycemia was covered with RISS. She received [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet. She was discharged on her usual dose of metformin. . 6. Back pain - Pt with back pain secondary to a L5 compression fracture. Pain service recommended starting OxyContin 20 mg [**Hospital1 **] with oxycodone 10 mg for breakthrough; OxyContin dose can be titrated up as necessary in the out-patient setting. Pain has been well-controlled on this regimen thus far. Pt can also get Tylenol to augment pain control regimen. . 7. Osteoporosis - Pt has osteoporosis insetting of chronic steroid use for her asthma. Will continue her osteoporosis medications: calcitonin, Fosamax, vitamin D, and calcium. . 7. Chronic asthma - Pt was continued on her home asthma regimen. Her prednisone was initially held while she was receiving Solu-Medrol IV. She was restarted on prednisone. Given her history of steroid use, we also discussed initiating PCP prophylaxis with her PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**]. He would like to defer the decision until he sees the patient in clinic. . 8. Hypothyroidism - Continued on levothyroxine. . 9. Depression- Continued on outpatient psych medications while in-patient: bupropion, fluoxetine, modafinil, and trazodone. . Medications on Admission: 1. Lasix 20 mg QOD 2. Fosamax 3. Vitamin D 400 units daily 4. Calcitonin 200 units injection daily 5. Modafinil 100 mg daily 6. Pantoprazole 40 mg daily 7. Bupropion 100 mg daily 8. Colace 100 mg [**Hospital1 **] 9. Senna 1 tab daily 10. Prozac 80 mg daily 11. Levothyroxine 150 mcg daily 12. Conjugated estrogens 0.3 mg daily 13. Medroxyprogesterone 2.5 mg daily 14. Singulair 10 mg daily 15. Ferrous sulfate 365 mg daily 16. Prednisone 20 mg daily 17. Metformin 500 mg daily 18. Fluticasone salmeterol 500/50 mcg [**Hospital1 **] 19. Albuterol ipratropium 2 puffs Q6H 20. Atorvastatin 20 mg daily 21. Ibuprofen 800 mg Q8H 22. Trazadone 200 mg QHS 23. Ativan 0.5 mg Q8H PRN 24. Diazepam 2 mg Q6H PRN 25. Morphine SR 60 mg Q12H PRN 26. Calcium carbonate 500 mg TID 27. Gabapentin 200 mg Q8H 28. Hydromorphone 4 mg Q4H PRN or 8 mg Q4H PRN depending on severity of pain Discharge Medications: 1. Lasix 20 mg QOD 2. Fosamax 70 mg po qWeek 3. Vitamin D 400 units daily 4. Calcitonin 200 units injection daily 5. Modafinil 100 mg daily 6. Pantoprazole 40 mg daily 7. Bupropion 100 mg daily 8. Colace 100 mg [**Hospital1 **] 9. Senna 1 tab daily 10. Prozac 80 mg daily 11. Levothyroxine 150 mcg daily 12. Conjugated estrogens 0.3 mg daily 13. Medroxyprogesterone 2.5 mg daily 14. Singulair 10 mg daily 15. Ferrous sulfate 365 mg daily 16. Prednisone 20 mg daily 17. Metformin 500 mg daily 18. Fluticasone salmeterol 500/50 mcg [**Hospital1 **] 19. Albuterol ipratropium 2 puffs Q6H 20. Atorvastatin 20 mg daily 21. Trazadone 200 mg QHS 22. Ativan 0.5 mg Q8H PRN 23. Diazepam 2 mg Q6H PRN 24. Calcium carbonate 500 mg TID 25. Gabapentin 200 mg Q8H 26. oxycontin 20 mg po BID 27. oxycodone 10 mg po q4-6 hr prn Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: anaphylactoid reaction to NSAIDs Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. Please follow-up with your PCP [**Last Name (NamePattern4) **] [**4-12**] days. Please avoid all NSAIDs and aspirin. Please return to the hospital if you should develop shortness of breath, if you feel that your mouth or throat is getting swollen, if you develop hives in response to taking your medications, if you have fevers/chills, chest pain, unctrolled back pain, or any other symptoms that are concerning to you. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 2450**] in [**4-12**] days.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12163, 12242

6582, 10409

298, 305

12318, 12324

3988, 6559

12843, 12921

3424, 3428

11327, 12140

12263, 12297

10435, 11304

12348, 12820

3443, 3969

247, 260

333, 2654

2676, 3241

3257, 3408

22,560

137,561

11966

Discharge summary

report

Admission Date: [**2164-3-30**] Discharge Date: [**2164-4-10**] Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: This is an 89-year-old female who was found face down lying in her driveway in a pool of blood. EMTs at the scene estimated about 500 cc of blood loss. She had been down an unknown amount of time, and the reason of her injuries were also unknown. She was brought in by ambulance to the [**Hospital6 649**] Emergency Room. She was confused but hemodynamically stable with a GCS of 13-14 on exam. She was not complaining of any one thing but was unable to give a clear history. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Cholecystectomy in [**2144**]. SOCIAL HISTORY: The patient lives at home with her [**Age over 90 **]-year-old husband. There is no alcohol use. No smoking or recreational drugs. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: General: The patient was awake and interactive; however, somewhat confused with a GCS of 13. Vital signs: Temperature 100.4?????? rectally, blood pressure 110/palp, heart rate 64, respirations 18, oxygen saturation 100% on nonrebreather. HEENT: There was a right frontal hematoma with a laceration above the right eyebrow. Pupils equal, round and reactive to light bilaterally from 3-2 mm. She had full extraocular movements. Tympanic membranes were clear bilaterally. Her trachea was midline with no tenderness over the clavicles. Lungs: Clear to auscultation bilaterally. Chest: No deformities or tenderness. Heart: Regular rhythm with no murmur. Abdomen: Soft, nontender, nondistended. Pelvis: Stable. Musculoskeletal: She had no deformities, stepoffs, or tenderness along her cervical spine or TLS spine. She was in a cervical collar. Rectal: She had normal rectal tone with a negative guaiac. Extremities: She had multiple lacerations to her right upper extremity across the wrist and forearm. She had superficial knee abrasions on the right side. No other visible bony deformities of the extremities were seen. She had 2+ symmetrical pulses throughout. RADIOLOGY: A FAST exam was performed which was negative. A chest x-ray was negative. An AP of the pelvis was negative. CT of the head showed a right subdural hematoma with a few millimeter shift, as well as a right frontal contusion. CT of the cervical spine was negative. CT of the abdomen and pelvis showed a right iliac aneurysm that was stable. X-rays of the right humerus were negative. X-rays of the right elbow showed an equivocal effusion. X-rays of the right radius and ulnar were negative. X-rays of the right hand and thumb were negative. X-rays of the right femur were negative. X-rays of the right knee were negative. X-rays of the right tibia-fibula were negative. A TLS x-ray showed no chronic compression deformities. HOSPITAL COURSE: While in the Trauma Bay, the patient was started on Nipride drip to maintain her systolic blood pressure below 140. She was also given a gram of Dilantin. An emergent Neurosurgery consult was obtained. The patient was transferred to the Trauma SICU where she was placed on q.1 hour neurochecks. A subclavian central line was placed, as well as an arterial line. Later on hospital day #1, it was noted that she had a change in her neurological exam at which point a CT was repeated, and there was equivocal worsening of the CT exam. At that point, it was decided to intubate the patient. The patient remained in the Trauma SICU for an additional three days. Her neurological exam was stable. She was periodically awakened from sedation and was able to move all extremities and follow commands. She was also started on Labetalol drip for tight blood pressure control. She also had tight glucose control as well. On hospital day #2, her hematocrit was noted to reach a nadir of 25.7 at which point she was transfused 2 U. While in the Intensive Care Unit, an MRI of the cervical spine was obtained which was negative, and her cervical spine was cleared. On hospital day #5, the patient was transferred to the floor. An NG tube was placed, and with Nutrition consult, tube feeds were started. At the time of her transfer to the floor, the patient was off all sedation. She continued to remain quite somnolent and would wake to sternal rub but was unable to articulate or follow command. She had regular family visits, and at various points throughout the day, her sons would report that she would wax and wane in delirium. On hospital day #6, the patient continued to remain somnolent, and head CT was repeated which was stable. She had an isolated fever spike of 101?????? at which point she was pancultured. Chest x-ray was negative. Blood cultures were sent, and the subclavian line was pulled. The tip was sent for culture which was negative. The blood cultures sent grew 3 out of 4 Methicillin sensitive Staphylococcus aureus. A urine showed that she had a urinary tract infection. The patient was started initially on Levofloxacin and Vancomycin for broad coverage. Once the sensitivities of the blood culture were known, the Vancomycin was discontinued, and she continued on a 10-day course of Vancomycin. On hospital day #7, 8 and 9, the patient continued to remain somnolent; however, she was hemodynamically stable throughout. She had frequent loud breathing, and the thought was that there was some secretions at the back of her throat, and therefore Respiratory Therapy was called in, and she had aggressive pulmonary toilet. By hospital day #10 and 11, the family was noting again that the patient would wax in and out of delirium and have periods of time where she would be able to interact and sing songs with them, and other times would be completely somnolent. She remained on tube feeds, and there was some question as to what her abilities with regards to nutrition would be. The question of PEG tube insertion was brought up with the family, and at that point they agreed. On hospital day #12, the patient was the most alert at any of the house staff or the family had seen her. She was asking questions, still seemed confused, but was coherent in her statements and appropriate. At the time of this dictation, placement of the PEG tube has been deferred. The patient will undergo a speech and swallow study, which if she is able to pass, will be able to be discharged to rehabilitation without a PEG. Throughout her time on the floor, the patient had close and frequent contact with Occupational Therapy and Physical Therapy who would assist her in getting out of bed. The patient also had suture removal on hospital day #12 from the right wrist laceration and the right forehead laceration. DISCHARGE STATUS: The patient will be discharged to [**Hospital3 7558**] Center in stable condition. DISCHARGE DIAGNOSIS: 1. Right subdural hematoma. 2. Right forearm and wrist lacerations, multiple. 3. Right forehead laceration with right frontal contusion. 4. Bacteremia. 5. Urinary tract infection. DISCHARGE MEDICATIONS: Heparin 5000 subcue q.12, Pantoprazole 40 mg p.o. q.d., Metoprolol 50 mg b.i.d., Acetaminophen 325 mg [**12-9**] tab p.o. q.4-6 hours as needed, Hydralazine 10 mg p.o. q.6 hours, Levofloxacin 250 mg q.d., last dose [**2164-4-13**], Bisacodyl 5 mg 2 tab p.o. q.d. p.r.n., Milk of Magnesia 30 ml p.o. q.6 hours p.r.n., the patient is to be placed on an Insulin sliding scale. FOLLOW-UP: 1. The patient is to follow-up with Neurosurgery, Dr. [**Last Name (STitle) 25918**], in five weeks. She can call [**Telephone/Fax (1) 3571**] for an appointment. She should have a head CT prior to this appointment and can call the above number to arrange for this. 2. She should follow-up with her primary care physician within one month. 3. She should follow-up in the Trauma Clinic in [**1-11**] weeks, call [**Telephone/Fax (1) 274**] for an appointment. Of note, communication has been made with the rehabilitation facility to have a home safety evaluation prior to the patient being discharged home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 37631**] MEDQUIST36 D: [**2164-4-10**] 13:30 T: [**2164-4-10**] 13:32 JOB#: [**Job Number 37632**]

[ "482.41", "507.0", "995.92", "851.86", "599.0", "038.9", "276.2", "790.7", "518.84" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.04", "31.1", "33.24", "96.72", "34.91", "38.93", "96.04", "96.6", "99.15", "86.59" ]

icd9pcs

[ [ [] ] ]

7040, 8319

6830, 7016

2860, 6809

665, 697

909, 2842

129, 611

634, 641

714, 886

4,958

117,750

3792

Discharge summary

report

Admission Date: [**2200-2-7**] Discharge Date: [**2200-2-16**] Date of Birth: [**2129-3-30**] Sex: F Service: SURGERY Allergies: Penicillins / Vancomycin / Cephalosporins Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 70 year old female who was admitted to Dr [**First Name (STitle) 2819**] on [**2200-1-30**] for gastroenteritis. Reports from the outside hospital included a diagnosis of possible internal hernia and SBO. Repeat abdominal CT at [**Hospital1 18**], however, demonstrated only wall thickening and fat stranding of a 23cm segment of the mid small bowel. There was no sign of SBO, and the patient had no peritoneal signs and she was discharged with a running diagnosis of gastroenteritis on [**2-3**]. She is on Coumadin for a mechanical valve and while in the hospital she was on a heparin drip. She was discharged from the hospital on 5 mg of Coumadin daily and taking Lovenox. She was told by her [**Hospital 197**] clinic that her last dose of Lovenox was to be taken yesterday. She denies any trauma. She comes in because she was having similar abdominal pain. She was having lower abdominal which was similar to her previous symptoms. She denies nausea or vomiting. Last bowel movement was two days ago. She is passing flatus. Denies melena or bright red blood per rectum. Past Medical History: PMHx: 1st degree AV block and episodes of 2nd degree AV block (Wenckiebach); HTN; hemolytic anemia; question of TIA when she had endocarditis 18 yrs ago; Hypothyroidism; Hyperlipidemia, HTN, OA, Hashimoto thyroiditis. . PSHx: CABG, mechanical MVR [**2175**], reoperative MVR St. [**Male First Name (un) 923**] [**2194**], open tubal ligation. Social History: Married. Has 4 daughters, has grandchildren. Family involved. Lives with husband in [**Name (NI) 392**]. Retired. Like to go down to a nearby beach with her husband. Denies smoking, alcohol, drugs. Safe at home. Family History: Non-contributory Physical Exam: On Admission: Vitals: 97.0, 128/88, 78, 18, 95% RA. General: Alert, oriented, no acute distress, conversational. 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, click heard with S1 at LLSB, harsh systolic murmur IV/VI heard throughout precordium Abdomen: soft throughout other than firmness at the midline and slightly to the left of midling in the infraumbilical region, +bs in surrounding regions but not auscultated over that firm region, non-distended, ttp+ at midline/infraumbilical region but not TTP elsewhere, no rebound or guarding. no organomegaly. No bruises. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Significant purple/blue bruising ranging from 2cm x 2cm to 6cm x 6cm lesions (not TTP) over the arms bilaterally. Neuro: Grossly intact. Pertinent Results: Admission CBC, chemistry panel, coags: [**2200-2-6**] WBC-9.2# RBC-3.79* Hgb-10.6* Hct-33.2* MCV-88 MCH-27.9 MCHC-31.9 RDW-15.1 Plt Ct-322 [**2200-2-6**] PT-41.3* PTT-34.9 INR(PT)-4.4* [**2200-2-6**] Glucose-114* UreaN-17 Creat-0.8 Na-139 K-3.7 Cl-104 HCO3-25 AnGap-14 . Cardiac enzymes: [**2200-2-6**] 11:45PM cTropnT-0.06* [**2200-2-7**] 09:10AM cTropnT-0.03* . [**2200-2-7**] 2:02AM CT abdomen and pelvis with contrast: 1. Interval development of new bilateral rectus abdominis hematomas. Superinfection of these fluid collections cannot be excluded. Linear hyperdensity in between fluid-fluid level of one of the hematomas is identified and may represent active extravasation. If clinical concern for active extravasation exists, repeat delayed imaging or angiography should be performed. 2. Small amount of high-density fluid in the right paracolic gutter, similar in appearance. 3. Mild biliary prominence, unchanged. 4. Renal and splenic hypodensities, incompletely characterized. Dedicated renal/spleen ultrasound is recommended on nonurgent basis. 5. Interval improvement in small bowel wall thickening as compared to prior exam. . [**2200-2-7**] 1:39PM ABD/PELVIC CT W/CONTRAST: 1. There is increase in size of the left rectus sheath hematoma in both transverse, AP and craniocaudal dimension with an increase of the extraperitoneal pelvic pre- and perivesical component of the hematoma. 2. Unchanged small amount of fluid in the paracolic gutters bilaterally. 3. No additional foci of bleeds including no retroperitoneal bleeding. . [**2200-2-8**] ABD/PELVIC CT W/CONTRAST: 1. Active extravasation idicating arterial bleeding into left rectus hematoma from a branch of the left epigastric artery. Multiple rectus sheath abdominal wall hematomas, in a different configuration although not significantly changed in size. Hematoma in the extraperitoneal pelvic pre- and perivesical space, unchanged. 2. Hemoperitoneum adjacent to the liver and in paracolic gutters, slightly increased when compared to prior exam. 3. Right basilar atelectasis. . MICROBIOLOGY: [**2200-2-8**] MRSA Screen: Negative. [**2200-2-10**] MRSA Screen: Negative. Brief Hospital Course: 70 year old female with h/o MVR on coumadin, with recent admission from [**1-30**] to [**2-3**] for gastroenteritis treated with cipro and flagyl, now with recurrent abdominal pain and found to have a new large rectus hematoma, which likely formed spontaneously in the setting of a supratherapeutic INR (likely secondary to coumadin plus antibiotic use). Also, the abdominal pain could include a component of the patient's resolving colitis. . The patient presented with decreased blood pressure and increased tense abdomen on [**2-7**] with a repeat CT scan showing an enlarging restus hematoma. Anticoagulation was held. The patient was transfused a unit of blood, and the HCT did not bump significantly. A subsequent repeat CT scan showed active bleeding, for which the patient given a unit of FFP and planned for Interventional Radiology to embolize the bleed. Cardiology was consulted. Based on risk/benefits of embolizing a patient with an elevated INR (3.3 at that time), the embolization was not performed. The patient remained hemodynamically stable, but with more tense/painful abdomen. As such, patient was then admitted to the SICU and transferred to the Surgical Service for further management. . In the SICU, The patient was given Vitamin K 2mg IV, 5units of FFPs, and 2units PRBC. A (R)IJ CVL was placed. On [**2-8**], she went to Interventional Radiology, where attempts to perform selective catheterization were unsuccessful, as the left inferior epigastric artery was found to be tortuous, thus no prophylatic embolization was performed. Of note, no active extravasation was seen on arteriogram. On [**2-9**], she received another unit of PRBC for a HCT of 22.6. Lasix was given to prevent fluid overload. Serial HCTs remained stable. On [**2-10**], Cardiology was consulted regarding anticoagulation recommendations, and a Heparin drip was started. Coagulation studies were closely monitored. Tha patient was transferred to the inpatient floor on [**2-11**], at which time Coumadin was restarted at 4mg in the evening. . The patient was continued on a Heparin drip, which was adjusted regularly according to routine PTT, until the INR became therapeutic again on Coumadin prophylaxis. Once the INR became therapeutic, the Heparin was discontinued. INR goal 2.5-3.5. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. She will follow-up with her PCP to further manage her Coumadin prophylaxis. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Lipitor 80mg qday Lovenox 120mg qday HCTZ 12.5mg qday Levothyroxine 125mcg qday Lisinopril 20mg qday Metoprolol Tartrate 50mg [**Hospital1 **] Cipro 250mg [**Hospital1 **] until [**2-5**] Metronidazole 500mg [**Hospital1 **] until [**2-5**] Coumadin 5mg alternating with 7.5mg daily ASA 81mg daily Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO QMON, TUES, THURS, FRI, SAT and 2 tab PO QWED. and SUN. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Over-the-counter. 3. 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* 4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Do NOT exceed 4gm (4000mg) acetaminophen daily. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Spontaneous rectus sheath hematomas. 2. Left epigastric artery bleed. 3. History of mechanical mitral valve replacement on Coumadin prophylaxis. Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and **drink adequate amounts of fluids.** Please follow-up with your Primary Care Provider (PCP) and The [**Hospital 197**] Clinic as advised. If you experience any of the following, please call your doctor or come to the emergency department: *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. Coumadin information: Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [**Name Initial (PRE) **]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD (PCP). Phone: [**Telephone/Fax (1) 457**]. Location: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 2260**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2200-2-20**] 10:00. Location: [**Hospital Ward Name **] 3, [**Last Name (NamePattern1) 439**], [**Hospital1 18**] [**Hospital Ward Name 517**].

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icd9cm

[ [ [] ] ]

[ "88.47" ]

icd9pcs

[ [ [] ] ]

9437, 9443

5197, 8159

315, 322

9635, 9635

3028, 3299

14548, 15029

2041, 2059

8508, 9414

9464, 9614

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261, 277

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2088, 3009

9650, 9759

1451, 1796

1812, 2025

11,390

180,386

30627

Discharge summary

report

Admission Date: [**2122-4-11**] Discharge Date: [**2122-4-17**] Date of Birth: [**2067-7-22**] Sex: M Service: MEDICINE Allergies: Penicillins / Seroquel / Ceftriaxone Attending:[**Known firstname 943**] Chief Complaint: Worsening Liver Disease Major Surgical or Invasive Procedure: none History of Present Illness: 54 year-old M with DM, CRI, and bipolar disorder who is transferred from [**Hospital3 3583**] for worsened liver dysfunction. He was admitted to [**Hospital3 3583**] on [**3-31**] with SOB and weakness. He was found to have fever and was started on ceftriaxone, with unknown source. His LFTs began to increase on [**4-2**] (bili 1.6->15.9). MRCP and CT Abdomen did not show intrahepatic or extrahepatic bile duct dilation. Small liver lesions found were likely hemangiomas; the spleen was moderately enlarged. Out of concern for drug-induced transaminitis, ceftriaxone was switched to levoflox on [**4-6**]. This was stopped on [**4-8**] due to continued increase in LFTs. His depakote was stopped, with psychiatry consultation, but then restarted on transfer. After consultation with Dr. [**Last Name (STitle) 497**], the patient was transferred for possible liver biopsy. During his hospital stay he presented in renal failure and a tunneled dialysis catheter was placed [**4-2**] for three times weekly HD. His SOB was attributed to CHF, uremia, and anemia. He was mildy hypoxic, requiring 2L of NC; ABG 7.33/60/87. This was thought to be due to a history of sleep apnea, although he had never been on CPAP in the past. He also had hematuria, seen by urology, that was attributed to foley trauma. ROS: He complains of pruritus. He also notes nausea and poor appetite, without vomiting. No changes in color of stools or urine. Pt denies recent weight loss or gain. Reports dry cough. No shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation, or abdominal pain. No melena or BRBPR. No dysuria. He was dialyzed 2L today. No history of blood transfusions, IVDA, liver disease. Past Medical History: DM - insulin-dependent, c/b neuropathy CRI - now on HD M,W,F CHF - suspected diastolic dysfunction, EF 60% with LVH HTN bipolar disorder - on depakote sleep apnea BPH - with h/o urinary retention hypothyroidism anemia Social History: Lives with his wife and teenage daughter. [**Name (NI) **] used to work as an accountant, but is now on disability. He denies tobacco or EtOH use. No h/o IVDA. Family History: No history of liver disease, pancreatic Ca. Physical Exam: Vitals: T: 1007. BP: 116/53 P: 90 RR: 27 SaO2: 97% on 2L NC wt 128 kg General: Awake, alert, tremulous, jaundiced, in NAD. HEENT: PERRL, EOMI, sclera icteric. MMM, OP without lesions Neck: supple, unable to appreciate JVP Pulm: CTAB Cardiac: RRR, nl S1/S2, no M/R/G appreciated Abdomen: soft, protuberant, NT/ND, + BS, no hepatomegaly noted. Ext: No edema b/t, warm. Skin: confluent macular rash to abdomen, chest, arms, back. R SCL tunneled line with small ecchymosis. Neurologic: Alert & Oriented x 3. Able to relate history without difficulty. tremulous, unable to determine asterixis. Pertinent Results: [**2122-4-14**] Liver U/S: This is an extremely limited study due to patient's size and inherent noise with limited acoustic windows. The liver appears normal in size. There are no grossly evident focal lesions seen. There is no evidence of ascites, but the spleen appears mildly enlarged at 13.4 cm. The portal vein and right and left branches are patent with forward flow. Hepatic veins are visualized in left middle and right trunks and are fully patent as is the cava. Hepatic arteries are also patent. The pancreas cannot be adequately imaged. Limited views of both kidneys show normal size and no evidence of hydronephrosis. No gallstones or bile duct dilatation is noted. CONCLUSION: Technically limited study with no gross liver lesions or ascites seen. Patent portal and hepatic venous vasculature. Mild splenomegaly. [**2122-4-15**] Renal U/S: FINDINGS: The left and right kidneys are unchanged in size or appearance when compared to the prior study. No renal mass lesions, stones, or hydronephrosis is noted. No perirenal fluid collections are noted. Right kidney measures 12.2 cm in length. The left kidney measures approximately 13.2 cm in length. Doppler studies are performed which reveal patent arterial and venous flow to the right kidney with peak systolic velocity of approximately 30 cm/sec. Patent arterial and venous flow is also noted in the left kidney with peak systolic velocities of approximately 25 cm/sec. IMPRESSION: No hydronephrosis in left or right kidneys, patent arterial flow to both kidneys. CXR: IMPRESSION: Low lung volumes. Bibasilar opacities likely represent atelectasis, but early basilar pneumonia is not excluded and followup radiographs may be helpful in this regard. If clinical suspicion for infection persists, followup radiograph with improved inspiratory level may be helpful to fully exclude early basilar pneumonia. PERTINENT LABS: LFTs: [**2122-4-11**] 10:21PM BLOOD ALT-396* AST-185* LD(LDH)-407* AlkPhos-1071* Amylase-101* TotBili-15.2* DirBili-12.0* IndBili-3.2 [**2122-4-12**] 06:44AM BLOOD ALT-361* AST-188* LD(LDH)-819* AlkPhos-1060* Amylase-145* TotBili-15.0* [**2122-4-13**] 05:03AM BLOOD ALT-258* AST-53* LD(LDH)-263* AlkPhos-967* Amylase-113* TotBili-13.6* [**2122-4-14**] 05:07AM BLOOD ALT-177* AST-36 LD(LDH)-254* AlkPhos-887* TotBili-9.0* [**2122-4-15**] 05:17AM BLOOD ALT-142* AST-38 LD(LDH)-300* AlkPhos-875* TotBili-6.8* [**2122-4-16**] 05:25AM BLOOD ALT-118* AST-42* AlkPhos-824* TotBili-5.2* [**2122-4-17**] 05:33AM BLOOD ALT-95* AST-39 AlkPhos-774* TotBili-5.4* Labs on discharge: [**2122-4-17**] Glucose-89 UreaN-64* Creat-10.3*# Na-131* K-5.1 Cl-92* HCO3-25 Calcium-9.5 Phos-7.3*# Mg-2.6 PT-10.8 PTT-36.1* INR(PT)-0.9 WBC-7.0 RBC-3.06* Hgb-9.7* Hct-29.8* MCV-98 MCH-31.6 MCHC-32.4 RDW-19.8* Plt Ct-430 [**2122-4-13**] 05:03AM BLOOD Neuts-61.0 Lymphs-3.0* Monos-17.0* Eos-14.0* Baso-5.0* [**2122-4-11**] 10:21PM BLOOD TSH-0.90 [**2122-4-13**] 11:09AM BLOOD PTH-34 [**2122-4-11**] 10:21PM BLOOD Valproa-17* [**2122-4-15**] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE Brief Hospital Course: 54 year-old M with DM, CRI, and bipolar disorder who is transferred from OSH for worsened liver dysfunction for liver biopsy. Active issues include: # Liver dysfunction: Etiology for liver disease remained unclear but as LFTs improved significantly, it was ultimately attributed to reaction to ceftriaxone with perhap underlying chronic liver disease such as NASH/NAFLD (given history of splenomegaly). Valproic acid may also cause chronic hepatocellular necrosis. Hepatitis serologies negative, [**Doctor First Name **]/AMA negative. His depakote was stopped. Liver biopsy was not necessary as LFT's improved rapidly. - Patient will f/u with Dr. [**Last Name (STitle) 497**] # Bipolar: Psychiatry was consulted to help manage patient's psych regimen after depakote was stopped. He was started on 5 mg Abilify and titrated to 10 mg daily. Depakote was not restarted given that it may have been chronically causing liver disease and is also hepatically cleared. Patient had been managed by his PCP regarding his psych meds, but has a new outpatient psychiatrist (Dr. [**Last Name (STitle) 29004**] in [**Location (un) 22287**])scheduled (first appointment 3 weeks post discharge). He was also started on Lamictal 25 mg daily given that it may be less hepatotoxic than depakote. Post discharge, he will need: - LFT's checked by PCP within [**Name Initial (PRE) **] week of starting lamictal - Patient and wife alerted of risk for [**Name (NI) **] [**Name (NI) **]. - Lamictal 25 mg X 2 weeks and then if tolerating, can double the dose. # Low-grade Fever: Patient intially had low grade temp with mild leukocytosis. This was felt to be inflammatory from drug-reaction and less likely to be infectious. For remainder of hospital course, he remained afebrile and had no sources for infection. # CHF: patient has history of diastolic dysfunction. He continued lisinopril, B-blocker, and imdur. # Rash: Upon tranfser, patient was noted to have rash over abdomen and extremities. The rash appeared to be drug-related and possibly from ceftriaxone (has allergy to PCN). By discharge, the rash had improved significantly. # ESRD on HD: Patient initiated dialysis at OSH and upon transfer to continued HD initiation. Renal was following and patient was set up with outpatient HD. He was discharged on sevelamer and lanthanum. He will need outpatient work-up for fistula. His lasix and metolazone were stopped. # Anemia: patient received 2 units pRBCs at OSH and his anemia was from chronic kidney disease. He had epogen at HD and remained hemodynamically stable during this admission. # HTN: He continued nifedipine, propranolol, lisinopril # DM: Patient continued NPH and humalog SSI # Prophylaxis: H2 blocker, SC heparin, bowel regimen # FEN: low Na cardiac renal diabetic diet; albumin 1.8 at OSH. # Contact: wife, [**Name (NI) 5627**] (HCP), [**Telephone/Fax (1) 72633**] # Access: 20g, and R SCL HD catheter ([**4-2**]) # Code Status: Full Medications on Admission: Medications at Home: insulin 50 NPH QAM / 18 NPH QPM, humalog SSI ASA 81 mg Qday depakote 50 mg QHS vitamin C finasteride 5 mg QDay lasix 420 mg [**Hospital1 **] nifedipine 90 mg QDay propranolol 120 mg Q12H renagel 1600 PO Q8H flomax 0.4 mg Qday synthroid 50 mcg PO QDay labetalol 200 mg Q12H lisinopril 10 mg Qday MVI aranesp 100 mcg FeSO4 Metolazone 2.5 mg QDay . . Medications on Transfer: finasteride 5 mg QD robitussin 200 mg Q4H prn cough haldol 5 mg [**Hospital1 **] prn Insulin NPH 50 SC QAM, 18 SC QPM ISMN 30 QDayy lisinopril 20 mg QDay reglan 10 mg ORN MVI QDay procardia 90 mg QDay oxybutynin 5 mg Q6H prn propranolol LA 120 mg [**Hospital1 **] ranitidine 150 mg prn sevelamer 1600 mg TID with meals albuterol Q4H prn atroven prn epgen 20,000 TIW depakote 1000 mg QHS Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for 1 months. Disp:*qs qs* Refills:*0* 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Propranolol 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 12. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 13. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as directed Subcutaneous twice a day: 50 units QAM; 18 units QPM. 15. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 16. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 17. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: acute liver failure chronic renal failure bipolar disorder Secondary: congestive heart failure Discharge Condition: stable, pain free Discharge Instructions: You had liver failure felt possibly due to ceftriaxone. You are also now on hemodialysis for your kidney failure. You have been started on new medications. Please take all medications as prescribed. 1) Abilify 10 mg in evenings 2) Lamictal 25 mg daily: You should take this dose for 2 weeks and then you may need adjustments from your psychiatrist. Please ask your primary doctor to check your liver function tests. Please note that the lamictal can cause a very serious rash leading to very serious complications including death in some patients. If you develop ANY symptoms of a rash you must see a doctor immediately. Your Lasix and metolazone have been stopped now that you are on dialysis. Please attend all follow-up appointments. Please call your doctor or go to the hospital if you have any fever, chills, nausea, worsening yellow skin or eyes, mental status changes, pain, or any other concerning symptoms. Followup Instructions: You have an appointment with [**Known firstname **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-5-22**] 1:00. You have an appointment with your primary doctor: Dr. [**First Name (STitle) **], on Thursday, [**2122-4-23**] at 1:30 PM. [**Telephone/Fax (1) 72634**]. Please ask Dr. [**First Name (STitle) **] to check your liver function tests while on the new psych meds. You have an appointment with Dr. [**Last Name (STitle) 29004**], your new psychiatrist on [**2122-5-14**] at 11 AM. Please call his office to confirm and try to get an earlier appointment.

[ "250.61", "428.30", "585.9", "285.9", "428.0", "570", "357.2" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11781, 11787

6268, 9218

319, 326

11936, 11956

3182, 5054

12925, 13538

2511, 2556

10050, 11758

11808, 11915

9244, 9244

11980, 12902

9265, 9613

2571, 3163

256, 281

5740, 6245

354, 2077

5070, 5721

9638, 10027

2099, 2318

2334, 2495

21,312

172,925

4087

Discharge summary

report

Admission Date: [**2182-4-16**] Discharge Date: [**2182-4-19**] Date of Birth: [**2105-5-21**] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 297**] Chief Complaint: Admitted for elevated BUN/Cr Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 76 F with PMH HTN, CAD, DM, dementia (baseline A&Ox3 with expressive aphasia [**1-31**] to L MCA CVA), [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] [**Male First Name (un) 1291**], CHF, presents for elevated BUN/Cr and assessment for need for emergent dialysis. Pt had enterobacter and pseudomonas pneumonia at [**Hospital 100**] Rehab. Pseudomonas was only susceptible to aminoglycosides, so pt was started on gentamicin and cefepime on [**4-5**]. Her Cr started to rise, so gent was d/ced [**4-12**]. After gent was d/ced, pt was maintained on cefepime, but BUN and Cr continued to rise. On [**4-16**], labs from [**Hospital **] Rehab showed her Cr was 3.7 and BUN was 180. Pt's baseline Cr 1.5, baseline BUN 30-50. She arrived from [**Hospital 100**] Rehab on Cefepime, that was started on [**4-12**]?. . Pt was recently discharged from [**Hospital1 18**] on [**2182-2-1**], and had been in ARF at that time. Cr had elevated from baseline 1.5 to 1.9. Etiology was attributed to being dehydrated on chronic DM, HTN. Renal was consulted at the time, and recommended weeklong course of CVVH, but no longterm hemodialysis, because of the grim prognosis for the patient at the time. She was discharged at that time on Lasix and metolazone for continued diuresis. She was admitted to [**Hospital 100**] Rehab in acute on CRF, with Cr of 2.0 on admission. Etiology was attributed to sepsis, hypotension with low renal perfusion, CHF exacerbation. At [**Hospital 100**] Rehab, pt underwent weeklong course of HD. . Pt had a foley placed at [**Hospital 100**] Rehab, but she had a UTI, and it was kept out. She was apparently incontinent and produced a good volume of urine per day (she was never anuric). Baseline BP has been 100-110. Pt was transferred on vent (IMV RR 9 with PS 18) and HD stable. She was transferred to [**Hospital1 18**] for dialysis catheter placement and to be assessed for need for emergent dialysis for elevated BUN and Cr. Past Medical History: HTN Dyslipidemia DM [**Hospital1 1291**] ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve) CAD. S/p cardiac cath in [**6-2**] and has been on plavix since then. Unclear if stent was placed at that time. Diastolic dysfunction EF >55%, 2+TR, moderate PASP CVA Left MCA [**2149**] and [**2151**] with expressive aphasia Dementia, oriented to person, place, time, can read watch recognizes son, has evidence of small vessel infarcts on CT h/o seizures after stroke on dilantin until late 80's PVD with amputations of three toes on right foot h/o R heel osteo H/o esophageal ulcers Depression Gallstones Spinal stenosis H/o pulmonary sarcoid H/o PBC h/o C diff h/o VRE urinary infection h/o decubitus ulcer followed at [**Hospital1 756**] by Dr. [**Last Name (STitle) 17974**] hypothyroidism Social History: Lives at [**Hospital 100**] Rehab, has two son's who are very supportive and involved in her care. Family History: h/o of PE x2 in son, no history of seizures, but son with heart disease Physical Exam: 96.8 / 90 (90-112) / 129/72 / 17 / 100% on trach on vent Trach on vent: AC 500 / 12+6 / 5.0 / 1.0 FiO2 General: Obese, responsive to voice, staring at ceiling HEENT: Anicteric, MMM without lesions Neck: JVD to 8 cm, no LAD, no carotid bruits CV: Irregularly irregular, clicking sound Resp: Rales bilaterally Abd: +BS Soft/NT/ND Ext: 2+ edema Skin: No rashes, petechiae Neuro: Responsive to voice Pertinent Results: CXR [**4-17**]: 1. Mild edema. 2. Moderate bilateral pleural effusions. 3. Nodular opacity seen next to left mediastinum, likely representing vessels, although dedicated PA and lateral chest radiograph following treatment is recommended to document resolution. . CT chest [**4-9**]: IMPRESSION: 1) Worsening bibasilar pneumonia and bilateral moderate pleural effusions, right greater than left. 2) Multiple lytic areas in the mid and lower thoracic spine without an adjacent mass. These can represent osteopenia. However, a bone scan can be helpful to exclude the presence of bony metastases. . EKG [**4-17**]: Atrial fibrillation. . [**2182-4-16**] 07:36PM GLUCOSE-114* UREA N-159* CREAT-3.8*# SODIUM-139 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-20* ANION GAP-18 [**2182-4-16**] 07:36PM ALT(SGPT)-13 AST(SGOT)-16 LD(LDH)-405* CK(CPK)-21* ALK PHOS-154* AMYLASE-20 TOT BILI-0.4 [**2182-4-16**] 07:36PM LIPASE-15 [**2182-4-16**] 07:36PM ALBUMIN-2.8* CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-3.4* [**2182-4-16**] 07:36PM WBC-11.3* RBC-2.78* HGB-9.4* HCT-28.7* MCV-103*# MCH-34.0* MCHC-32.9 RDW-17.0* [**2182-4-16**] 07:36PM NEUTS-89.8* BANDS-0 LYMPHS-4.5* MONOS-3.3 EOS-2.3 BASOS-0.1 [**2182-4-16**] 07:36PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2182-4-16**] 07:36PM PLT SMR-NORMAL PLT COUNT-153 [**2182-4-16**] 07:36PM PT-17.0* PTT-30.7 INR(PT)-1.6* Brief Hospital Course: 76 F with PMH DM2, HTN, dementia (baseline A&Ox3 with expressive aphasia [**1-31**] to L MCA CVA), [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] [**Male First Name (un) 1291**], CHF, with renal failure improving on HD and pneumonia. . # Hypoxic respiratory failure: The patient has been chronically vented due to an unknown etiology. CXR shows moderate bilateral pleural effusions, which are likely due to pulmonary edema from renal failure. She is trached on the same vent settings as on admission. Her pleural effusions were not tapped because the patient was clinically doing so well and did not have any signs of sepsis. She was afebrile, with no leukocytosis, was not tachycardic, and was normotensive throughout admission. . # Enterobacter, Pseudomonas, B. cepacia pna: Followup of the [**Hospital 100**] Rehab sputum cultures showed Enterobacter, pseudomonas, and B. cepacia in cultures. Patient developed ATN due to gentamicin, so she was kept on Cefepime for a total 14 day course. Her sputum culture here only shows 3+ GNR in the gram stain, and the culture is still pending. [**Hospital 100**] Rehab physicians will need to follow up on blood cultures, sputum cultures, and urine cultures from [**Hospital1 18**], to make sure that the patient's cefepime 14 day course is sufficient, and to make sure that no new antibiotics need to be started. . # Acute on chronic renal failure: The etiology of the patient's acute renal failure is likely acute tubular necrosis from gentamicin-induced nephropathy. Many muddy brown casts were found in urine sediment. CK was 31 (to assess for rhabdomyolysis). Pt's chronic renal failure is likely due to DM and HTN. Pt had a tunneled LSC dialysis cath placed on [**4-17**], and she received HD x2, once on [**4-18**], once on [**4-19**]. Renal US was performed, but because of the patient's habitus, the kidneys could not be visualized bilaterally. The patient's baseline BUN is 30-50, baseline Cr 1.5. . # Altered mental status: Pt can track her eyes appropriately, but she cannot communicate or indicate whether she is having pain. During admission, it was difficult to assess how different her MS is from her baseline aphasia and dementia. The likely etiology of her altered mental status is her baseline dementia. Her uremia does not appear to be severe enough to be causing encephalopathy. Her mental status did not change appreciably with hemodialysis. . # UTI: Urine culture shows 1+ gram positive bacteria, likely alpha-streptococcus or lactobacillus. The 14 day course of Cefepime should cover her UTI. The pt has a history of VRE UTIs, so this urine culture will need to be followed up for characterization and sensitivities, and to make sure that no further organisms appear in the culture. . # AFIB with intermittent RVR and St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]: Patient is currently on no rate control, no rhythm control, and her anticoagulation is currently with heparin gtt as a bridge to coumadin anticoagulation. On [**4-19**], the patient's INR was 1.6. Coumadin dose is 5 mg QHS, which was given on [**4-18**] and [**4-19**], and patient has been maintained on heparin gtt as a bridge. Patient's INR goal is 2.5-3.5, since she has a St. [**Male First Name (un) 923**] mechanical [**Male First Name (un) 1291**] and AFIB. . # CAD: Patient is not on a BB or an ACEI. Her TTE shows a normal EF 55-60%, severe pulm HTN (60), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1914**], RA dilated, 3+ TR, [**Last Name (Prefixes) 1291**] mechanical St. [**Male First Name (un) 923**] prosthesis. . # DM2: Patient was maintained on her normal regimen of NPH 30 [**Hospital1 **] and iss. . # Anemia: Anemia of chronic disease. Fe, B12, folate was wnl on her last admission. . # History of CVA: Pt will be kept on coumadin for [**Hospital1 1291**] and AFIB, but not on ASA or plavix for history of GIB and also because of spontaneous hematomas into muscle. . # History of seizures: Patient was maintained on home regimen of Keppra 1g [**Hospital1 **]. . # Hypothyroidism: Patient was maintained on home regimen of Levothyroxine 75 QD. . # GERD: Patient has history of GIB requiring hospitalization, and was kept on Lansoprazole per NGT/PO 30 qd. . # History of primary biliary cirrhosis and gallstones: Stable. Ursodiol was continued per home regimen. . # History of depression and post partum psychosis: Risperdone and prozac were held given unresponsiveness and desire to decrease mediaction interactions. . COMM: son [**Name (NI) 1193**] [**Telephone/Fax (1) 17978**] (HCP) ACCESS: L midline placed [**4-15**] at [**Hospital 100**] Rehab. Medications on Admission: Acetaminophen prn Albuterol 8 puffs Q4H Ipratropium 8 puffs Q6H Artificial tears 1-2 drops OU Q6H Docusate Clotrimazole cream 1 app TP [**Hospital1 **] (to axillae bl, to intertriginous areas of abdomen) Fluoxetine 20 PO QD Heparin gtt Insulin SS, NPH 30 [**Hospital1 **] Lansoprazole 30 mg QD Levothyroxine 75 mcg PO QD Lorazepam 0.5 mg PO Q4H:prn Papain-urea ointment 1 app TP QOD Senna Simvastatin 10 PO QD Ursodiol 600 mg PO QD Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Primary diagnosis: Acute tubular necrosis due to gentamicin-induced nephropathy . Secondary diagnosis: DM2, HTN, UTI Discharge Condition: Fair. Pt returned to the same ventilator settings as on admission, mental status has improved somewhat, VS stable. Discharge Instructions: 1. Please take medications as prescribed. 2. Please call the primary care physician if the patient experiences change in mental status, increase in creatinine and renal failure. 3. Please follow up with physicians as below. Followup Instructions: 1. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14936**] [**Telephone/Fax (1) 17980**] to make an appointment within 1-2 weeks. 2. Please call the microbiology lab for final identification of the GNRs in the patients sputum ****Patient's INR goal 2.5-3.5. Currently at INR 1.6. Needs to have an INR check Q2days to get her up to goal. Will have heparin gtt as bridge.******** Completed by:[**2182-4-19**]

[ "403.91", "294.8", "428.32", "250.40", "V44.0", "518.83", "530.81", "599.0", "428.0", "V43.3", "427.31", "397.0", "486", "584.5", "780.39", "438.11", "E930.8" ]

icd9cm

[ [ [] ] ]

[ "99.07", "39.95", "96.71", "38.95" ]

icd9pcs

[ [ [] ] ]

10403, 10476

5257, 7238

299, 314

10637, 10754

3794, 5234

11026, 11466

3288, 3362

10497, 10497

9946, 10380

10778, 11003

3377, 3775

231, 261

342, 2308

10600, 10616

10516, 10579

7253, 9920

2330, 3154

3170, 3272

75,668

131,252

21800

Discharge summary

report

Admission Date: [**2124-4-24**] Discharge Date: [**2124-4-28**] Date of Birth: [**2075-1-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: hyperkalemia, bradycardia, and pancreatitis Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: The pt is a 49 yo Spanish Speaking only male with h/o CAD s/p CABG, DM, ESRD secondary to DM on HD, HTN, HL, cardiomyopathy EF 25% from Chagas, and pancreatitis who presented to the ED this AM c/o acute onset of epigastric pain radiating to back yesterday with 2 episodes of non bloody emesis. He reports his pain started in the afternoon after eating a [**Location (un) 6002**] and was [**6-17**] constant sharp pain overnight. He had associated anixety and chills. Yesterday he reports any air hitting his body caused pain. He also had one episode of watery non bloody diarrhea last night. He denies any other associated sx. Pertinent negatives were no CP, SOB, jaw pain, arm pain, back pain, or shoulder pain. He was not able to answer whether this pain is consistent with previous episodes of pancreatitis. Vitals on arrival to the ED were 98.4 166/73 62 16 100% RA. In the ED intial labs were notable for hyperkalemia to 6.8 (hemolyzed), hyponatremia to 132, gap 18, lipase 196, trop of 0.12. He receiced calcium gluconate 1g Iv, 10 units of insulin, and an amp of D5. His K was 5.8 at recheck and the 6.9. He received 4 IV morphine, 4 IV zofran, and O.5mg of IV dilaudid with improvement of his pain. While in the [**Name (NI) **] pt became bradycardic to 41 and was found to have a new partial RBBB with RVR in v1 and v2, new flipped t wave inversions in v1/v2/aVL, and PR prolongation in the setting of his bradycardia. Cardiology was consulted and bradycardia and EKG changes could be explained by his hyperkalemia. HR improved to the 60s while in the ED without further intervemtion. A CT of the abd with IV contrast was done due to his severe abd pain and showed fat stranding of the pancreas c/w possible pancreatitis, trace gall bladder edema, and no evidence of aortic deissection or AAA. The bases of his lungs showed small bilateral pleural effusion improved compared to prior. Pt was guiac negative on exam with epigastric and tenderness in the right and left upper quadrant. A CXR showed small pleural effusions bilaterally and cardiomegaly similar to prior study. Vitals on transfer were 98 64 174/93 16 99% RA. On arrival to the ICU vitals were T98.4 BP166/77 HR62 RR18 100% RA. He reports a small amount of abdominal pain but better compared to the ED. He has no other complaints. Past Medical History: -ESRD on hemodialysis, on transplant list, s/p L brachiocephalic AV fistula, left brachiocephalic AV fistula [**12-17**], s/p angioplasty in [**5-16**], s/p thrombectomy in [**8-16**], left upper extremity graft placed [**11-15**] -CABG x4 [**2123-3-9**]: Left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the diagonal branch, third marginal branch, and acute marginal branch. -Diabetes c/b neuropathy -Dyslipidemia -Hypertension -Cardiomyopathy secondary to Chagas -Gastritis, GERD -History of pancreatitis -Obstructive Sleep Apnea -Depression -Hyperuricemia Social History: Patient is married with five children. Patient with disability due to poor vision from diabetic retinopathy. Wife works at [**Hospital1 4601**]. Denies tobacco, no EtoH use and no h/o abuse, no illicits. Family History: Mother and father with diabetes, no coronary disease, no colon cancer, no prostate cancer. Physical Exam: Vitals: T:97.3 BP:166/77 P:60 R:18 O2:100% RA General: NAD, answering questions appropriately 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: +bs, tenderness in epigastric and RUQ/LUG, soft, no rebound tenderness or guarding Ext: warm, well perfused, distal pulses, chronic skin changes on LE consistent with dialysis. Left arm: fistula without any erythema, good thrill, appropriate to auscultation Neuro: CN II-XII intact, UE and LE strength 5/5, sensation grossly intact. Pertinent Results: ADMISSION LABS: [**2124-4-24**] 05:50AM WBC-6.1 RBC-3.77* Hgb-12.6* Hct-37.8* MCV-101* Plt Ct-165# [**2124-4-24**] 05:50AM Neuts-71.4* Lymphs-23.0 Monos-4.3 Eos-0.9 Baso-0.3 [**2124-4-25**] 03:36PM PT-14.3* PTT-31.3 INR(PT)-1.2* [**2124-4-24**] 05:50AM Gluc-212 UreaN-83* Cr-9.8* Na-132* K-6.8* Cl-94* HCO3-20* [**2124-4-24**] 05:50AM ALT-36 AST-77* CK(CPK)-124 AlkPhos-77 TotBili-0.5 [**2124-4-24**] 05:50AM Lipase-196* [**2124-4-24**] 05:50AM cTropnT-0.12* [**2124-4-24**] 05:50AM TotProt-8.9* CE TREND: [**2124-4-24**] 05:50AM CK(CPK)-124 [**2124-4-24**] 02:09PM CK(CPK)-179 [**2124-4-24**] 09:51PM LD(LDH)-239 CK(CPK)-51 [**2124-4-24**] 05:50AM cTropnT-0.12* [**2124-4-24**] 02:09PM cTropnT-0.11* [**2124-4-24**] 09:51PM cTropnT-0.14* LIPASE TREND: [**2124-4-24**] 05:50AM BLOOD Lipase-196* [**2124-4-24**] 09:51PM BLOOD Lipase-231* [**2124-4-25**] 03:36PM BLOOD Lipase-146* [**2124-4-26**] 03:40AM BLOOD Lipase-139* MICRO: [**2124-4-24**] BCx: pending STUDIES: [**2124-4-24**] EKG: Normal sinus rhythm. Incomplete right bundle-branch block. Non-specific ST-T wave abnormalities. Compared to the previous tracing heart rate is increased and is now sinus rhythm. [**2124-4-24**] CXR: Small bilateral pleural effusions, stable. Stable cardiomegaly. [**2124-4-24**] CT abdomen/pelvis: 1. No evidence of aortic dissection or abdominal aortic aneurysm. 2. Trace fat-stranding about the tail of the pancreas. Given the patient's elevated lipase, this finding is compatible with acute pancreatitis. No focal fluid collections. 3. Cholelithiasis without evidence of acute cholecystitis. Trace gallbladder wall edema is likely secondary to acute pancreatitis. 4. Small bilateral pleural effusion. [**2124-4-25**] CXR: As compared to the previous radiograph, today's upright AP radiograph confirms the presence of mild right-sided pleural effusion. On the left, no effusion is seen. Unchanged status post sternotomy with unchanged appearance of the cardiac silhouette. No hilar or mediastinal changes. No focal parenchymal opacity suggesting pneumonia. [**2124-4-27**] ECG: Sinus rhythm. ST-T wave abnormalities with borderline prolonged QTc interval are non-specific but cannot exclude possible drug/electrolyte/metabolic effect or possible myocardial ischemia. Since the previous tracing of [**2124-4-24**] incomplete right bundle-branch block is now absent. DISCHARGE LABS: [**2124-4-28**] 06:20AM BLOOD WBC-3.4* RBC-3.51* Hgb-11.5* Hct-35.6* MCV-102* MCH-32.6* MCHC-32.2 RDW-13.6 Plt Ct-149* [**2124-4-28**] 06:20AM BLOOD Glucose-187* UreaN-37* Creat-7.7*# Na-139 K-3.9 Cl-97 HCO3-28 AnGap-18 [**2124-4-27**] 06:20AM BLOOD Lipase-67* [**2124-4-28**] 06:20AM BLOOD Calcium-8.6 Phos-6.3* Mg-2.1 Brief Hospital Course: Mr. [**Known lastname **] is a 49 yo Spanish Speaking only male with h/o CAD s/p CABG, DM, ESRD secondary to DM on HD, HTN, HL, cardiomyopathy EF 25% from Chagas, and pancreatitis who presents with hyperkalemia with associated EKG changes (bradycardia & PR prolongation), pancreatitis, and new partial RBBB. . # New partial right bundle: Has h/o CAD and CABG. Trop elevated to 0.12-0.14, but CK remained flat. Elevated trop more likely related to CKD. The patient was continued on his home ASA, statin, fenofibrate, ACEi. BB was restarted after bradycardia improved. Chart review showed it has been intermittently present in the past. # Bradycardia: Seen by cardiology in the ED, who felt that bradycardia is related to the hyperkalemia. Pt remained asymptomatic. The bradycardia resolved after dialysis. # Hyperkalemia: Unclear etiology - has only very occasional hyperkalemia when reviewing the records, despite being on HD. Pt received calcium gluconate, insulin 10 IV x1 and 1 amp of glc in the ED. Infectious w/u has been negative to date. K improved with dialysis and has remained WNL. # Pancreatitis: Pt has h/o pancreatitis. Is most likely explanation for abdominal pain radiating to the back as there is fat stranding in the tail of the pancreas on CT scan and his lipase is elevated. He was kept NPO and on gentle IVF, with Dilaudid for pain control. Compazine was given for nausea with good effect. The patient was started on a clear liquid diet and was advanced as tolerated. On discharge, tolerating more full diet, pain controlled with PO dilaudid. Unclear etiology, perhaps d/t pancreatic anatomy. # ESRD: Pt on MWF schedule for HD, which was continued during the hospitalization. Nephrocaps were continued, but Sensipar was held per renal recs while the patient was NPO. Plan to continue outpt dialysis schedule. # Systolic CHF: EF 25% ? due to chagas. BB was held initially for bradycardia, and torsemide was held initially given NPO for pancreatitis. Pt was restarted on his home medications. # HTN: Pt was continued on his home dose of captopril for BP control. BB and torsemide held initially, as above, but have been restarted. # DM: Pt was given 80% home lantus dose (home dose 12units) with ISS while NPO. Pt was noted to drop glucose to 56 and was mildly symptomatic - improved with juice. Pt is now back on home dosing, as he is tolerating a PO diet. On the floor, on home DM regimen. # GERD/gastritis: continued home omeprazole # OSA: Not using CPAP at home # Access: peripheral plus left fistula # Communication: Patient and his wife [**Name (NI) **] who is emergency contact [**Telephone/Fax (1) 57223**] # Code: Full confirmed with patient in ICU Medications on Admission: 1. Cinacalcet dose unknown 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for CHF. 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for CHF. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily) as needed for ESRD. 9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for CHF. 11. Lantus 100 unit/mL Solution Sig: One (1) 12 Subcutaneous once a day. 12. Humalog 100 unit/mL Solution Sig: SS Subcutaneous prn as needed: Please use sliding scale that you have at home. Discharge Medications: 1. Cinacalcet Oral 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for HTN. 11. Lantus 100 unit/mL Solution Sig: Twelve (12) units subcutaneously Subcutaneous once a day. 12. Please continue to use your insulin sliding scale. 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not drive, operate machinery, or drink alcohol while taking this medication as it may make you drowsy. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pancreatitis Hyperkalemia ESRD on hemodialysis Coronary artery disease Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain, and were found to have pancreatitis. With pain control, time, and slowly advancing your diet, the pancreatitis and abdominal pain improved. You will need to be very cautious about your diet and avoid fried or fatty foods as they may worsen your pain. You also had high potassium levels, likely due to the pancreatitis and then worsened by your kidney failure, so you needed to be monitored in the ICU; with medical management and dialysis, this resolved as well. Continue to take your regular home medications, and ADD the following: - Take dilaudid as needed for abdominal pain with the goal to decrease the dose of this medication that you need daily until you no longer need this medication Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please attend the following important appointment with your primary care physician: Department: [**Hospital3 249**] When: TUESDAY [**2124-5-2**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please attend the following previously-scheduled cardiology appointments: Department: CARDIAC SERVICES When: WEDNESDAY [**2124-5-10**] at 9:00 AM With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2124-5-10**] at 10:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2124-5-1**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11923, 11929

7099, 9787

359, 374

12053, 12053

4375, 4375

13073, 14102

3585, 3678

10803, 11900

11950, 12032

9813, 10780

12206, 13050

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3693, 4356

276, 321

402, 2712

4391, 6739

12068, 12182

2734, 3348

3364, 3569

15,605

167,295

4945

Discharge summary

report

Admission Date: [**2195-1-9**] Discharge Date: [**2195-1-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: RUQ pain cholecystitis Major Surgical or Invasive Procedure: Percutaneous Cholecystostomy tube History of Present Illness: This is a 89 year old Russian speaking male with dementia who presented to [**Hospital1 18**] ED with a fever and RUq pain and tenderness. A RUQ US revealed acute cholecystitis with impendig sepsis. He was hemodynamically stable at the time. Past Medical History: PMH: CAD, HTN, dementia '[**89**] . PSurgH: CABG '[**82**], cataracts [**2181**] Social History: Per chart, he lives alone and has a HHA who checks on him q 2hrs. Case management has made a protective services referral. Family History: Not obtainable. Physical Exam: VS: 102.8, 62, 155/70, 20, 94% RA Gen: Dementia, awake, not alert, shivering Head: PERRLA CV: Bradycradic, RR, s1/s2 Chest: ronchi, wheezes bilateral bases. Abd: RUQ tenderness, guarding. soft, nondistended, unable to reliably appreciate tenderness. Ext: +1 bilateral LE edema Pertinent Results: [**2195-1-9**] 03:45PM PT-12.5 PTT-20.7* INR(PT)-1.1 [**2195-1-9**] 03:45PM PLT COUNT-414# [**2195-1-9**] 03:45PM NEUTS-78.4* LYMPHS-17.9* MONOS-2.3 EOS-1.2 BASOS-0.1 [**2195-1-9**] 03:45PM WBC-15.1*# RBC-4.61 HGB-14.6 HCT-41.6 MCV-90 MCH-31.6 MCHC-35.1* RDW-13.8 [**2195-1-9**] 03:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2195-1-9**] 03:45PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-2.4 [**2195-1-9**] 03:45PM CK-MB-NotDone cTropnT-0.11* [**2195-1-9**] 03:45PM LIPASE-63* [**2195-1-9**] 03:45PM ALT(SGPT)-105* AST(SGOT)-44* CK(CPK)-39 ALK PHOS-695* TOT BILI-1.0 [**2195-1-9**] 03:45PM estGFR-Using this [**2195-1-9**] 03:45PM GLUCOSE-113* UREA N-42* CREAT-1.0 SODIUM-150* POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-33* ANION GAP-13 [**2195-1-9**] 03:57PM LACTATE-2.0 [**2195-1-9**] 04:20PM URINE MUCOUS-FEW [**2195-1-9**] 04:20PM URINE HYALINE-0-2 [**2195-1-9**] 04:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2195-1-9**] 04:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2195-1-9**] 04:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2195-1-9**] 05:01PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2195-1-9**] 05:01PM URINE HOURS-RANDOM [**2195-1-9**] 06:16PM K+-2.6* [**2195-1-9**] 08:00PM PT-12.7 PTT-20.9* INR(PT)-1.1 [**2195-1-9**] 08:00PM PLT COUNT-330 [**2195-1-9**] 08:00PM WBC-13.0* RBC-3.75* HGB-11.6* HCT-34.7* MCV-93 MCH-30.9 MCHC-33.3 RDW-13.7 [**2195-1-9**] 08:00PM ALBUMIN-2.8* CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1 [**2195-1-9**] 08:00PM LIPASE-68* [**2195-1-9**] 08:00PM ALT(SGPT)-81* AST(SGOT)-32 ALK PHOS-553* AMYLASE-47 TOT BILI-1.1 [**2195-1-9**] 08:00PM GLUCOSE-136* UREA N-36* CREAT-0.8 SODIUM-153* POTASSIUM-2.8* CHLORIDE-113* TOTAL CO2-33* ANION GAP-10 [**2195-1-9**] 10:30PM URINE OSMOLAL-711 [**2195-1-9**] 10:30PM URINE OSMOLAL-711 [**2195-1-9**] 10:30PM URINE HOURS-RANDOM CREAT-53 SODIUM-171 POTASSIUM-37 CHLORIDE-180 [**2195-1-9**] 11:21PM POTASSIUM-3.6 . [**1-12**] ECHO: Conclusions: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-6**]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Brief Hospital Course: From Surgery: . Cholecystitis: An US in the Ed revealed A large gallstone is within the neck of the gallbladder. The gallbladder wall is thickened measuring up to 9 mm. The common bile duct is slightly distended at 11 mm. There is mild intraheptic biliary ductal dilatation. There is no pericholecystic fluid. Son[**Name (NI) 493**] [**Name2 (NI) **] sign is positive. LFT's were elevated with an AlkPhos of 695. He had gallbladder drainage with 8 French [**Last Name (un) 2823**] catheter at IR. . Cardiac Ischemia: Th pt had a history of CAD and CABG in '[**82**]. He had episodes of afib and tachycardia to the 120's, during which he would become diaphoretic, clammy and likely ischemic with EKG showing ST depression lead V2-V6. On [**1-17**] he developed a severe episode of apparent ischemia associated with SOB and was transferred to the ICU (see below). . Hypokalemia: Potassium repletion . Dehydration: IV resuscitation . ID: He was started on IV Unasyn and Flagyl for empiric therapy. . From Medicine: Assessment and Plan: 89 Russian-speaking male with dementia with cholecystitis s/p perc chole now s/p afib with RVR and NSTEMI. . #) Hypoxemia: Trigger for hypoxemia every night after being transferred to cardiology. Based on CXR and the fact that he is peri-NSTEMI with ongoing ischemia, likely [**2-6**] pulmonary edema. - diuresis with IV furosmide - O2 via shovel mask as he is a mouth breather . #) NTEMI: Family would like conservative management. Likely in setting of post-op stress. - ASA, plavix, b-blocker, imdur, Ca channel blockers as blood pressure tolerates - goal HR in 50s - trend CE . #) Cholecystitis s/p perc chole: Surgery following - continue Amp/sul, metronidazole, change to pipercillin/tazo on [**1-16**] given tachypnea and hypoxemia . #) R middle lobe PNA: Per ED nursing record, he was being treated for a PNA at home. - hold on additional antibiotics at this time. - follow clinically . #) Oliguria: Pre-renal based on urine lytes but volume overload on CXR. Does not appear dry on exam. Could have had a hypotensive episode during afib with RVR episode leading to ATN. - foley in place - monitor I/O . #) HTN: BP well-controlled. - continue metop, nifedipine, isosorbide . #) Prophylaxis: PPI, sc heparin, bowel regimen . #) FEN: p.o. diet as tolerated . #) Access: PIVs . #) Communication: Daughter ([**Telephone/Fax (1) 20530**] . On [**1-17**] was transferred to the CCU for SOB secondary to ischemia. Because of the pateint's age and comorbidities, the family opted not to pursue aggressive treatment strategies such as cardiac catheterization. THe pt developed MS changes and was found to be less responsive (the day before he had been somewhat combative). He was tachypnic and tachycardic and appreared to be developing cardiogenic shock. He was transferred to the ICU and started on pressors. After discussion with the family regarding their and the patient's wishes, his family opted for comfort measures and he passed away 2 hours later. Medications on Admission: Metoprolol 50" asa 81 mg po daily HCTZ 25 mg po daily risperidol 0.25 mg po bid aricept 5 mg po daily Vit C 500 mg po daily senekot Nifedipine XL 30 mg po daily Isoso Nit 60 XL ',30 XL ' Namenda 5 mg po bid Lorazepam 0.5 mg po qhs Ambien 10 mg po qhs KCl 10 meq qd Ibuprofen Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: Cholecystitis Sepsis Atrial Fibrillation with RVR Dementia Hypokalemia Dehydration NSTEMI Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "87.59", "51.03", "38.93" ]

icd9pcs

[ [ [] ] ]

7323, 7338

3969, 6970

283, 319

7472, 7482

1181, 3946

7534, 7540

852, 869

7295, 7300

7359, 7451

6996, 7272

7506, 7511

884, 1162

221, 245

347, 590

612, 694

710, 836

4,239

140,282

10913

Discharge summary

report

Admission Date: [**2114-8-18**] Discharge Date: [**2114-8-25**] Date of Birth: [**2059-11-12**] Sex: F Service: CT [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female with a past medical history of coronary artery disease and a previous myocardial infarction. Eight days prior to admission, the patient experienced increased shortness of breath and left shoulder pain. On [**2114-8-14**], the patient saw her primary care physician and discussed fibromyalgia and pain medications. On [**2114-8-15**], the patient continued to have shortness of breath. She went to her primary care physician and then was transferred to the emergency department. The patient had increased paresthesia in the left hand with left arm pain. The episode occurred both at rest and on exertion. The patient did state that the pains were worse with increased activity. PAST MEDICAL HISTORY: 1. Breast cancer, status post left mastectomy 11 years ago. 2. Gastroesophageal reflux disease. 3. Coronary artery disease, status post myocardial infarction. 4. Hodgkin's disease, status post radiation treatment. 5. Fibromyalgia. 6. Radiation pericarditis. 7. Hypothyroidism. 8. Asthma. 9. Status post cholecystectomy. 10. Hypertension. ALLERGIES: There were no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg p.o. b.i.d. 2. Albuterol two puffs q.i.d. 3. Aspirin 325 mg p.o. q.d. 4. Nitroglycerin gtt. 5. Heparin gtt. 6. Ativan 0.5 mg p.o. every eight hours p.r.n. 7. Synthroid 0.88 mg p.o. q.d. 8. Flovent one puff b.i.d. LABORATORY DATA: Initial laboratory values included a white blood cell count of 7500, hemoglobin of 11.4, hematocrit of 32.9 and platelet count of 329,000. INR was 1, prothrombin time was 11.9 and partial thromboplastin time was 20. There was a sodium of 144, potassium of 4.2, chloride of 104, bicarbonate of 28, BUN of 23, creatinine of 0.9 and glucose of 104. ELECTROCARDIOGRAM: The electrocardiogram showed normal sinus rhythm, a right bundle branch block and ST depressions of 1 mm in II, III and aVF and of 1 to 2 mm in V1 through V6. HOSPITAL COURSE: On [**2114-8-18**], the patient was transferred from [**Hospital3 15174**] to [**Hospital1 190**] for a stress test, which was positive for ischemia. On [**2114-8-18**], the patient was brought to the operating room with an initial diagnosis of coronary artery disease with an 80% ulcerated left main coronary artery. The patient had coronary artery bypass grafting times two with a saphenous vein graft to the left anterior descending artery and a saphenous vein graft to the first obtuse marginal artery. The patient tolerated the procedure well and was transferred to the post anesthesia care unit in stable condition. On postoperative day #1, the patient was extubated and had an uneventful intensive care unit stay until transfer to the floor on [**2114-8-23**]. On [**2114-8-24**], the patient's physical therapy level was at a 2 and she had difficulty with walking. On postoperative day #2, the patient continued to do well, but was progressing at a suboptimal level with reference to physical therapy. The patient will be discharged to a rehabilitation facility today, [**2114-8-25**]. DISCHARGE PHYSICAL EXAMINATION/LABORATORY DATA: The patient had a temperature maximum of 99??????F, a heart rate of 78, a blood pressure of 105/54, a respiratory rate of 20 and an SaO2 of 96% on two liters, in 510 and out 1000. There was a white blood cell count of 9000, hematocrit of 27.9, BUN of 15, creatinine of 0.5. In general, the patient was alert and oriented, in no acute distress. The cardiovascular examination was a regular rate and rhythm with no murmurs or rubs. The respiratory examination was clear to auscultation bilaterally. The abdomen was soft, nontender and nondistended with positive bowel sounds. The extremities had positive pitting edema and positive swelling. The incision was intact, dry and clean. DISCHARGE MEDICATIONS: Lasix 20 mg p.o. b.[**Initials (NamePattern4) **] [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. Docusate sodium 100 mg p.o. b.i.d. Aspirin 81 mg p.o. q.d. Protonix 40 mg p.o. q.d. Synthroid 0.88 mg p.o. q.d. Flovent 110 mg metered dose inhaler two puffs b.i.d. Lopressor 25 mg p.o. b.i.d. (hold for systolic blood pressure of less than 100 or heart rate of less than 60). Ibuprofen 600 mg p.o. every six hours p.r.n. Percocet one to two tablets p.o. every three to four hours p.r.n. Milk of Magnesia 30 mg p.o. h.s. p.r.n. for constipation. Acetaminophen 650 mg p.o. every four hours p.r.n. Ativan 0.5 mg p.o. every six hours p.r.n. Albuterol metered dose inhaler two puffs every four hours p.r.n. PRIMARY DIAGNOSIS: Status post coronary artery bypass grafting times two. SECONDARY DIAGNOSES: Breast cancer, status post left mastectomy 11 years ago. Gastroesophageal reflux disease. Coronary artery disease, status post myocardial infarction. Hodgkin's disease, status post radiation therapy. Fibromyalgia. Radiation pericarditis. Hypothyroidism. Asthma. Hypertension. DISPOSITION: The patient will be discharged to a rehabilitation facility. FOLLOW UP: The patient will follow up in three to four weeks with Dr. [**Last Name (STitle) 1537**]. She will also follow up in three to four weeks with her primary care physician. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2114-8-25**] 10:12 T: [**2114-8-25**] 11:26 JOB#: [**Job Number 35471**]

[ "411.1", "729.1", "493.90", "244.9", "V10.3", "V10.79", "401.9", "414.01", "424.0" ]

icd9cm

[ [ [] ] ]

[ "36.12", "37.23", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

4023, 4768

1357, 2145

2163, 4000

4864, 5217

5229, 5682

193, 912

4787, 4843

934, 1331

47,275

100,583

40339

Discharge summary

report

Admission Date: [**2131-3-5**] Discharge Date: [**2131-3-19**] Date of Birth: [**2071-7-31**] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Anterior/posterior fusion with instrumentation T3-S1 History of Present Illness: Ms. [**Known lastname 13469**] has a long history of back pain due to scoliosis. She has attempted conservative therapy but continues to experience back pain. She now is electing to proceed with surgical intervention. Past Medical History: Scoliosis PM/SH: HTN depression/anxiety chronic back pain on opioid therapy Appy [**2115**] chole [**2128**] tubal ligation [**2102**] rotator cuff [**2127**] tonsils out as child Social History: Denies tobacco Family History: N/C 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: [**2131-3-19**] 04:30AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.1* MCV-91 MCH-30.8 MCHC-33.7 RDW-14.9 Plt Ct-1088* [**2131-3-18**] 09:00AM BLOOD WBC-12.0* RBC-3.12* Hgb-9.6* Hct-28.2* MCV-91 MCH-30.9 MCHC-34.1 RDW-14.8 Plt Ct-1019* [**2131-3-17**] 04:57AM BLOOD WBC-14.1* RBC-3.01* Hgb-9.2* Hct-27.1* MCV-90 MCH-30.4 MCHC-33.8 RDW-14.9 Plt Ct-806* [**2131-3-16**] 09:05AM BLOOD WBC-16.1* RBC-3.01* Hgb-9.1* Hct-27.6* MCV-92 MCH-30.4 MCHC-33.1 RDW-14.6 Plt Ct-672* [**2131-3-15**] 05:05AM BLOOD WBC-16.5* RBC-3.07* Hgb-9.4* Hct-28.5* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.9 Plt Ct-652* [**2131-3-14**] 09:38AM BLOOD WBC-16.0* RBC-3.25* Hgb-9.9* Hct-29.9* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.9 Plt Ct-537* [**2131-3-13**] 07:35PM BLOOD WBC-14.6* RBC-3.25* Hgb-10.0* Hct-29.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-14.8 Plt Ct-502* [**2131-3-13**] 05:30AM BLOOD WBC-14.7* RBC-3.27* Hgb-10.0* Hct-29.4* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.9 Plt Ct-517* [**2131-3-12**] 04:20AM BLOOD WBC-11.5* RBC-3.25* Hgb-9.8* Hct-29.0* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.7 Plt Ct-357 [**2131-3-11**] 01:45AM BLOOD WBC-10.3 RBC-2.97* Hgb-9.2* Hct-26.3* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.8 Plt Ct-266 [**2131-3-10**] 09:46AM BLOOD WBC-9.4 RBC-3.18* Hgb-9.8* Hct-28.3* MCV-89 MCH-30.8 MCHC-34.7 RDW-15.1 Plt Ct-226 [**2131-3-9**] 02:14PM BLOOD WBC-9.6 RBC-3.07* Hgb-9.5* Hct-26.9* MCV-88 MCH-31.1 MCHC-35.5* RDW-15.3 Plt Ct-201 [**2131-3-16**] 09:05AM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-135 K-3.7 Cl-99 HCO3-29 AnGap-11 [**2131-3-12**] 04:20AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-100 HCO3-31 AnGap-10 [**2131-3-11**] 01:45AM BLOOD Glucose-134* UreaN-6 Creat-0.3* Na-139 K-3.3 Cl-101 HCO3-32 AnGap-9 [**2131-3-10**] 02:12AM BLOOD Glucose-122* UreaN-9 Creat-0.3* Na-138 K-3.5 Cl-102 HCO3-33* AnGap-7* [**2131-3-9**] 03:52AM BLOOD Glucose-100 UreaN-13 Creat-0.4 Na-141 K-3.7 Cl-106 HCO3-29 AnGap-10 [**2131-3-15**] 05:05AM BLOOD ALT-34 AST-26 LD(LDH)-336* AlkPhos-152* TotBili-0.3 [**2131-3-16**] 09:05AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 [**2131-3-11**] 01:32PM BLOOD Calcium-7.8* Phos-2.1* Mg-2.0 [**2131-3-10**] 02:12AM BLOOD Calcium-7.6* Phos-1.4* Mg-1.9 [**2131-3-13**] 07:35PM BLOOD CRP-217.6* Brief Hospital Course: Ms. [**Known lastname 13469**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2131-3-5**] and taken to the Operating Room for L3-S1 interbody fusion through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 she returned to the operating room for a scheduled T11-L3 anterior fusion through a thoractomy. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was stable. HD#3 she returned for a scheduled T4-S1 posterior fusion. Postoperative hematocrit was low and she was transfused multiple units of packed cells and platelets. She was transfered to the T/SICU from close monitoring. Her chest tube was removed POD2 from the third procedure. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one from the third procedure. She was kept NPO until bowel function returned then diet was advanced as tolerated. She developed a persistently elevated white count and a medical consult was obtained. A thorough workup was conducted but returned negative for a source. She remained afebrile and on HD#9 her leukocytosis decreased. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3 from the third procedure. She was fitted with a lumbar warm-n-form brace for comfort. 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: diltiazem alprazolam escitalopram 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. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 3. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). Disp:*90 Tablet Extended Release(s)* Refills:*0* 5. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for PRN Pain. Disp:*100 Tablet(s)* Refills:*0* 7. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. 8. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Home with Service Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Scoliosis Acute post-op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/Lateral/ 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 Treatment Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2131-3-22**]

[ "348.89", "338.18", "285.1", "722.51", "433.10", "737.30", "518.5", "780.39", "401.9", "780.62", "300.4", "304.01", "288.60", "E929.9", "998.11" ]

icd9cm

[ [ [] ] ]

[ "81.64", "38.91", "81.04", "03.90", "84.51", "96.71", "77.71", "38.93", "81.62", "81.06", "81.63", "96.04", "77.79", "84.52", "81.05" ]

icd9pcs

[ [ [] ] ]

6619, 6693

3616, 5629

317, 371

6779, 6785

1412, 3593

8986, 9065

872, 877

5713, 6596

6714, 6758

5655, 5690

6809, 6924

892, 1393

8787, 8870

6960, 7153

268, 279

7189, 7656

7668, 8768

399, 620

8891, 8963

642, 824

840, 856

43,589

170,710

49536

Discharge summary

report

Admission Date: [**2196-7-4**] Discharge Date: [**2196-7-12**] Date of Birth: [**2132-9-21**] Sex: F Service: CARDIOTHORACIC Allergies: Percodan / simvastatin / Levaquin Attending:[**First Name3 (LF) 1406**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: [**2196-7-8**] 1. Mediastinal thymic fat pad biopsy. 2. Mitral valve replacement with a St. [**Male First Name (un) 923**] Epic tissue valve, serial #[**Serial Number 103612**], reference #[**Serial Number 103613**]. History of Present Illness: Ms. [**Known lastname 84873**] is 63 yo female with a history of metastatic breat CA on chemotherapy (Fulvestrant 500mg IM and a study drug). She also has a history of mitral valve prolapse and 2+ MR based on last echocardiogram. She presents with a few days of increasing dyspnea on exertion. She notes progressive DOE limiting her activities over 3-4 days, which started on Satuday when she was walking a lot during her trip to [**State 531**]. She has noted an occasional cough recently. She denies orthopnea or PND or chest pain. She denies fevers, chills, n/v/d, hematuria, dysuria. She denies peripheral edema. Her DOE has been progressive over the past few days prompting her visit to the ED where her NT-proBNP was noted to be elevated. In the ED, initial VS were: 98.4 99 107/67 98% 2L NC. EKG showed SR HR 100. Q V1, V2. Lateral ST depressions. Inferior tWI. Cardiology was consulted for evaluation of CHF. A bedside cardiac ultrasound was performed with limited images that did not show any obvious effusion or RV dysfunction. There was some suggestion of apical LV dysfunction. CXR showed nodular opacity in right lung field. Small bilateral pleural effusions. CTA chest was performed but no prelim results on arrival to floor. Patient received Levaquin, aspirin, and 20mg IV Lasix. 1st set of enzymes negative. Patient admitted to floor for further workup of new onset volume overload. REVIEW OF SYSTEMS: + fatigue Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Mitral Regurgitation, s/p Mitral Valve Replacement PMH: Metastatic Breast Cancer on Fulvestrant and study drug Degenerative Disk Disease Mitral valve prolapse and severe mitral regurgitation Depression Hyperlipidemia Neck pain Osteoprosis Past Surgical History: right total mastectomy, sentinel node biopsy, and immediate reconstruction with [**Last Name (un) 5884**] flap removal of right ovarian cyst Umbilical hernia repair Right axillary lymph node dissection Social History: No smoking, social alcohol use, lives alone in [**Location (un) 4628**]. Family History: Breast Cancer: Mother [**Name (NI) 3495**] Disease/MVP: Mother Physical Exam: VITALS: 98.9, 84-99/53-57, 104-114, 20, 97% RA weight 60.6 kg GENERAL: NAD, comfortable while lying on bed HEENT: MMM, EOMI NECK: JVP at 12 cm LUNGS: CTABL, no crackles HEART: [**4-10**] holosystolic murmur heard best at apex with radiation across the precordium, RRR ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 Pertinent Results: TTE [**2196-7-5**]: The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. There is moderate/severe primarily posterior leaflet mitral valve prolapse. The P1 and/or P2 mitral leaflet scallop is flail. An eccentric, anteriorly directed jet of at least 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). The tricuspid valve leaflets are mildly thickened. Tricuspid valve prolapse is present. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2196-5-26**], the posterior mitral leaflet is now flail, and the mitral regurgitation is markedly increased (at least moderate-to-severe, and likely frankly severe). CTA [**7-4**]: 1. No evidence of pulmonary embolism. 2. Stable left hilar lymphadenopathy with central necrosis. 3. Mild congestive heart failure with new small to moderate sized bilateral pleural effusions, right greater than left, with adjacent compressive atelectasis. 4. New 10 x 12 mm nodule within the right upper lobe concerning for metastasis. 5. Worsening hepatic metastatic disease. Cardiac cath [**7-6**]: 1. No angiographically-apparent coronary artery disease. 2. Systemic arterial normotension. PFTs [**7-6**]: no pulmonary function abnormalities Intra-op TEE [**2196-7-8**] Conclusions Prebypass: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). 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. Trace aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. The mitral valve leaflets are myxomatous. There is moderate/severe P2 leaflet mitral valve prolapse. There is partial P2 mitral leaflet flail. The mitral valve leaflets do not fully coapt. An eccentric, anteriorly directed jet of mitral valve. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is systolic flow reversal in left upper pulmonary vein. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] distance is 2.9cm and the A:P ratio is 1.03 as predictors for systolic anterior motion. There is mild Tricuspid valve regurgitation with normal appearing valves, the tricuspid annulus is 3cm. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2196-7-8**] at 0830. Postbypass: There is a well seated, well functioining, bioprostetic in the mitral position. Trace valvular mitral regurgitation is noted. There is no evidence of aortic dissection. Left ventricular function is grossly unchanged from prebypass. [**2196-7-11**] 04:35AM BLOOD WBC-8.4 RBC-3.20* Hgb-9.7* Hct-28.5* MCV-89 MCH-30.2 MCHC-33.9 RDW-14.4 Plt Ct-129* [**2196-7-10**] 02:12AM BLOOD WBC-9.5 RBC-3.29*# Hgb-9.8*# Hct-29.4* MCV-89 MCH-29.8 MCHC-33.3 RDW-14.6 Plt Ct-97*# [**2196-7-9**] 11:44AM BLOOD Hct-29.1* [**2196-7-11**] 04:35AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-138 K-3.5 Cl-102 HCO3-28 AnGap-12 [**2196-7-10**] 02:12AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-139 K-4.0 Cl-102 HCO3-30 AnGap-11 [**2196-7-9**] 11:44AM BLOOD Glucose-107* Na-133 K-3.5 Cl-98 Brief Hospital Course: MEDICINE COURSE: This is a 63 yo F with h/o metastatic breast cancer and Mitral valve prolapse who presents with progressive shortness of breath. # SOB: Echo shows new mitral leaflet flail, with markedly increased mitral regurg. The etiology of her SOB was [**1-7**] worsening mitral regurg with resultant volume overload/heart failure. Pulmonary embolism was ruled out with CTA. PFTs wnl. Cardiac surgery evaluated the patient and recommended mitral valve surgery (open heart). Cardiac cath was preformed before surgery and showed clean coronary arteries. # Breast Ca: CTA showed increasing size of metastasis in the liver. Oncology followed the patient while in house, and requested a biopsy of a metastatic lesion during open heart surgery given her radiographic disease progression. The patient's study drug was held during hospitalization, but she did recieve Fulvestrant during admission. SURGICAL COURSE: [**2196-7-8**]-Discharge The patient was brought to the Operating Room on [**2196-7-8**] where the patient underwent Mitral Valve Replacement and Thymectomy with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient developed atrial fibrillation which converted to Sinus Rhythm with increase in beta blocker and Amiodarone. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Oncology was consulted and at this point all study medications other than Faslodex are on hold. Planning of further breast cancer treatments with Dr. [**Last Name (STitle) **] once patient recovers from mitral valve repair. At the time of discharge, mitral valve and thymic fat pad biopsy were pending - these results need to be followed up. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. She was evaluated by physical therapy and cleared for home. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Venlafaxine XR 225 mg PO DAILY 2. zoledronic acid-mannitol&water *NF* unknown Injection unknown 3. Acetaminophen Dose is Unknown PO Q6H:PRN pain 4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200 mg-unit Oral [**Hospital1 **] 5. Docusate Sodium Dose is Unknown PO BID 6. Multivitamins 1 TAB PO DAILY 7. Naproxen Dose is Unknown PO Q8H:PRN pain 8. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/temp 2. Docusate Sodium 100 mg PO BID 3. Venlafaxine XR 225 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *Dilaudid 2 mg [**12-7**] tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 6. Metoprolol Tartrate 25 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*1 7. Potassium Chloride 20 mEq PO DAILY Hold for K+ > 4.5 RX *Klor-Con M20 20 mEq 1 tablet by mouth once a day Disp #*5 Tablet Refills:*0 8. Ranitidine 150 mg PO BID RX *Acid Reducer (ranitidine) 150 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 9. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200 mg-unit Oral [**Hospital1 **] 10. Multivitamins 1 TAB PO DAILY 11. Senna 1 TAB PO BID:PRN constipation 12. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Regurgitation, s/p Mitral Valve Replacement PMH: Metastatic Breast Cancer on Fulvestrant and study drug Degenerative Disk Disease Mitral valve prolapse and severe mitral regurgitation Depression Hyperlipidemia Neck pain Osteoprosis Past Surgical History: right total mastectomy, sentinel node biopsy, and immediate reconstruction with [**Last Name (un) 5884**] flap removal of right ovarian cyst Umbilical hernia repair Right axillary lymph node dissection Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2196-8-4**] at 1:15p Dr. [**Last Name (STitle) **] [**2196-8-11**] at 3pm [**Hospital Ward Name 23**] 7 Oncologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2196-8-1**] at 10:00 AM Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 133**] in [**3-10**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2196-7-12**]

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icd9cm

[ [ [] ] ]

[ "07.16", "88.56", "39.61", "35.23" ]

icd9pcs

[ [ [] ] ]

11585, 11643

7392, 9962

319, 542

12151, 12321

3271, 7369

13192, 13871

2822, 2887

10520, 11562

11664, 11903

9988, 10497

12345, 13169

11926, 12130

2902, 3252

1991, 2228

260, 281

570, 1972

2250, 2489

2732, 2806

30,011

183,545

32120+57785

Discharge summary

report+addendum

Admission Date: [**2160-6-25**] Discharge Date: [**2160-6-28**] Date of Birth: [**2090-4-13**] Sex: F Service: NEUROSURGERY Allergies: Lactose Attending:[**First Name3 (LF) 78**] Chief Complaint: aneurysm recannulization Major Surgical or Invasive Procedure: [**2160-6-25**]: Cerebral angiogram with re-coiling of Left ICA aneurysm History of Present Illness: 70yo woman with history of incidental finding of a left ICA aneurysm that was coiled in [**2154**]. This has been monitored since that time but recently noted to have recannulized. It was recommended that she undergo an angiogram and re-coiling of this aneurysm. Past Medical History: left ICA aneurysm HTN hypercholesterolemia osteoporois gastritis Social History: Spanish speaking only. Lives alone. no ETOH. No tobacco. No illicits Family History: no aneurysms. No strokes. Son who died or renal/cardiac disease. Physical Exam: AVSS NAD Sitting upright in bed breathimg comfortably symmetric chest rise CNII-XII intact EOMI, PERRL Bilat Full strength UE/LE bilat SITLT UE/LE bilat gait normal R femoral cath incision c/d/i, dressed. Pertinent Results: [**2160-6-25**] 06:15PM GLUCOSE-147* UREA N-12 CREAT-0.7 SODIUM-144 POTASSIUM-3.1* CHLORIDE-110* TOTAL CO2-22 ANION GAP-15 [**2160-6-25**] 06:15PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.1 [**2160-6-25**] 06:15PM PTT-138.0* Brief Hospital Course: Pt electively presented and underwent a cerebral angiogram with coiling of her re-canalized left ICA. A total of 9 coils were deployed. The post-coiling angiogram showed no residual inflow. Patient was then transferred to the PACU where she remained neurologically intact postoperatively. She was then brought to the ICU for monitoring overnight. A heparin drip was started post-operatively for prevention of emboli. Overnight on HD #1, patient had an episode of nausea and emesis which resolved with supportive care and zofran. On HD#2 (POD #1), patient's nausea had resolved; she was asymptomatic and neurologically intact. Her heparin drip was stopped. She was started on ASA 81mg daily as a post-coiling antiplatelet [**Doctor Last Name 360**]. In light of her significant hypertension on admission (SBP 200), her antihypertensive regimen was switched from atenolol (3rd line [**Doctor Last Name 360**]) to amlodipine. She was then called out to the floor for BP monitoring and to work with PT prior to discharge. On HD #3 (POD#2) The patient tolerated diet advancement without difficulty and made steady progress with PT. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care regaring her hypertension and aneurysm. The patient will be continued on chemical prophylaxis (ASA) post-operatively. On HD#4, patient had mild low grad fever. CBC, UA and CXR was obtained which was essentially negative. She was deem stable for discharge. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from PatientwebOMR. 1. Atenolol 25 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Pioglitazone Dose is Unknown PO Frequency is Unknown 4. Citalopram Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H:PRN pain 3. Amlodipine 5 mg PO DAILY HOLD for SBP<100 RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Bisacodyl 10 mg PO/PR DAILY 5. Docusate Sodium 100 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*30 Tablet Refills:*0 7. Senna 1 TAB PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atenolol 25 mg PO DAILY 10. Scopolamine Patch 1 PTCH TP ONCE Duration: 1 Doses 11. Pioglitazone 30 mg PO DAILY 12. Citalopram 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left ICA aneurysm hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications Followup Instructions: * Please call [**Telephone/Fax (1) 1669**] to schedule a follow up appointment with Dr [**First Name (STitle) **] in [**5-9**] weeks. You will need the following imaging before this appointment: - You will need a brain MRI/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] post angio protocol prior to your appointment - Please follow up with PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14696**] [**Telephone/Fax (1) 30453**]); his office will call pt promptly after DC for f/u with BP recheck Completed by:[**2160-6-27**] Name: [**Known lastname 12360**],[**Known firstname **] Unit No: [**Numeric Identifier 12361**] Admission Date: [**2160-6-25**] Discharge Date: [**2160-6-28**] Date of Birth: [**2090-4-13**] Sex: F Service: NEUROSURGERY Allergies: Lactose Attending:[**First Name3 (LF) 40**] Addendum: The patient remained in hospital until [**2160-6-28**] as physical therapy recommended one more session prior to discharge. On the morning of [**6-28**], patient reported a severe headache not associated with visual changes or neurological deficits. A CT-Head demonstrated no acute changes, and patient reported that her headache soon therafter resolved. Following her CT-Head, she performed well with physical therapy and was deemed safe to discharge home alone. The patient was accompanied by a cousin upon discharge and feels safe being discharged to home, although she would prefer to stay in the hospital a few more days. All questions were answered using interpreter services. The patient was given detailed follow-up instructions explained to patient in Spanish. Patient expressed readiness for discharge. Of note, the patient will be discharged on aspirin 81mg daily. No plavix or full strength aspirin are required for prophylaxis. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2160-6-28**]

[ "437.3", "733.00", "272.0", "784.0", "780.62", "401.9", "787.01" ]

icd9cm

[ [ [] ] ]

[ "39.75" ]

icd9pcs

[ [ [] ] ]

7364, 7505

1415, 3180

295, 370

4209, 4209

1163, 1392

5490, 7341

854, 923

3527, 4105

4155, 4188

3206, 3504

4360, 5467

938, 1144

231, 257

398, 662

4224, 4336

684, 751

767, 838

28,118

154,067

51753

Discharge summary

report

Admission Date: [**2145-7-6**] Discharge Date: [**2145-7-18**] Date of Birth: [**2065-6-17**] Sex: F Service: SURGERY Allergies: Penicillins / Clindamycin / Furosemide Attending:[**First Name3 (LF) 2597**] Chief Complaint: AAA Major Surgical or Invasive Procedure: Open RP AAA & R renal artery endarterectomy with Dacron graft & supraceliac clamping [**2145-7-6**] History of Present Illness: This 80-year-old lady has a 5.7 cm juxta renal abdominal aortic aneurysm with a probable stenosis of the right renal artery. The proximal neck was unsuitable for endovascular aneurysm repair. Past Medical History: PMH: AAA, hypothyroidism, CAD s/p cath ([**2127**]), s/p L frontal hemorrhagic stroke with residual aphasia & seizures, chronic renal insufficiency, diverticulitis PSH: 2 evacuations of L frontal hemorrhages, LAR, TAH, LIH repair Social History: Former smoker. Lives alone; nephew is caretaker. Family History: No DM. No CAD. Physical Exam: A/O NAD CTA RRR ABD - POS BS SURGICAL SCAR c/d/i PALP DISTAL PULSES Pertinent Results: [**2145-7-16**] 06:10AM BLOOD WBC-9.5 RBC-3.66* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.2 MCHC-32.7 RDW-15.7* Plt Ct-338 [**2145-7-13**] 02:26AM BLOOD PT-15.0* PTT-32.9 INR(PT)-1.3* [**2145-7-16**] 06:10AM BLOOD Glucose-104 UreaN-16 Creat-1.3* Na-138 K-4.7 Cl-100 HCO3-29 AnGap-14 [**2145-7-16**] 06:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 [**2145-7-17**] 06:53PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2145-7-14**] 12:19 am STOOL CONSISTENCY: WATERY Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2145-7-14**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. CHEST (PA & LAT) FINDINGS: There has been interval removal of the endotracheal tube, NG tube, right IJ and right subclavian lines. There is volume loss in the left lower lobe and plate-like atelectasis in both lower lungs. IMPRESSION: Severe lung volume loss in the left lower lung, probably left lower lobe collapse, no new infiltrate [**2145-7-7**] 2:48 AM PORTABLE ABDOMEN Reason: Assess for ileus/free air. ABDOMEN, SINGLE VIEW: There are no gas-filled dilated loops; there is a nonspecific bowel gas pattern. There is no evidence for free air. Gas is seen in the rectum. Surgical staples are seen along the left abdomen. An OG tube sidehole projects below the diaphragm into the expected location of the gastric level. No gross osseous abnormality. IMPRESSION: No radiographic evidence for ileus or free air. UNILAT UP EXT VEINS US RIGHT Reason: RT ARM SWELLING,EVAL FOR DVT FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 1417**] of right IJ, subclavian, axillary, brachials, basilic, and cephalic veins were obtained. Heterogeneous echogenicity within the mid and distal portions of the right internal jugular vein, without demonstrable compression is compatible with a right IJ thrombus. There is some color flow around the right IJ thrombus, suggesting that the thrombus is non-occlusive. The remainder of the venous structures demonstrate normal compression and color flow. A single view of the left subclavian vein was obtained for comparison and is unremarkable. IMPRESSION: Right internal jugular vein non-occlusive thrombus. Brief Hospital Course: Mrs. [**Known lastname 93621**] was admitted on [**7-18**] with AAA. She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a Resection and repair of abdominal aortic aneurysm with 20-mm Dacron tube graft and right renal artery endarterectomy. She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. She was then transferred to the CVICU for further recovery. While in the CVICU she recieved monitered care. She was extubated. She did recieve one unit PRBC for post operative blood loss. She was also diuresed, She develeoped a rash. Thought to be drug related. He lasix was changed to bumex, perioperative vancomycin was DC. A derm consultas obtained. On DC rash was improved. When stable she She was transferd to the VICU. NFG tube was DC'd / Aline was DC'd / Peripheral line placed / Central line DC'd. She did have some abdominal distention, Illeus was ruled out. On Dc taking po. Pt also was febrile / pan cx'd / Pos urine - txtd with cipro for 3 days RUE swelling / US revealed Right internal jugular vein non-occlusive thrombus. Her diet was advanced. A PT consult was obtained. When she was stabalized from the acute setting of post operative care, she was transfered to floor status On the floor, she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged to a home in stable condition. Medications on Admission: [**Last Name (un) 1724**]: sertraline 50', simvastatin 20', phenobarbital 15''', ASA 325', atenolol 50', Triamterene/HCTZ 37.5/25', Synthroid 112 mcg', ranitidine 150' Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Phenobarbital 30 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 200 cc* Refills:*0* 7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: For urinary tract infection. Disp:*5 Tablet(s)* Refills:*0* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold for heart rate < 60 or blood pressure < 100 systolic. Disp:*30 Tablet(s)* Refills:*2* 15. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*60 grams* Refills:*2* 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*100 grams* Refills:*2* 17. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: [**2-10**] Inhalation Q6H (every 6 hours) as needed. 19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: AAA (pre-op) PMH: hypothyroidism CAD L frontal hemorrhagic stroke Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**7-18**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**3-14**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Please take your home medications as directed. Please follow up with your primary care physician in next [**2-10**] weeks to have your blood pressure checked and medications adjusted. Followup Instructions: PLease follow up with your PCP [**Last Name (NamePattern4) **] [**2-10**] weeks. Please follow up with Dr. [**Last Name (STitle) **] in [**2-10**] weeks; call his office at ([**Telephone/Fax (1) 18181**] to schedule an appointment. Completed by:[**2145-7-22**]

[ "599.0", "441.4", "V15.82", "453.8", "287.5", "272.0", "496", "V12.79", "E944.4", "285.1", "442.1", "693.0", "560.1", "244.9", "440.1", "401.9", "458.29", "112.3", "276.6", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.44", "00.41", "99.07", "99.04", "38.14", "99.05", "38.93", "38.16" ]

icd9pcs

[ [ [] ] ]

7366, 7424

3293, 5080

301, 403

7534, 7543

1081, 3270

10468, 10732

962, 978

5298, 7343

7445, 7513

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Discharge summary

report

Admission Date: [**2128-3-22**] Discharge Date: [**2128-3-24**] Date of Birth: [**2055-7-18**] Sex: M Service: MEDICINE Allergies: Morphine / Vicodin Attending:[**First Name3 (LF) 3276**] Chief Complaint: fatigue and weakness Major Surgical or Invasive Procedure: none History of Present Illness: 72 y/o male with PMHx of NSCLC, PE, who presented to the ED on [**3-22**] with generally increasing fatigue and tachypnea. . In the ED, He underwent CTA chest and abdomen which no PE but marked progression of metastatic disease including innumerable new metastases in the lungs and liver and increased size of metastases in the adrenals, kidneys, mesentary, soft tissues. He had negative CT head and EKG. His hematocrit was 26 from baseline around 30, and INR was 3.6 on admission. He received FFP, 1 unit PRBC, and a dose of cefepime vanc. Due to slightly low blood pressure, the patient was also given steroids and 1L NS and admitted to the [**Hospital Unit Name 153**]. . In the ICU, his HCT improved and BP remained stable in the 100's, and HR in the 90-100's. EGD or further GI workup was refused. Oncology came to meet with the patient and his family, and decided that focusing goals of care on comfort was most appropriate. He was made DNR/DNI but medications were continued, and he was admitted to OMED. . ROS: He denies chest pain, shortness of breath. He does feel somewhat fatigued. He reports some right flank/back pain, [**9-6**] before receiving IV dialudid. He denies other concerns. . Onc History: Initially found to have a large right sided mass on CXR in [**10-2**] performed for 1 month history of cough. CT scan confirmed the mass and biopsy of [**Last Name (un) 29217**] nodes were suspicious, but FNA of the primary mass showed likely NSCLC. PET showed abnormality on the right thyroid. He started radiation therapy in [**11-2**] and started cycle 1 of cisplatin/etoposide in [**12-2**] and cycle 2 in [**1-4**]. He completed XRT [**2128-1-5**]. He was hospitalized for chest pain and found to have a PE in [**1-4**], and started on coumadin. PET scan in [**2-3**] demonstrated metastatic disease to the adrenals, so he was changed to taxotere therapy in [**3-3**] which he tolerated reasonably well. Past Medical History: PMH: 1. NSCLC- former smoker, originally presented to PCP [**10-2**] with cough x 1 mo., CXR with lg R-lung mass, CT showed right upper lobe posterior segment mass abutting the chest wall but not invading with an enlarged upper R paratracheal node and lower R paratracheal node, s/p TBNA of mediastinal LAD [**10-22**] showing highly atypical cells suggestive of NSCLC and CT-guided biopsy of the lung mass [**10-29**] confirming NSCLC, MRI brain negative for met, s/p 2 cycles of cisplatinum/etoposide + XRT (completed [**2128-1-5**]). Had PET scan 2. HTN- per son used to be on meds but has been normotensive 3. Hypercholesterolemia 4. LBP Social History: SH: Born in [**Country 5881**], lives in Montreal, Canadian citizen, 3 children who live in the area. Retired owner of a restaurant. Primarily speaks Greek, speaks little English. + remote tobacco, 40pk-yr, quit at age 36, extensive passive exposure at the restaurant. No asbestos exposure. . Family History: FH: No history of malignancy. Physical Exam: V: 96.5 BP 120/60 HR 106 R 18 Sat 98% 2L, 93% RA Gen: 72 yo M sitting in a chair, NAD, comfortable Heent: AT/NC, EOMI, PERRLA, anicteric, MMM Neck: supple no JVD Lungs: decreased BS at L base, o/w CTAB no w/r/r Abd: soft, obese, ND/NT +BS Ext: trace to 1+ pretibial edema, wwp, good pulses Neuro: A&Ox3. Mild intention tremor. CN II-XII in tact. Pertinent Results: [**2128-3-22**] 11:15AM PT-33.4* PTT-33.5 INR(PT)-3.6* [**2128-3-22**] 11:15AM WBC-26.3* RBC-3.18* HGB-9.6* HCT-30.5* MCV-96 MCH-30.3 MCHC-31.5 RDW-20.1* [**2128-3-22**] 11:15AM NEUTS-75* BANDS-9* LYMPHS-3* MONOS-9 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-1* [**2128-3-22**] 11:53AM LACTATE-2.3* [**2128-3-22**] 04:46PM CK-MB-NotDone cTropnT-<0.01 [**2128-3-22**] 12:55PM GLUCOSE-137* UREA N-24* CREAT-0.7 SODIUM-126* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-22 ANION GAP-15 [**2128-3-22**] 11:36PM URINE OSMOLAL-234 Brief Hospital Course: 72 y/o M with PMHx of NCSLC who presents with increased weakness and fatigue with progressive lung cancer. . The patient had a brief stay in the [**Hospital Unit Name 153**] and was transferred to the floor after the goals of care were transitioned to a goal for a move to hospice. He arrived on the floor on [**3-23**], vitals were stable. Overnight, the patient had increased work of breathing and became diaphoretic and tachycardic and with the family and attending's involvement, the goal of care became comfort measures only. The patient passed away at 11:52am on [**2128-3-24**]. Medications on Admission: Home meds: Pantoprazole Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID Acetaminophen 325 mg Hydromorphone 2 mg prn q4-6 Fentanyl 25 mcg/hr Patch 72HR Coumadin 2.5 mg/5mg alternate days qhs Florinef 0.1 decadron 4 qd . Meds on Transfer HYDROmorphone (Dilaudid) 2-4 mg PO Q4-6H:PRN Dexamethasone 4 mg PO DAILY Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Fentanyl Patch 50 mcg/hr TP Q72H Senna 1 TAB PO BID:PRN Fludrocortisone Acetate 0.1 mg PO DAILY Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Non small cell lung cancer Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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Discharge summary

report

Admission Date: [**2133-8-18**] Discharge Date: [**2133-8-28**] Date of Birth: [**2103-11-25**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Lumbar puncture at an OSH ([**Hospital3 **], [**Location (un) 86**]) History of Present Illness: Ms [**Known lastname 72203**] [**Known lastname 84291**] is a 29-year-old Rh woman known to Dr. [**Last Name (STitle) 2340**] with PMH of h/o neurocystercicosis and ventriculitis (s/p third ventriculostomy, fourth ventricular cyst resection in [**2132**] obstructive hydrocephalus s/p 3rd VCS per Dr. [**Last Name (STitle) **], HBV, found down today in the morning. HPI obtained from partner: ([**Telephone/Fax (1) 84303**]) in Spanish. Today, she was down and unresponsive in the morning (around 11:30 am when he returned for his lunch break). She was last seen at her baseline at 5:30 am. However, he reports that she had a headache starting 24h ago. He cannot describe the features of the pain. He feels it was similar to the previous headaches she had had when she was sick. She did have nausea but did not vomit. There were no problems with her vision. She did feel she was going to faint several times, but did not lose consciousness. She did not report any other symptoms to her partner. She had remained afebrile per his report. He was concerned at 11:30 am and called EMS. Per report, she had a GTC event that required ativan 2 mg *2 and valium 5 mg. We do not know for how long the event lasted. Once at OSH ([**Hospital3 **]) she had a normal CBC. Her Lp showed 11 WBC (8L, 3 G) and [**3-11**] RBC. Unknown protein or glucose. She received rocephin 2 g iv, acyclovir 700 mg iv and vancomycin 1 g iv. In addition she got ampicillin 1 g (not 2 g) iv. Her coags were normal. Her serum and urine tox were negative. OSH. Her examination at OSH reported a left sided hemiparesis. She was unresponsive and febrile to 103. In addition, she was severely agitated and was intubated (due to agitation and combative behavior). She received Tylenol at OSH and was transferred uneventfully to [**Hospital1 18**]. Once at [**Hospital1 18**], (no further seizures happened) she received phos-PHT 1 g iv. Per OMR notes: "She initially presented with intractable excruciating headache and was found to have an abnormal MRI of the brain on [**2133-1-29**], which showed lesions in the right and left frontal lobes, left putamen, and fourth ventricle. The lesion within the fourth ventricle was causing obstructive hydrocephalus. She then underwent a ventriculostomy and drainage of fourth ventricle cyst: 3rd ventriculostomy on [**1-29**] and [**1-31**] partial ventricular cyst removal with wall adherent to 4th ventricle. Neurocysticercosis serology was positive and she was treated with albendazole for one month and dexamethasone. She was also treated with lamivudine for hepatitis B. After the neurosurgical intervention, she was headache free. She continued her medications as an outpatient and was seen in [**Hospital **] clinic for follow up. She complained of left facial swelling in [**Month (only) 404**] at which time she was found to take double the dose of Decadron. She received a tapering schedule and her complaints disappeared. On [**3-6**], she was again seen and at this time, she had stopped Decadron on her own and remained off medication since then". In [**2133-5-7**] she began to have low grade headaches with intermittent nausea and vomiting. There was extensive inflammation seen on MRI. The ID team decided to start medical therapy with Albendazole and steroids as well as hepatitis B prophylaxis and baseline testing in the setting of steroid induction with Albendazole 400 mg po bid with meals, Decadron 2 mg PO q 8 hrs and Hepatitis B prophylaxis with lamivudine 100 mg PO daily. In [**2133-7-7**]: Dr. [**Last Name (STitle) **] (neurosurgery) felt that MRI revealed a significant interval improvement in the pattern of enhancement involving the cerebral aqueduct and fourth ventricle with decrease in the pattern of vasogenic edema at the level of the tectum, the ventricular system remains stable, the ventricular shunt tract is unremarkable with no evidence of abnormal enhancement, right frontal burr hole appears unchanged. Stable ring-enhancing lesion in the right frontal lobe with no evidence of significant vasogenic edema. Unchanged mucus retention cyst identified on the right maxillary sinus. Dr. [**Last Name (STitle) **] felt that the patient had "improved with conservative management. Will suggest to taper Dex and send patient to ID for further discussion of coverage". Past Medical History: HIV unknown VL or CD4 count. HBV Neurocystercircosis, s/p third ventriculostomy, fourth ventricular cyst resection in [**2132**] obstructive hydrocephalus s/p 3rd VCS per Dr. [**Last Name (STitle) **] Pertinent negatives: CNS bleeds (-), brain aneurisms (-), avm (-) Strokes (-) Procoagulant conditions (-) CAD (-) , AF (-) HTN (-), DM (-), HLD (-), OSA (-) migraine (-), CNS tumors (-) Prior Hepatitis B infection (date unknown - in [**1-/2133**] HBsAg negative, HBsAb positive, HBcAb positive) Neurocysticercosis: The brief timeline of her disease as outlined in prior ID notes: - c/o headaches, syncope; dx involvement of 3rd/4th ventricles - [**1-29**]: stereotactic endoscopic third ventriculostomy - [**1-31**]: stereotactic endoscopic resection of 4th ventricle cyst - [**2-2**]: Albendazole 400mg po bid + decadron lamivudine 100mg po qday (h/o HBV sAb/cAb +) (ivermectin x1 on [**1-30**]) - Recommended 4-week course of albendazole [**Date range (1) 84292**] - [**3-2**]: [**Hospital **] clinic visit; identified accidental overdose of decadron; d/c albendazole. To taper decadron. - [**3-6**]: [**Hospital **] clinic follow-up: improved symptoms, although ran out of and did not continue lamivudine. Continue steroid taper. - [**3-13**]: Had stopped steroids a week prior to appt. Asymptomatic. Labs checked and no evidence of adrenal insufficiency. To remain off steroids. -Seen by neurology on [**4-29**] for evaluation of new headaches. MRI performed on [**5-7**] which showed evidence of decompression, no hydrocephalus, smaller enchancing scolices Social History: she is not married, is living together with her partner, has two children. She is originally from [**Country 7192**]. She did not go to school. She works packaging scallops, but has not worked since the surgery. She does not smoke, does not drink alcohol and denies any illicit drug use. Born in village in [**Country 7192**], moved to US in [**2124**]. Has a 9-year old daughter who lives in [**Country 7192**], and a 3 year old son, who lives with her and her husband. [**Name (NI) **] known TB contacts. She lives in [**Location (un) 5503**] and feels safe at home. Family History: CNS bleeds ( ), brain aneurisms ( ), avm ( ) Hx of early strokes (-) Seizures (-) CNS tumors (-) Demyelinating conditions (-) Autoimmune conditions (-) Procoagulant conditions (-) CAD (-) Physical Exam: PE: 99.7 BP: 99/61 HR: 125 R: 15 On ventilator: CMV mode CMV mode breathing at 16 RR Sedated on Propofol at_ 40 mcg/ kg/ min which was stopped 15 minutes prior to my examination. Gen: Lying in bed. Arousable with sternal rub. She is responsive to noxious stimuli (moves all limbs symmetrically and antigravity). HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No meningismus. No photophobia. MS: Arousable with sternal rub. She is responsive to noxious stimuli (moves all limbs symmetrically and antigravity. CN: Corneals + bl. Pupils 2 to 1 bl and symmetrically. No gaze deviation. Look sto right and left spontaneously. No nystagmus. Gag +. Motor: tries to remove the tube purposely. Tone: DTR: 2+ throughout. Toes downgoing. Sensory preserved to noxious stimuli. Pertinent Results: [**2133-8-18**] 06:06PM TYPE-ART PO2-244* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 [**2133-8-18**] 05:00PM GLUCOSE-82 LACTATE-3.1* NA+-139 K+-2.9* CL--102 TCO2-23 [**2133-8-18**] 04:50PM UREA N-10 CREAT-0.5 [**2133-8-18**] 04:50PM ALT(SGPT)-40 AST(SGOT)-22 ALK PHOS-50 TOT BILI-0.3 [**2133-8-18**] 04:50PM LIPASE-20 [**2133-8-18**] 04:50PM ALBUMIN-3.1* CALCIUM-7.1* PHOSPHATE-2.7# MAGNESIUM-1.7 [**2133-8-18**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-6* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2133-8-18**] 04:50PM WBC-5.3 RBC-4.47 HGB-13.2 HCT-37.2 MCV-83 MCH-29.5 MCHC-35.4* RDW-16.9* [**2133-8-18**] 04:50PM PT-11.6 PTT-25.9 INR(PT)-1.0 [**2133-8-18**] 04:50PM PLT COUNT-201 [**2133-8-18**] 04:50PM FIBRINOGE-461* [**2133-8-20**] 04:10PM [**Month/Day/Year 3143**] WBC-8.3 Lymph-3* Abs [**Last Name (un) **]-249 CD3%-65 Abs CD3-162* CD4%-20 Abs CD4-49* CD8%-45 Abs CD8-111* CD4/CD8-0.4* [**2133-8-21**] 06:05AM [**Month/Day/Year 3143**] Neuts-91.2* Lymphs-6.3* Monos-2.0 Eos-0.1 Baso-0.4 [**2133-8-22**] 07:00PM [**Month/Day/Year 3143**] ALT-42* AST-21 LD(LDH)-300* CK(CPK)-405* AlkPhos-84 Amylase-273* TotBili-0.2 [**2133-8-23**] 10:15AM [**Month/Day/Year 3143**] Triglyc-249* HDL-64 CHOL/HD-4.5 LDLcalc-173* [**2133-8-24**] 07:35AM [**Month/Day/Year 3143**] Lipase-777* . MICRO: 1) [**Hospital6 302**] labs, obtained for proper management([**8-18**]): [**Month/Year (2) **] culture (FINAL): coag (-) Staph found on 1 bottle (aerobic), 3 bottles negative, suggested to be "possible contaminant"; LP opening pressure 28 mm Hg; CSF protein 34, glucose 79; CSF culture: no growth, 5 WBCs; VDRL: non-reactive; Cryptococcal Ag: Neg; CSF Herpes Simp DNA: <80 copies (WNL); EBV DNA: Neg; CSF bacterial Ag H. influenzae type B, Strep pneumo, N. meningitidis group A, B, C, Y, W135, Group B Strep, E. coli - all Neg. 2) Stool ([**2137-8-18**]): no ova or parasites, no C diff tox A&B, no campylobacter, salmonella, shigella, or worm. 3) HIV-1 VL ([**8-22**]): no RNA detected. 4) Urine yeast ([**8-22**]): 10,000-100,000 organisms/ml 5) Sputum P. jirovecii IF test ([**8-23**]): NEG. 6) Mumps IgG antibody, serology ([**8-24**]): . IMAGING: 1) EEG ([**8-20**]): background slowing indicative of severe encephalopathy, could be due to infection, toxic or metabolic, anoxia. 2) Echo ([**8-20**]): nl size LA, PFO, LVEF>55%, right vent chamber size and free wall motion nl, valves nl, no aortic regurg, MV normal with trivial regurg, estimated pulm artery systolic pressure nl; physiologic pericardial effusion. 3) MR head +/- GAD ([**8-20**]): foci of restricted diffusion within right thalamus and right occipital lobe, compatible with embolic infarcts in the PCA distribution; re-demonstration of rim-enhancing lesion in R frontal lobe w/ interval decrease in enhancing volume but increase in surrounding edema which may be attributed to post-tx change versus superinfection; stable enhancement in 4th ventricle, may reflect residual post-tx inflammation; punctate foci of susceptibility artifact within L tentorium not present on prior studies, possibly representing focus of hemorrhage or hemosiderin deposition. 4) CT head w/ contrast ([**8-21**]): no evidence for aneurysm or high grade stenosis. 5) Bilateral lower extremity veins Doppler ([**8-21**]) to r/o DVT: no evidence of DVT in both common femoral, superficial femoral, popliteal veins, with normal color flow, waveforms, augmentation. 6) Chest portable AP ([**8-21**]) for chest pain and difficulty breathing: unchanged cardiomediastinal silhouette; pulm vasculature normal; persistent left retrocardiac density; no pleural effusion or PTX. 7) Chest PA & Lateral ([**8-23**]) to eval the retrocardiac density: normal heart, lungs, hila, mediastinum, pleural surfaces. 8) CT abdomen/pelvis C+ ([**8-23**]) to eval for pancreatitis: no evidence of complications of pancreatitis, no pseudocyst, vascular occlusion, or necrosis; Cholelithiasis. 9) Parotid ultrasound ([**8-24**]) to eval for parotitis: no evidence of parotitis and no masses or fluid collection identified in the parotid region bilaterally. 10) RUQ ultrasound ([**8-25**]) to eval for GB: small amount of [**Doctor Last Name 5691**]-like sludge seen within the lumen of the gallbladder. No signs of cholecystitis and no biliary dilatation seen. The pancreas appears unremarkable. . Brief Hospital Course: 1) Neuro: Ms. [**Known lastname 72203**] [**Known lastname 84291**] is a 29-yo right-handed Guatemalan woman with h/o neurocysticercosis (dx [**1-/2133**]) and ventriculitis, s/p third ventriculostomy, fourth ventricular cyst resection in [**2132**]. In [**2133-6-6**], she again was admitted for headache and found to have ventriculitis, at which point Albendazole and Deceadron were restarted. An MRI of the brain on [**7-21**] showed a stable ring enhancing lesion in the right frontal lobe. After developing herpes zoster on [**8-5**], she was started on a Decadron taper. She presented after being found unresponsive on [**2133-8-18**] at 11:30 AM (last seen nomral 5:30 AM). The prior day she reported headahce, nausea, several brief episodes of presyncope. While en route to OSH, she had a witnessed generalized seizure and was intubated for agitation. Her T max was 103 and on exam, it was noted that she had a left heimparesis. She had [**Date Range **] cultures drawn, had a head CT showing chronic right frontal hypodensity and an LP with an opening pressure of 18 and CSF showing 11 WBC, [**3-11**] WBC and normal protein and glucose. CSF cultures were negative. Upon arrival here, she remained intubated, but was moving all 4 extremities. Initial EEG showed background slowing and delta suppression, indicative of severe encephalopathy; there was no clear epileptiform discharges or electrographic seizures. It is likely that the patient had a partial seizure with the focus being the neurocystercicosis lesion in the right frontal lobe and that this parital seizure secondarily generalized. The patient completed the Decadron taper to help relieve the edema associated with the neurocystercicosis lesion. Repeat EEGs were not indicative of any epileptiform discharges or electrographic seizures. Initially patient was on both Dilantin and Keppra for the seizures but the Dilantin was subsequently discontinued. The patient was maintained on Keppra. Clinically, patient improved and currently she has no neurologic deficits on exam. She did note an episode of rhythmic left arm shaking while on Keppra 1000 mg [**Hospital1 **], so the dose was increased to 1000 mg qAM and 1500 mg qPM. There have been no further shaking episodes noted since the Keppra dose increase. Incidentally, MRI revealed foci of restricted diffusion in right thalmus and right occipital lobe consistent with embolic infarcts in the PCA distribution (along with re-demonstration of rim-enhancing lesion in the R frontal lobe). Initially, it was believed this could be septic emboli. However, the 2D Echo did not reveal any vegetations, but a PFO was noted. A TEE was discussed but the valves were noted to be very well visualized on TTE with no vegetations and since [**Hospital1 **] cx were negative (except for a [**2-9**] culture positive at OSH attributed to contamination with coag negative Staph); it was decided, along with Cardiology, that a TEE would not be of much added clinical benefit. A CTA was performed to evaluate for a vertebral atery souce of emboli; but the vertebreals were noted to be of normal course and caliber and with no high grade stenosis. Given the PFO, it is likely that the infarcts were due to a paradoxial embolus. LE Dopplers were obtained but were negative. Once it was known that cultures were negative and that this was likely a paradoxic emboli given the PFO, the patient was started on a baby Aspirin. [**Name2 (NI) **] had elevated lipid panel and should be started on a statin given her stroke; this was currently held off on given elevated LFTS, but should consider starting as an outpatient when LFTs normalize. There is currently no clinical sequelae of stroke noted. 2) ID: Pt. had T 103 at OSH. She had [**Name2 (NI) **] cultures drawn and an LP with an opening pressure of 18 and CSF showing 11 WBC, [**3-11**] WBC and normal protein and glucose. CSF gram stain showed no growth but final cultures were pending upon arrival to [**Hospital1 18**]. She empirically received rocephin 2 g iv, acyclovir 700 mg iv,vancomycin 1 g iv, and ampicillin 1 g and was transferred to [**Hospital1 18**] for further work-up. ID was consulted and intitially, the patient was mainted on these antibiotics (except the Ampicillin was increased to meningitic doses) for empiric treatment of bacterial meningitis. CSF cultures all returned negative and 1 out of 4 [**Hospital1 **] cultures were positive. The one positive culuture was for coag negative staph and this was attributed to contamination. Antibiotics were discontinued with the negative culture results. For the neurocystercicosis, it was determined that she had already completed longer than needed course of Albendazole and this was not continued; she did complete a Decadron taper. During hospitalization, a low CD4 count of 49 was noted; however it was believed this was more likely due to acute illness rather than HIV. Nonetheless, HIV testing was performed and HIV serology was negative with nondetectable viral load. Can consider repeat testing of CD4 in future to see if it normalizes. Also, given that it is currently low, can consider starting Bactrim prophylaxis at time of outpatient follow-up; this was held off on at this time given elevated LFTS/amylase/lipase. She does have a history of HBV and HBV viral load was sent, but remains pending at this time. She currently remains on Lamivudine; the need to continue this should be reassessed at outpatient follow-up. 3) GI: On [**8-21**], she complained of mid-chest/epigastric pain that caused her difficulty with breathing. Her vitals were stable, and EKG and cardiac enzymes showed no evidence for myocardial ischemia. However, on the morning of [**8-22**], her LDH and lipase were found to be elevated, with further elevation in both LDH and lipase, along with amylase, by the same evening. She complained of vague lower abdominal pain and epigastric pain radiating to the back, but was not in any apparent distress. Acute pancreatitis was suspected given the lab values and she was started on IV fluids and made NPO. CT of the abdomen/pelvis was obtained to evaluate for pancreatitis and did not detect any evidence for complications of pancreatitis, but did note gallstones. Despite improvements clinically, lipase and amylase levels continued to rise. A GI consult was called and per their recommendations, RUQ ultrasound was obtained, which showed no evidence for cholecystitis or biliary dilatation and unremarkable pancreas. While there is no clear idea of what resulted in this episode of pancreatitis, possibilites include medication side effects (particularly the Dilantin she received early during hospitalization or Lamivudine) or a stone/sludge that has subsequently passed. Amylase and Lipase levels are now both trending down. The LFTs did rise briefly but these too are trending down and are possibly from passed biliary sludge. LFTS, amylase, lipase can be checked as an outpatient to ensure that they have returned to [**Location 213**]. She remains abdominal pain-free and is tolerating her diet, which is a low-fat no alcohol diet and which should be continued for a month. 4) Facial swelling: On [**8-24**], patient complained of bilateral facial swelling and tenderness that she had for 3 weeks. Given the elevated amylase and inability of the patient to recall whether she had been vaccinated for mumps, concern for the remote possibility of mumps parotitis was raised. A parotid ultrasound was obtained and was negative. A mumps IgG antibody was positive, indicating likely immunization or a past history of infection, but no evidence current infection. It is more likely that the swollen face is a Cushingoid side effect of the Decadron she was previously on. Medications on Admission: ID: ALBENDAZOLE [ALBENZA] - 200 mg Tablet - 2 Tablet(s) by mouth twice a day DEXAMETHASONE - (Dose adjustment - no new Rx) - 2 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours for 10 days, then 1 tab po bid for next 10 days, then 1 po qd for next 10 days LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth once a day VALACYCLOVIR - 1,000 mg Tablet - 1 Tablet(s) by mouth three times a day until gone METRONIDAZOLE - 500 mg Tablet - 4 Tablet(s) by mouth once 2. GI: OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily 3. OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for severe pain Discharge Medications: 1. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:*60 Tablet(s)* Refills:*2* 4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: neurocysticercosis generalized tonic clonic seizures posterior circulation stroke pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with loss of consciousness and generalized tonic clonic seizure. This was most likely secondary to one of your neurocystercicosis lesions. You also reported experiencing left arm tremors for 3 days prior to this hospitalization and also reported one episode while in the hospital. For seizure prevention, you were begun on Keppra, 1000 mg in the morning and 1500 mg in the evening. You were also found to have suffered a stroke in your right thalamus and occipital lobe, most consistent with the distribution of the right posterior cerebral artery. For prevention of recurrence, you were started on baby aspirin of 81 mg. During your hospitilization, you developed abdominal pain and was found to have elevated pancreatic and liver enzymes. CT and liver/pancreas ultrasound were performed which revealed no cholecystitis, biliary dilation, or other acute abdominal processes. Because of this likely episode of pancreatitis, you were initially instructed not to eat and then was transitioned back to the low-fat, no-alcohol diet. Please stay on this diet for one month. As outpatient, consider discussing starting medication for elevated lipids (a statin) with your PCP or Dr. [**Last Name (STitle) **] (your neurologist) when your liver enzymes improve. Please discuss starting Bactrim prophylaxis with your ID doctor on follow-up. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2133-9-2**] 11:00 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 8618**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2133-9-2**] 1:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2133-10-27**] 3:30 Please follow with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge Completed by:[**2133-8-28**]

[ "434.11", "123.1", "112.1", "577.0", "V08", "070.30", "745.5", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

21587, 21593

12630, 20363

336, 406

21732, 21732

8281, 12607

23268, 23850

6956, 7146

21096, 21564

21614, 21711

20389, 21073

21883, 23245

7161, 7825

286, 298

434, 4762

21747, 21859

7849, 8262

4784, 6352

6368, 6940

78,778

193,248

47867

Discharge summary

report

Admission Date: [**2134-4-9**] Discharge Date: [**2134-4-11**] Date of Birth: [**2053-11-25**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Keflex Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hematuria. Major Surgical or Invasive Procedure: Continuous Bladder Irrigation. 3-Way Foley catheter placmenet. History of Present Illness: Mr. [**Known lastname **] is an 80 year old male with history of prostate CA with a chronic indwelling foley, CVA, s/p trach, CAD, who presented today to [**Location (un) 620**] with hematuria and intermittent clots. He has has hematuria for the past three months since his most recent stroke in [**2133-12-15**] and has required CBI since that time. Several attempts to discontinue CBI led to repeated bladder clots. He is not any anticoagulants, but was transiently on aspirin in [**Month (only) 404**], but this was stopped as it led to worsening hematuria. A cystoscopy performed at [**Hospital1 1774**] in [**Month (only) 1096**] was felt to demonstrate radiation cystitis, patient's radiation was 15 years ago and had no prior history of hematuria. . In the ED, initial vitals 96.9, 120, 102/60, 18, 88%. Patient was seen by urology. An ultrasound revealed the presented of a bladder clot and urinary obstruction. A foley was placed and it hand irrigated with removal of several clots. He was started on CBI. . In the ED, he denies cough, SOB, fevers, chills, but he was noted to be hypoxic to 88%. CXR showed atelectasis but no pneumonia. He was requiring frequent sunctioning by RT, so the decision was made to place the patient in the unit. . Upon arrival to the floor, he denies difficulty breathing and denies abdominal pain. Furthery history is limited by patient's difficulty with speach. Patient's daughter reports his breathing looks comfortable and at baseline. Past Medical History: CAD s/p CABG CVA, right hand weakness Prostate cancer Right TKR Appendectomy Catracts Social History: Patient was a resident of [**Hospital3 **] from [**12-23**] to [**2134-4-5**], but now is at [**Hospital1 **]. Family History: Unknown Physical Exam: Vitals: T 98.5, HR 118, BP 134/62, RR 21, 99% on TCM General: NAD, HEENT: Sclera anicteric, +trach Lungs: Rhonchi diffusely, no wheezes, good air movement CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: three way foley present, urine clear Ext: warm, well perfused, 2+ pulses, trace edema Pertinent Results: [**2134-4-9**] 04:15PM BLOOD WBC-10.4# RBC-3.65* Hgb-10.3* Hct-32.1* MCV-88 MCH-28.3# MCHC-32.3 RDW-14.9 Plt Ct-548*# [**2134-4-10**] 03:21AM BLOOD WBC-9.5 RBC-2.98* Hgb-8.8* Hct-26.9* MCV-90 MCH-29.4 MCHC-32.5 RDW-14.8 Plt Ct-398 [**2134-4-9**] 04:15PM BLOOD Neuts-78* Bands-0 Lymphs-14* Monos-6 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2134-4-10**] 03:21AM BLOOD Neuts-71.9* Lymphs-13.8* Monos-6.6 Eos-7.5* Baso-0.2 [**2134-4-9**] 04:15PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2134-4-9**] 04:15PM BLOOD PT-12.1 PTT-23.4 INR(PT)-1.0 [**2134-4-9**] 04:15PM BLOOD Plt Smr-HIGH Plt Ct-548*# [**2134-4-10**] 03:21AM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1 [**2134-4-10**] 03:21AM BLOOD Plt Ct-398 [**2134-4-9**] 04:15PM BLOOD Glucose-132* UreaN-40* Creat-1.2 Na-137 K-4.3 Cl-94* HCO3-29 AnGap-18 [**2134-4-10**] 03:21AM BLOOD Glucose-124* UreaN-39* Creat-1.0 Na-137 K-4.3 Cl-99 HCO3-28 AnGap-14 [**2134-4-10**] 03:21AM BLOOD Calcium-9.1 Phos-4.9*# Mg-2.0 [**2134-4-9**] 04:30PM BLOOD Lactate-2.4* PORTABLE AP VIEW OF THE CHEST: Patient is status post median sternotomy and CABG. A tracheostomy tube is new since the prior study and terminates approximately 7 cm from the carina. The heart size is normal. The mediastinal and hilar contours are within normal limits. Patchy air-space opacity in the retrocardiac region is likely atelectasis, but infection cannot be excluded. The remainder of the lungs are clear without focal consolidation. No pleural effusion or pneumothorax is present, however the right apex is excluded from the field of view. No acute skeletal abnormalities are present. . IMPRESSION: Retrocardiac patchy opacity, likely representing atelectasis. Please note that developing infection cannot be excluded. . Brief Hospital Course: Mr. [**Known lastname **] is an 80 yo male with CAD, h/o CVA, here with hematuria off all anticoagulation and increased pulmonary secretions. . 1. Hematuria. Clot was evacuated by urology in ED and hematuria has resolved with replacement of three way foley. Per records, this is attributed to radiation cystitis. Urology followed through his hospitalization. Hematocrit remained stable. He was continued on his home dose of flomax. Patient will need to follow with Dr. [**Last Name (STitle) 8494**] (Urology) as outpatient. . 2. Hypoxia. Patient had hypoxia to 88% on RA that improved with deep suctioning. Patient was requiring increased secretions. No evidence of PNA on CXR and no fever or leukocytosis. Patient's oxygenation was improved with frequent suctioning, and was weaned to room air. . 3. Tachycardia. Likely secondary to hypovolemia. Patient denied pain, and tachycardia improved with IV hydration. . 4. Anemia. Likely secondary to chronic disease and hematuria. . 5. CAD. Patient is s/p CABG, but intolerant of aspirin due to frequent hematuria. he was continued statin and beta block. He is not treated with aspirin due to chronic hematuria. . 6. HTN. He was continued on his home doses of amlodipine, lopressor and flomax. . 7. Hyperlipidemia. While here, he was treated with atorvastatin as a therapeutic interchange for mevacor. He was discharged on his home dose of mevaocor. Medications on Admission: Norvasc 10 mg daily Vitamin B12 daily Mevacor 20 mg daily Lopressor 100 mg TID Nystatin TID Transdermal scopolamine 1.5 q 72 hours Mucomyst 20% 5ml inh TID Flomax 0.4 mg daily Albuterol prn Combivent prn Peridex mouthwash as needed Colace 100 mg [**Hospital1 **] Guiafenesin 200 mg QID prn senna 10 mg prn ativan 0.5 mg PO prn anxiety Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mevacor 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Five (5) ML Miscellaneous Q6H (every 6 hours) as needed for SOB. 7. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) IH Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) IH Inhalation every four (4) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Hematuria Increased Respiratory Secretions Discharge Condition: Mental Status: Confused - always Level of Consciousness: Lethargic but arousable Activity Status: Bedbound Discharge Instructions: You were admitted for blood in the urine. Urology irrigatated your bladder and removed significant blood clot. Your foley catheter was replaced and you were started on continuous bladder irrigation. Your bleeding stopped and then your catheter was changed again. You will need to follow up with urology as indicated below. . You were admitted to the intensive care unit for frequent suctioning of your tracheostomy. With frequent suctioning, your breathing improved and you did not require supplemental oxygen. Followup Instructions: Please arrange to follow up with your PCP on discharge. Please arrange to follow up with Urology at ([**Telephone/Fax (1) 772**] with Dr. [**Last Name (STitle) **].

[ "E879.2", "438.89", "276.52", "366.9", "V45.81", "V10.46", "V44.1", "414.00", "785.0", "729.89", "909.2", "280.0", "595.82", "V44.0", "799.02", "599.71", "272.4" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

7470, 7547

4384, 5789

292, 356

7634, 7634

2582, 4361

8305, 8474

2118, 2127

6175, 7447

7568, 7613

5815, 6152

7767, 8282

2142, 2563

242, 254

384, 1864

7649, 7743

1886, 1974

1990, 2102

31,473

171,502

19930

Discharge summary

report

Admission Date: [**2171-2-1**] Discharge Date: [**2171-2-5**] Date of Birth: [**2117-3-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 53 y/o M hx DMT2, HTN, hyperlipidemia presents with chest pressure and found to have inferior STEMI. . He was in his usual state of health until about 1 week prior to admission when he began to develop mild epigastric discomfort, pain [**1-30**], lasting most of the day while at work. He works as a construction worker during the day and cleaning at night. The symptoms became slightly more severe on the day of admission, and he went to see his cardiologist. Per pt, his cardiologist did an EKG at the time and told him it was likely MSK. Then, at 8PM at night while mopping the floor, he developed severe [**11-8**] substernal CP without radiation followed by diaphoresis, dizziness, and nausea. He called EMS and per report, was cool, pale, diaphoretic. HR 50, SBP 50. He received 1 mg atropine on the field. . He presented to OSH with CP and bradycardia to 49 as well as borderline low BP 103/54, RR 20. EKG with mild ST elevations in II,III,AVF, mild ST depressions in I, AVL. He was received plavix 600 X1, integrillin gtt, heparin gtt and transferred to [**Hospital1 18**] for cath. . Upon arrival to [**Hospital1 18**], Pt was afebrile, HR 44, BP 105/69, RR15, 97%RA. CK 108, Trop 0.06. He was taken to cath lab, and a temp wire was placed in lab. He was also given an additional 2 mg atropine for bradycardia. He was found to have: R dominant LMCA: normal LAD: 30% proximal disease RCA: total proximal occlusion . He underwent stenting to prox RCA lesion, 3X15 Vision stent. Temp wire removed in cath lab. . Upon transfer to CCU, pt reports [**2173-1-30**] epigastric discomfort similar to his symptoms from several days ago. He denies any radiation, SOB, palpitations, LHD, Dizzyness. His major complaint is dry mouth. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On review of symptoms, + loud snoring and feeling tired during the day. + sciatica. 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. Past Medical History: HTN Dyslipidemia diabetes: diagnosed 5 years ago GERD Sciatica Social History: Pt works as construction worker during day. He is married Smoking: 80 pack years (2ppd X 40 years) EtOH: rare over last 5 years Family History: There is no family history of premature coronary artery disease or sudden death. Mother had heart disease and DM. Brother has DM, but no hx of MI Physical Exam: VS: T97.3 , BP 144/51 , HR 55 , RR 16, O2 % on Gen: middle aged male, obese. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MM dry Neck: Supple with JVP at angle of jaw CV: RR, normal S1, S2. No S4, no S3. No murmurs 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; 2+ DP Pertinent Results: EKG demonstrated bradycardia with ectopic atrial, nl axis, nl intervals <1mm ST elev in II, III, AVF, mild ST depressions in I, AVL, TWI in AVF . Compared with EKG from ealrier, the changes are now less pronounced . CARDIAC CATHETERIZATION COMMENTS: 1. Coronary angiography in this right dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically-apparent disease. The LAD had a 30% proximal stenosis. The LCx had no angiographically-apparent disease. The RCA had a total proximal occlusion. 2. Resting hemodynamics revealed elevated right and left filling pressures with RVEDP of 15 mmHg and mean PCW of 25 mmHg. There was moderate pulmonary arterial pressure with PASP of 40 mmHg. There was normal systemic arterial pressure with SBP of 126 mmHg and DBP of 71 mmHg. The cardiac index was preserved at 2.5 L/min/m2. 3. Left ventriculography was deferred. 4. Successful treatment of inferior STEMI with stenting of proximal RCA with a Vision 3x15mm bare metal stent. 5. Prior to intervention patient had bradycardia, relative hypotension and strong vagal reaction necessitating use of transvenous pacer. After re-establishment of flow his HR and hemodynamics improved and the pacer was removed at the end of the case. 6. Succesful closure of RFA arteriotomy with 6F Angioseal FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Inferior STEMI 3. Moderate pulmonary hypertension. 4. Moderate left ventricular diastolic dysfunction. 5. Successful stenting of RCA with bare metal stent. . . ECHOCARDIOGRAM The left atrium is mildly dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild focal left ventricular systolic dysfunction with overall preserved EF Brief Hospital Course: On arrival to the [**Hospital1 18**], the patient was already loaded with plavix, and on integrillin and heparin drips. His EKG and clinical presentation were consistent with a right-sided myocardial infarction, as he had mild ST elevations in II, III, and AVF with an ectopic atrial rhythm; bradycardia, and hypotension. He was immediately taken to the cath lab where he was found to have total proximal RCA occlusion, with 30% proximal LAD disease. A bare metal stent was placed into the RCA, and a temp wire was also place during cath. Upon transfer to the floor, he was bradycardic in the 50's, with stable blood pressure. CK's peaked on [**2-2**] and began to trend down thereafter. A post-cath echocardiogram was obtained which showed segmental wall motion abnormalities in distribution of his MI, with preserved overall LV function (EF >55%). Over the course of his hospitalization, his heart rate improved to the 60-75 range and he returned to his pre-hospitalization hypertensive state. His EKG returned to a normal sinus rhythm with Q waves in the distribution of his MI. We started metoprolol succinate and his home regimen of lisinopril, high-dose atorvastatin, aspirin, and plavix. He was evaluated by physical therapy. Medications on Admission: lipitor 20mg daily lisinopril 5mg daily ToprolXL 100mg daily metformin 1000 mg [**Hospital1 **] glyburide 5mg [**Hospital1 **] ASA 81mg daily 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:*12* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*12* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Place one tab under your tongue every five minutes as needed for chest pain. You may repeat this for a total of three times. If you still have chest pain after three doses then call 911. Disp:*20 Tablet, Sublingual(s)* Refills:*2* 5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Myocardial infarction (heart attack) Discharge Condition: Vital signs stable. Chest pain free. Discharge Instructions: You were admitted because you had a myocardial infarction (a heart attack). We performed a cardiac catheterization, which is a procedure where we use a stent to improve blood flow in your blocked coronary artery. You did very well after this procedure. . . We started some new medications, please reference the attached list and take all of these medications as directed. You will follow-up with Dr. [**Last Name (STitle) **], the cardiologist that did your cardiac catheterization on [**2171-3-4**]. . . Please return to the emergency room if you develop any concerning symptoms. Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in Cardiology. Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2171-3-4**] 12:00 This is located in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. if you have any questions or concerns please call ([**Telephone/Fax (1) 5909**] to make changes to this appointment.

[ "250.00", "401.9", "414.01", "278.00", "724.3", "427.89", "416.8", "272.4", "530.81", "410.41", "305.1", "786.09" ]

icd9cm

[ [ [] ] ]

[ "00.45", "88.56", "00.40", "00.66", "37.22", "36.06" ]

icd9pcs

[ [ [] ] ]

8972, 8978

6316, 7560

323, 348

9059, 9098

3790, 5109

9730, 10169

2885, 3033

7753, 8949

8999, 9038

7586, 7730

5126, 6293

9122, 9707

3048, 3771

273, 285

376, 2637

2659, 2723

2739, 2869

6,510

128,087

47779

Discharge summary

report

Admission Date: [**2130-4-13**] Discharge Date: [**2130-4-19**] Date of Birth: [**2081-6-15**] Sex: F Service: PLASTIC SURGERY HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1968**] is a patient with a left breast mass and presents for excision of the breast lesion and reconstruction with a TRAM flap. PAST MEDICAL HISTORY: Insulin-dependent diabetes, breast cancer invasive ductal carcinoma, sarcoidosis, hepatitis C with chronic cirrhosis and mitral valve prolapse MEDICATIONS: Cozaar 25 mg by mouth once daily, insulin NPH HOSPITAL COURSE: On the first day of her hospital stay, the patient was taken to the operating room, where she underwent an uncomplicated left simple mastectomy, left axillary sentinel node biopsy, and TRAM flap to the left breast, as performed by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 364**]. In the perioperative period, the patient had significantly inadequate urine output as well as the development of a left abdominal wall hematoma. Given the patient's multiple medical problems and concern over the patient's urine output, the patient was taken to the Surgical Intensive Care Unit for observation. The patient received aggressive fluid rehydration. A central venous line was placed in order to provide adequate fluid resuscitation. The patient also had an increase in her serum creatinine to 1.8, at which point a Renal consult was also obtained. The Renal team felt this was most likely pre-renal hypoperfusion in the setting of relative hypotension during extended period in the operating room. These circumstances likely exacerbated issues associated with her chronic underlying diseases. The next two days, the patient was closely monitored and aggressively rehydrated per the recommendations of the Renal team. The patient's serum creatinine gradually dropped. The patient's vital signs stabilized. The patient overall continued to improve. By postoperative day number three, the patient was ready to be transferred to the floor. During this time, the patient was also receiving intravenous Kefzol for antibiotic, and for pain control, the patient had been receiving an epidural, however, given the setting of her postoperative complications, the epidural was discontinued and a patient-controlled analgesia was begun. Once the patient arrived on the regular floor, her diet was advanced. She was begun on a regular diet. She was changed over to oral pain medications, which provided adequate control. The patient began getting up and out of bed and ambulating. The apparent hematoma which had been forming on the anterior abdominal wall continued to remain soft and decreasing in size and presented no further problems or complications. The patient's serum creatinine continued to decrease and return to its preoperative level of less than 1. By postoperative day number five, the patient's urine output was considered to be adequate. The patient's Foley catheter was discontinued, and the patient continued to make adequate urine with spontaneous voiding. At this point, on postoperative day number six, the patient had remained afebrile, with stable vital signs, making good urine. The patient was tolerating a regular diet, and was up ambulating on her own power. It was decided at this time that the patient could be discharged to home. DISCHARGE CONDITION: The patient is stable at the time of discharge, with three [**Location (un) 1661**]-[**Location (un) 1662**] drains remaining. DISCHARGE DISPOSITION: The patient will be discharged to home with VNA services for assistance in managing the patient's drains. DISCHARGE MEDICATIONS: Keflex 250 mg by mouth four times a day until drains removed, Cozaar 25 mg by mouth once daily, insulin per preoperative dosages. FOLLOW UP: The patient will see Dr. [**First Name (STitle) **] in clinic next week, as well as Dr. [**Last Name (STitle) 364**] as previously scheduled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 17228**] MEDQUIST36 D: [**2130-4-19**] 00:24 T: [**2130-4-19**] 01:41 JOB#: [**Job Number 100859**]

[ "458.2", "424.0", "174.8", "998.12", "135", "571.5", "070.54", "250.01" ]

icd9cm

[ [ [] ] ]

[ "85.7", "38.93", "85.41", "40.11" ]

icd9pcs

[ [ [] ] ]

3535, 3642

3383, 3511

3667, 3798

577, 3361

3810, 4234

178, 330

354, 559

28,227

134,768

33967

Discharge summary

report

Admission Date: [**2182-11-9**] Discharge Date: [**2182-12-4**] Date of Birth: [**2119-10-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: mechanical ventilation Central Line Placement Arterial Line Placement Tracheostomy History of Present Illness: This is a 63yoM w/h/o 4V CABG in [**4-21**] and PUD who is transferred from OSH for management of severe pancreatitis and STEMI. Hx is per pt's family as pt is intubated and sedated. Per pt's wife, pt had been feeling well but "tired" the past couple of days. His wife notes that this AM, he awoke, ate breakfast w/o difficulty/complaint, and worked on the computer as he usually dose. They had a plan to meet at the mall. The pt's wife drove away and noted that the pt was not getting in his car. About an hour later, she got a call from him saying that he felt terrible. When she arrived at home, he was on the bathroom floor having vomited. She noted that he was responding appropriately, but slurring his speech. She then called EMS and they took him to the OSH. Per EMS record, vitals en route to OSH: HR 40, BP 90/palp, sat 89% RA. He was given 1 dose of 0.5mg atropine IO w/improvement of HR to 50s. There, pt was afebrile; he was IVF resuscitated w/5L NS which resolved pt's intial hypotension to 70s/40s. Labs revealed amylase 4313, libpase >[**Numeric Identifier **], ALT 178, AST 148, Cr 2.1, WBC 12.0, HCT 47.2; 1st set CK 261 MB 2 TNI <0.10, 2nd set CK 89 TNI <0.10. When he presented at the OSH. He had no further episodes of bradycardia. He and given Levofloxacin 750mg IV x 1, morphine and dilaudid for pain. He was noted to have intermittent ST elev 1 mm in II/III/F. ABG was 7.25/44/188 on NRB. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: CAD s/p Coronary Arterty Bypass Graft x 4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) [**2182-4-29**] Hypertension Hypercholesterolemia Borderline Diabetes Chronic Obstructive Pulmonary Disease Benign Prostatic Hypertrophy Depression History of kidney stones History of peptic ulcer disease s/p Tonsillectomy Social History: Lives w/his wife, but had been staying with son due to power outage until past couple of days. Works in IT. tobacco [**12-17**] ppd x 20 years, quit 22 years ago; no ETOH per wife. Family History: Father deceased early 60s from MI 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: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2182-11-9**] 09:36PM BLOOD WBC-7.5 RBC-4.96 Hgb-15.4 Hct-44.4# MCV-90 MCH-31.0 MCHC-34.6 RDW-14.8 Plt Ct-166 [**2182-11-9**] 09:36PM BLOOD Neuts-79* Bands-7* Lymphs-9* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2182-11-9**] 09:36PM BLOOD PT-13.6* PTT-35.1* INR(PT)-1.2* [**2182-11-9**] 09:36PM BLOOD Glucose-183* UreaN-28* Creat-1.7* Na-139 K-6.4* Cl-111* HCO3-23 AnGap-11 [**2182-11-9**] 09:36PM BLOOD ALT-126* AST-120* LD(LDH)-364* CK(CPK)-402* AlkPhos-180* Amylase-2381* TotBili-0.9 [**2182-11-9**] 09:36PM BLOOD Lipase-3705* [**2182-11-9**] 09:36PM BLOOD Albumin-3.9 Calcium-7.8* Phos-4.7* Mg-1.8 [**2182-11-10**] 03:23PM BLOOD Triglyc-61 HDL-52 CHOL/HD-2.0 LDLcalc-38 LDLmeas-<50 . MICROBIOLOGY: The following blood cultures were collected and were negative: [**2182-11-9**] x 2 sets; [**2182-11-10**] x 2; [**2182-11-11**]; [**2182-11-16**] x 3; [**2182-11-17**]; [**2182-11-18**] x 2 with mycotic cultures. The following urine cultures were collected and were negative: [**2181-12-9**]; [**2182-12-12**]; [**2182-11-16**] Sputum Cultures from [**2182-11-10**] grew: ESCHERICHIA COLI. SPARSE GROWTH. | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Sputum Cultures from [**2181-11-14**] grew: GRAM NEGATIVE ROD(S). RARE GROWTH. To speciation or sensitivities performed. Sputum Cultures from [**2181-11-15**] grew: no growth Stool C. Diff toxin A & B [**2182-11-12**]: no growth All catheter cultures were negative, including: Right IJ CVL Catheter Tip [**2182-11-18**], right radial arterial line [**2182-11-26**], L PICC [**2182-11-27**], and L IJ CVL [**11-28**]. . KEY RADIOLOGY STUDIES: [**2183-11-10**] ABDOMINAL ULTRASOUND: Limited exam given body habitus. No focal liver lesion is identified. There is no intra- or extra-hepatic biliary dilatation. The common duct measures 3 mm. The gallbladder is contracted and thus difficult to evaluate for the presence of stone. The portal vein is patent with the hepatopetal flow. The splenic vasculature is not examined. The pancreas is obscured by bowel gas. The right kidney measures 10.0 cm. The left kidney measures 11.0 cm. There is no hydronephrosis or ascites. IMPRESSION: Limited exam shows no focal liver lesion or intra/extrahepatic biliary dilatation. The gallbladder is contracted and thus difficult to evaluate for the presence of stones. [**2182-11-14**] ABDOMEN, SUPINE: No dilated loops of large or small bowel present and there is no evidence of obstruction. Nasogastric tube is present, curled up within the upper abdomen. [**2182-11-15**] ABDOMEN, SUPINE: No evidence of obstruction. [**2182-11-18**] CT ABD W/ CONTRAST: 1. There is extensive pancreatic necrosis, with only minimal residual enhancing pancreatic tissue in the region of the head and uncinate process. Fluid interdigitates with retroperitoneal and mesenteric fat. A small amount tracks inferiorly into the paracolic gutter and into the pelvis. However, there is no drainable fluid collection at this time. 2. Gallstones. 3. Bilateral small effusions and consolidation/atelectasis. [**2182-11-30**] HEAD CT: 1. Right frontal and right parietal hypodensities appear to represent infarct of unclear chronicity, but possibly subacute. Recommend MRI with diffusion-weighted imaging for further evaluation. 2. Near complete opacification of the sphenoid sinus with opacification of multiple posterior ethmoid air cells. Opacification of multiple right mastoid air cells also observed. ADDENDUM: The right frontal hypodensity is associated with local tissue loss, and is therefore chronic. The right parietal low density region has no tissue loss and may be subacute. [**2182-12-2**] CAROTID US: read pending . [**2182-12-3**]: ECHO (Transthroacic) with bubble study) Technically suboptimal study due to very poor acoustic windows. Suboptimal saline contrast did not demonstrate a right-to-left shunt. Left ventricular wall thickness, cavity size, and global systolic function are grossly normal (LVEF>50%). Right ventricular chamber size and free wall motion are normal. The aortic is dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral leaflets are grossly normal without definite mitral regurgitation. There is an anterior space which most likely represents a prominent fat pad. . Compared with the prior study (images reviewed) of [**2182-11-11**], the overall findings are similar. If the clinical suspicion for a paradoxical embolism is high, a TEE with saline contrast is suggested. Brief Hospital Course: 63M with h/o CAD s/p CABG who presented with acute severe nectoriting pancreatitis. Hospital course by problem: . ACUTE PANCREATITIS, NECROTIC Mr. [**Known lastname 19816**] was admitted with pancreatitis thought to be due to gallstones (CBD stone measuring 5.5mm was identified on imaging). His transaminases trended down quickly, and it was felt that he had spontaneously passed the stone. He was kept NPO and given IVF as well as insulin drip. Abdominal CT was ordered on [**2182-11-18**] for persistent fevers; he was found to have a necrotic pancreas with no drainable fluid collection. He was maintained on meropenem for possible infected necrotic pancreas and completed a full two week course for that. . ARDS, ICU COURSE His course was complicated by SIRS and ARDS. He was intubated for hypoxia, had initial bradycardia and hypotension. He was volume resuscitated and did require pressors which were slowly weaned. His abdomen was distended and very firm, and he had elevated bladder pressures, concerning for abdominal compartment syndrome. Surgery was consulted and followed closely. Fortunately, his bladder pressures improved, along with his abdominal distention, and he did not require surgery on the abdomen. There was difficulty in extubating Mr. [**Known lastname 19816**] largely due to inability to decrease sedation (he would become tachypneic, tachycardic and hypertensive as his propofol was weaned). Trach was placed on [**2182-11-27**] without complication. . PERSISTENT FEVERS Throughout the admission, he was persistently febrile up to 102. He was initially started empirically started on vancomycin/meropenem on [**2182-11-10**] and completed a two week course. All urine and blood cultures were negative, including mycotic blood cultures; sputum culture . There was no evidence of line infection (several lines were resited w/o improvement in fevers; catheter tips were cultured after removal and were negative. Drug fever was considered though he never developed a rash and blood and urine eosinophil count was normal. Within two days of the vanco/[**Last Name (un) 2830**] being stopped, he had recurrent fevers. Vanco/zosyn/ciprofloxicin were started on [**2182-11-27**] for worsening thick secretions concerning for HAP/VAP. Multiple sputum cultures were negative and there was little radiographic change suggestive of infiltrates, yet he continued to spike fevers. There was evidence of opacified sinues on head CT from [**2182-11-30**] (ordered for MS). NG tube was pulled and he was given Afrin and saline irrigation. No new antibiotics were started as the course of prior antibiotics was thought to be sufficient to cover a bacterial sinusitis. There was little concern of fungal sinusitis. He defervesced with removal of the NG tube and remained afebrile over 48 hours after antibiotics were discontinued. Dobhoff tube was placed on [**2182-12-3**] and he remained afebrile overnight after placement. . MENTAL STATUS, STROKE After tracheostomy was performed and extubation, Mr. [**Known lastname **] [**Last Name (Titles) 78453**]g medications stopped. However, he was noted to have a delay in recovery of his mental status. When he did begin to recover some degree of interaction, it was noted to be largely limited to the right side. Asa result, a CT head was performed, which showed multiple right-sided infarctions of differing chronicities. As he had presented on aspirin, these strokes were felt to be an aspirin failure, so he was switched to clopidogrel. Carotid ultrasounds and a bubble echocardiogram were performed. TTE showed no PFO or clots. The official read on the carotid ultrasound was pending at the time of discharge. Risk factor modification was attempted; a HbA1c was at goal at 5.7%, and fasting lipids were near target goals. He will need extensive PT/OT at rehab to begin work on regaining pre-stroke functionality. . ILEUS He was initially maintained on versed/fentanyl for sedation while on the ventillator; in addition, there was concern that the pancreatitis was causing prolonged ileus. There was no evidence of obstruction on abdominal imaging. Sedation was changed to propofol, and he was started on PO narcan and Reglan with improvement in bowel movements. He was on TPN for the prolonged ilues, but eventually bowel sounds returned and he was begun on enteral feedings with no residuals or aspirations. . NUTRITION He was initially maintained on TPN. With resolution of the ileus and several weeks of NPO for the pancraetitis, he was started on tube feeds with no complication. He currently has a Dobhoff tube that was placed on [**2182-12-3**] (he had had an NG tube prior ot this). The option of a PEG tube was discussed with surgery, though that was deferred for now given the necrotic pancreatitis and concern for seeding the tissue via the procedure. . DIABETES Due to his pancreatitis, Mr. [**Known lastname 19816**] required insulin therapy. He was discharged on NPH 50 units [**Hospital1 **] with sliding scale insulin Q6 hours according to fingersticks. His regimen may need to be updated pending any change in nutritional regimen. . HYPERNATREMIA Mr. [**Known lastname 19816**] has had periodic hypernatremia in the setting of diuresis. Free water flushes via the NG/Dobhoff have been adjusted to improve the sodium. . ELEVATED LFT's Thought to be due to a medication effect. They have been steadily trending down since discontinuation of the antibiotics (vanco/zosyn/cipro). . CODE STATUS Confirmed full code . . . PENDING ISSUES FOR FOLLOW-UP: (1) Volume balance Mr. [**Known lastname 19816**] was aggressively volume resuscitated at the beginning of his admission due to shock in the setting of pancreatitis. Once he stabilized, he was steadily diuresed with lasix drip and then boluses. By the time of discharge, he was approximately 7-8 liters positive for the length of stay. He was discharged on lasix 40 mg IV BID to work towards removing this fluid. This will need to be adjusted as his volume balance normalizes. Renal function should befollowed closely druring diuresis (BUN 49, Cr 1.2 on discharge). (2) Hypernatremia In the setting of diuresis, he developed intermittent hypernatremia. Free water flushes should be adjusted accordingly to sodium until levels stabilize. (3) Carotid Ultrasound A carotid ultrasound was performed on [**2182-12-2**] as part of a stroke work-up. The read was still pending at the time of discharge and should be follow-up. (4) Possible Need for PEG Mr. [**Known lastname 19816**] currently has a Dobhoff tube for feeding. PEG tube placement was deferred for now given his necrotic pancreatitis and concern for doing a percutaneous procedure in this setting. The issue should be reviited in the future as his pancreatitis continues to resolve, if he remains unable to take PO's. (5) Elevated LFT's, Cholesterol Medications Likely elevated from antibiotic/medication effect; have been trending down on discharge, but should be followed periodically. He was on niacin and atorvastatin on admission, though these were held in the setting of the elevated LFT's. They may be restarted once LFT's normalize. (6) Stroke [**Name (NI) **], PT Mr. [**Known lastname 78454**] mental status continues to improve; at discharge, he was responding to questions attempting to speak, moving his head and right arm'leg, and able to sit up in a chair. (7) Has a history of BPH Tamsulosin 0.4 mg and finasteride 5 mg were held on admission. These should be restarted if the foley is discontinued. Medications on Admission: Medications at home: Aspirin 81 mg PO DAILY Atorvastatin 40 mg PO DAILY Niacin 1000 mg Sustained Release PO DAILY Metoprolol Tartrate 50 mg Tablet PO BID lisinopril 5 mg daily Finasteride 5 mg PO DAILY Tamsulosin 0.4 mg PO HS Bupropion SR 300 mg PO DAILY Tiotropium Bromide 18 mcg Inhalation DAILY MTV glucosamine chondroitin . Medications on transfer: Heparin gtt Propofol Fentanyl Versed Levofloxacin 750mg IV Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: severe necrotizing pancreatitis Discharge Condition: improved, hemodynamically stable, weaned down to trach collar, tolerating enteral feeding. Discharge Instructions: You were admitted to the hospital with severe gallstone pancreatitis. The pancreatitis was so severe that it caused multiple organ systems in your body to fail, including your liver, kidneys, and bowels. you also had a stroke as a result of your severe illness. You required ICU level care for your hospitalization. We had difficulty weaning you off of the ventilator, so you received a tracheostomy for help with your breathing during recovery. Your kidneys and bowels continue to recover every day. You will be going to a [**Hospital 65799**] rehab facility where you will continue to work on your recovery. . Please take all medications as prescribed. Return to the hospital for further evaluation should you experience fevers > 101, vomiting that causes any choking, worsening ability to move any part of your body, or for other concerns you may have. Followup Instructions: You will be monitored closely in your rehab. You will need to follow up with our division of neurology, gastroenterology (post-pancreatitis), and interventional pulmonology (for tracheostomy evaluation and eventual removal). Completed by:[**2182-12-7**]

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Discharge summary

report

Admission Date: [**2175-7-4**] Discharge Date: [**2175-7-25**] Date of Birth: [**2118-2-26**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1384**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**2175-7-5**]: portocaval shunt History of Present Illness: 57M with HCV and EtOH cirrhosis with a MELD of 18 on admission who was transferred to [**Hospital1 18**] MICU from [**Hospital 8**] Hospital [**7-4**] after presenting [**7-3**] with coffee groind emesis x2 days. The pt had fallen yesterday after an episode of bright red blood per rectum and presented to [**Hospital 8**] hospital where he again vomitted 500cc of bright red blood. He was seen by GI at the OSH and was found to have a hematocrit of 25 with an unknown baseline. Of note, the patient has had 3 episodes of B hematemesis in the past 3 years with one admission requiring up to 7 unites of blood. Adiitionally he had has laser therapy to esophageal varices in the past. He was given Octrotide and pantoprazole at [**Hospital1 8**] and transferred to [**Hospital1 18**]. Upon arrival to [**Hospital1 18**] he was hypotensive with a systolic in the 70s and was transferred to the MICU. In the MICU the patient had 500mL of hematemesis and several episodes of bleeding per rectum. He was resuscitated with fluid and blood products and underwent an EGD which revealed: Esophageal varices Blood in the fundus; Varices at the fundus- Injected with mix of ethadiol and dermabond glue; and referred yesterday TIPS procedure which was attempted but unfortunately unsuccessful due to hepatic fibrosis. In all the patient has received 23Units of Packed red blood cells; 18FFP; 3 platlet; 4 cryo. The patient's lowest HCT was 17.6 at 5pm yesterday evening. Surgery is consulted for the possibility of an emergent portosystemic shunt. The information obtained in this note is from a combination of medical records and team interviews as the patient is unable to provide history at this point due to intubation. Past Medical History: Hep C; EtOH cirrhosis; Manic depression; Chronic anemia, Low back pain Social History: Reportedly last drink was three years ago, h/o tobacco use but none since three years ago. Has four children that live with him in [**Location (un) 2251**]. Their mother is deceased. [**Name (NI) **] sister reported that this was from HCV. The 2 oldest are son's and the 2 daughter's are staying with maternal grandparents in N.Y. while he is hospitalized. Dtr's usually go there for the summer. Patient reports that his 87 y.o. mother lives on [**Location (un) **] with his step father, but they do note speak. He only contacts her in emergencies or when absolutely necessary. Patient's 2 sisters [**Name2 (NI) 88679**] lives in same apartment bldg and [**Doctor First Name **])report that patient has turned his life around and has been doing well up until this hospitalization. He stays home most of the time and had been exercising. Patient reported that he had been seeing a nutritionist and had been taking vitamins (vit b) and ginseng. He does not have a phone. Offered son, [**Name (NI) **] as 1st phone # to call [**Telephone/Fax (1) 88680**]. Mother [**Telephone/Fax (1) 88681**] if unable to contact [**Name (NI) **]. Sister [**Name (NI) **] offered her # [**Telephone/Fax (1) 88682**], Family History: Mother 87 alive Physical Exam: 98.6 84 109/57 14 95% AC 60% 550 x 14 peep 5 (7.39/49/135/29/4) Intubated and sedated with [**Last Name (un) 10045**] tube in place Pupils equal and round, sclera anicteric RRR no m/r/g CTAB Gastric port inflated on [**Last Name (un) 10045**] soft, obese, non distended no fluid waves (no ascites) No c/c/e, WWP rectal tube in place draining old blood Pertinent Results: [**2175-7-6**] 09:14AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HBc-NEGATIVE [**2175-7-5**] 03:07AM BLOOD AFP-2.6 [**2175-7-6**] 09:14AM BLOOD CEA-4.5* PSA-0.5 AFP-2.6 [**2175-7-7**] 10:14AM BLOOD CEA-5.0* [**2175-7-7**] 10:14AM BLOOD HIV Ab-NEGATIVE Labs on discharge: [**2175-7-25**] 05:40AM BLOOD WBC-5.8 RBC-2.99* Hgb-10.0* Hct-30.9* MCV-103* MCH-33.5* MCHC-32.5 RDW-20.4* Plt Ct-125* [**2175-7-25**] 05:40AM BLOOD PT-17.5* PTT-51.1* INR(PT)-1.6* [**2175-7-25**] 05:40AM BLOOD Glucose-150* UreaN-17 Creat-1.0 Na-134 K-4.4 Cl-105 HCO3-23 AnGap-10 [**2175-7-25**] 05:40AM BLOOD Glucose-150* UreaN-17 Creat-1.0 Na-134 K-4.4 Cl-105 HCO3-23 AnGap-10 [**2175-7-25**] 05:40AM BLOOD ALT-70* AST-145* AlkPhos-143* TotBili-1.4 [**2175-7-25**] 05:40AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.3 Mg-1.6 [**2175-7-12**] 02:53AM BLOOD TSH-3.9 [**2175-7-12**] 02:53AM BLOOD Free T4-0.77* Brief Hospital Course: Mr. [**Known lastname 88683**] was admitted to [**Hospital1 18**] on [**2175-7-4**] with massive GI bleed. He required 24 units of red blood cells in the first 24 hours of his admission. He was intubated for declining mental status and airway protection. He underwent EGD on admission which demonstrated esophageal varices, but no clear bleeding source. A TIPS procedure was attempted on [**2175-7-4**] and again on [**2175-7-5**], but was unsuccessful. [**Last Name (un) **] tube was placed and an emergent surgery consult was obtained. He was taken to the OR for emergent portosystemic shunt, which he underwent on [**2175-7-5**]. Postoperatively he stabilized from a hemodynamic standpoint and the GI bleeding ceased. His respiratory status remained quite tenuous, however, and he required maximum venilatory support in the initial postoperative period. A summary of his hospital course by systems is provided below: Neuro: Sedation / pain control was achieved with versed and fentanyl. In the first 24 hours postop he was paralyzed with cisatricurium to assist with ventilation, and ultimately the paralysis was discontinued as the vent was weaned. Once extubated he was confused and agitated. He was started on lactulose / [**Date Range 8005**] (started [**7-15**]) and zyprexa. Mental status continued to improved with patient alert, oriented and cooperative. Zyprexa was weaned the last 2 days of hospital stay. CV: Required pressors (levophed, transitioned to neosynephrine) intermittently in the perioperative period; pressor requirement weaned. TTE done [**7-11**] demonstrated hyperdynamic myocardium and evidence of intravascular volume depletion; fluids replaced with crystalloid and albumin. Troponins cycled and negative x3. Ultimately weaned of neosynephrine, hemodynamically stable. TTE repeated [**7-24**] for transplant eval protocol. This demonstrated EF >75%, mild symmetric LVH with small LV cavity size and near-hyperdynamic systolic function. Consequently, a mild LVOT gradient develops during systole. No significant valvular abnormality seen. Resp: Volume control ventilation initially with 100% FiO2. CVVHD started postoperatively with net negative fluid balance; vent weaned as tolerated while diuresis continued. Extubated on [**7-17**]. GI: Ultrasound following portosystemic shunt demonstrated patency of shunt; no ongoing bleeding. LFTs stabilized. Initially kept NPO. On [**7-8**] an EGD was performed with placement of a nasojejunal Dobhoff tube. Tube feeds were initiated and increased incrementally to goal. Nutren 2.0 with beneprotein. Insulin sliding scale was used with tube feed administration. Passed speech and swallow evaluation after extubation, continued tube feeds via Dobhoff with ad lib eating regular diet as tolerated. Feeding tube was removed on [**7-25**] as patient was refusing feeding tube. He was eating. On [**7-25**], a repeat abdominal US was done showing patent shunt. Home nadolol was not resumed. GU: UOP augmented with CVVHD perioperatively from [**Date range (1) 85094**], creatinine stablilized in low 1's, increasing moderately as total body volume decreases. JP drain output was non-bilious and was initially serosanguinous. This became ascitic fluid with high outputs averaging 2.5-1.5 liters per day. The JP remained in place until [**7-24**] when it was removed and site sutured. This site remained dry. Abdominal incision was intact with staples which were removed on [**7-25**]. Staple line was a red at staple insertion sites. No drainage was noted. There were no further bleeding episodes after surgery. Hct was stable in 32-30 range. Of note, abdominal CT on [**7-5**] demonstrated the following: a focus of high density adjacent to segment VI of the liver, which may represent blood clot. In segment [**Doctor First Name 690**] of the liver, there is a 4.3 x 2.5 cm ill-defined heterogeneous mass with areas of arterial enhancement and washout. An MRI was scheduled for [**7-24**], but the patient was unable to undergo this due to severe claustrophobia. He stated that he would need to have anesthesia to be able to complete the study. MRI to characterize the liver lesion was to be scheduled in followup as an outpatient in conjunction with anesthesia. ID: Prophylactic coverage with vancomycin, zosyn and fluconazole postoperatively. Meropenem was added. Multiple negative blood and urine cultures, normal WBC; antibiotics scaled back to ciprofloxacin for SBP prophylaxis. Physical therapy cleared him for ambulation and stairs and declared him safe for home. He was set up with the VNA for nursing. Social Work was consulted for eval. Full work up for transplant eval was to be completed as an outpatient. His 2 sisters and son were present at time of discharge. Sister [**Doctor First Name **] offered her # as a contact if needed, [**Telephone/Fax (1) 88682**]. Follow up with surgery was scheduled for [**8-3**] and hepatology (Dr. [**Last Name (STitle) **] on [**8-1**]. MRI of liver was to be arranged as an outpatient. Patient and family were informed. Of note, the patient did not have a phone and requested that his son, [**Name (NI) **] be contact[**Name (NI) **] at [**Telephone/Fax (1) 88680**]. His 87 y.o. mother was 2nd contact [**Telephone/Fax (1) 88681**]. Medications on Admission: nadolol (dose unknown), lactulose prn Discharge Medications: 1. [**Telephone/Fax (1) 8005**] 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three times a day as needed for hepatic encephalopathy. Disp:*1000 ML(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 5. Other [**Company 4916**], [**Street Address(1) 88684**], [**Location (un) 3786**] [**Telephone/Fax (1) 88685**] contact[**Name (NI) **] regarding [**Name (NI) **] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: GI bleeding ETOH/HCV cirrhosis malnutrition Liver Mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you have any fever (101 or greater), chills, nausea, vomiting, bloody vomiting, bloody or black bowel movements, abdominal pain, abdomen appears larger, confusion No heavy lifting/straining Drink 3 Ensures per day plus food. 4 if you are not eating Followup Instructions: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD (Hepatologist)Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2175-8-1**] 4:00 [**Last Name (NamePattern1) 439**],[**Location (un) 86**]. [**Hospital **] Medical Office Building, [**Location (un) 858**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Surgeon)Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-8-3**] 2:00 [**Last Name (NamePattern1) 439**], [**Location (un) 86**]. [**Hospital **] Medical Office Building, [**Location (un) **] An MRI of your liver with general anesthesia will be arranged. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator ([**Telephone/Fax (1) 88686**] contact you will appointment You will also need to have a social work appointment scheduled for transplant evaluation work up Please schedule an appointment with your PCP [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) 29079**] at [**Hospital6 12736**] in [**Location (un) 3786**] Completed by:[**2175-7-26**]

[ "280.0", "456.8", "303.90", "578.0", "276.69", "518.81", "578.9", "263.9", "276.7", "456.21", "276.1", "285.1", "571.2", "572.3", "584.5", "070.70", "573.9", "458.9" ]

icd9cm

[ [ [] ] ]

[ "39.1", "33.29", "96.04", "96.72", "38.93", "96.6", "45.13", "33.24", "39.95", "38.87", "39.79", "88.47" ]

icd9pcs

[ [ [] ] ]

10860, 10918

4744, 10029

311, 345

11017, 11017

3826, 4092

11561, 12646

3422, 3439

10117, 10837

10939, 10996

10055, 10094

11168, 11538

3454, 3807

263, 273

4112, 4721

373, 2091

11032, 11144

2113, 2186

2202, 3406

25,326

102,006

5290+55659

Discharge summary

report+addendum

Admission Date: [**2116-4-19**] Discharge Date: [**2116-4-21**] Date of Birth: [**2058-5-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: thrombosed AVG Major Surgical or Invasive Procedure: Thrombectomy of AV graft with jump graft revision, [**2116-4-19**] History of Present Illness: The patient is a 57y.o. man with ESRD seconddary to hypertensive nephropathy on hemodialysis who presented on [**4-19**] after his LUE AVG was not funtioning during HD on [**4-17**] secondary to thrombosis of the graft. He was admitted for thrombectomy. Past Medical History: - Seizure disorder, onset of seizures in mid [**2097**] after starting dialysis. He seems to have seizures quite frequently at dialysis, per neurology this seems to be attributed to both non-compliance with the medications, as well as taking his medications later on those days. - End stage renal disease on hemodialysis due to hypertensive nephropathy - Non-ischemic cardiomyopathy, EF 25-30% per echo in [**10/2114**] - AV fistula, status post thrombectomy [**7-/2114**] - Hungry bone syndrome status post parathyroidectomy - Hepatitis B - Pituitary mass -LUE AVG thrombectomy [**2115-12-11**] Social History: Pt reports he lives alone in an apartment in the [**Location (un) 4398**]. Notes say he is living with a friend in [**Name (NI) 3494**] currently. He denies any alcohol. No tobacco use. Occasion alcohol use as per patient. No IV drug use that he admits. Reports director of music at local church and states sole source of income. Concerned illness will lead to loss of livelihood. Family History: Mother died at age of 41 of renal failure. Father is 85 and has diabetes. He does have a son who is healthy. Physical Exam: On Admission: VS: 98.7 74 144/77 18 98%RA General: A&Ox3, NAD Heart:RRR Lungs:CTA B Abd:soft, N-T, N-D Extr:LUE graft: no thrill, no audible bruit Pertinent Results: [**2116-4-19**] 02:41PM K+-6.3* [**2116-4-19**] 07:50PM CK-MB-7 cTropnT-0.08* [**2116-4-19**] 07:50PM CK(CPK)-323* [**2116-4-19**] 07:50PM POTASSIUM-7.4* [**2116-4-19**] 11:23PM K+-6.6* [**2116-4-20**] 06:44AM BLOOD WBC-5.8 RBC-3.41*# Hgb-9.5*# Hct-29.3*# MCV-86 MCH-27.9 MCHC-32.5 RDW-17.2* Plt Ct-277 [**2116-4-20**] 09:00AM BLOOD PT-13.1 PTT-30.1 INR(PT)-1.1 [**2116-4-20**] 06:44AM BLOOD Glucose-58* UreaN-77* Creat-12.1*# Na-144 K-3.7 Cl-102 HCO3-21* AnGap-25* [**2116-4-20**] 06:44AM BLOOD CK(CPK)-227* [**2116-4-19**] 07:50PM BLOOD CK(CPK)-323* [**2116-4-20**] 06:44AM BLOOD CK-MB-6 cTropnT-0.09* [**2116-4-19**] 07:50PM BLOOD CK-MB-7 cTropnT-0.08* Brief Hospital Course: The patient was admitted to the transplant service on [**4-19**] and was taken to the OR for thrombectomy of AV graft with jump graft revision. He tolerated the procedure well. Following the procedure he had an elevated K+ of 7.4 for which he was treated with insulin, glucose, calcium and kayexalate. He received HD in the AM of POD#1. His K+ following HD was 3.7. He was noted to have a junctional rhythm on EKG but no sing of ischemia. He was transferred to the floor and transitioned to regular low sodium diet and pain was controlled with PO medication. He was discharged home in good condition on POD#1. Medications on Admission: 1.Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2.Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4.Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5.Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 6.Docusate Sodium 50 mg Capsule Sig: One (1) Capsule PO once a day. 7.Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8.Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO post hemodialysis. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO after dialysis. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Discharge Disposition: Home Discharge Diagnosis: Thrombosed AVG ESRD secondary to hytpertensive nephropathy Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Continue your regular home medications and take new medications as directed. Call your physician [**Name Initial (PRE) **]: -fever, abdominal pain, nausea or vomiting -increasing redness, swelling, pain or drainage at the incision Followup Instructions: [**Hospital **] Care Center [**4-21**] at 9am for catheter placement Continue dialysis as scheduled. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **] Date/Time:[**2116-5-12**] 8:30 Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2116-6-3**] 4:30 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-5-7**] 9:00 Name: [**Known lastname 3418**],[**Known firstname 3419**] Unit No: [**Numeric Identifier 3420**] Admission Date: [**2116-4-19**] Discharge Date: [**2116-4-21**] Date of Birth: [**2058-5-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2648**] Addendum: The patient was kept over night [**Date range (1) 3599**] for a fever of 101. He was administered 1 dose vancomycin. He defervesced and remained afebrile through the day [**4-21**] and was discharged home that evening. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**] Completed by:[**2116-4-22**]

[ "V12.09", "V18.0", "V12.54", "780.6", "345.90", "996.73", "585.6", "403.91", "998.89", "276.7" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.42" ]

icd9pcs

[ [ [] ] ]

6320, 6483

2702, 3316

329, 398

4794, 4801

2012, 2679

5180, 6297

1716, 1826

4005, 4662

4712, 4773

3342, 3982

4825, 5157

1841, 1841

275, 291

426, 681

1855, 1993

703, 1301

1317, 1700

4,113

103,203

4938

Discharge summary

report

Admission Date: [**2149-10-7**] Discharge Date: [**2149-10-20**] Date of Birth: [**2103-6-23**] Sex: F Service: MEDICINE Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance / Adhesive Tape Attending:[**Doctor First Name 3290**] Chief Complaint: productive cough Major Surgical or Invasive Procedure: ORTHOPEDIC: 1. Removal implant deep left fibula. 2. Open biopsy bone deep left medial malleolus CARDAIC: Cardiac Catherization ([**10-17**]) History of Present Illness: Per report patient was in USOH when began experiencing cough productive of clear sputum with nausea worse than baseline. (She felt sx were related to left ankle infection; as it was not chararacteristic of CHF excerbation which includes PND, orthopnea) Called EMS and admitted to [**Hospital1 34**]. On initial presentation febrile to 100.1 BP: 80/50, tachycardiac, leukocytosis to 10.7. Initial CXR: flash pulmonary edema vs PNA. She was admitted to ICU, initially requiring 100% Fio2, started on stress dose steriods, IV vanc and levofloxacin 750mg QD and diuresis with IV lasix 20mg. Notable OSH labs: influenza A and B: neg, urine legionella neg, urine strep pneum antigen neg. Urine cx neg. Blood cx positive 2/4 bottles for gram + cocci in clusters (coag neg staph) - deemed contaminant by ID (levofloxacin stop date per notes [**10-8**]). Creatinine at time of transfer: 2.0 (1.4 admission -> 2.0; per renal recs at OSH stop Lasix). Vancomycin had been stopped and patient continued on Levofloxacin (750mg IV q48hrs) for atypical PNA vs brochitis Per report initially hyperglycemic neccisitating insulin gtt on night of admission b/c of mild DKA which resolved and pt transitioned to SQ inusulin. Prior to transfer transitioned to home regime. At time of transfer she was saturating well on 3L NC, BG controlled. . Of note, patient with history of left ankle fracture in [**2148-10-1**] status post ORIF, c/b complicated by failure of healing of the medial malleolar wound and medial malleolar hardware-associated osteomyelitis with coag-negative staph. Drs. [**Name5 (PTitle) **] ([**Name5 (PTitle) 1957**]), [**Doctor Last Name **] (ID), and [**Last Name (un) 3407**] (vascular) have been following. She is s/p wash out and 2 courses of prolonged IV vanco (6weeks) currently on doxycycline suppression therapy (100mg PO BID). In the last 1-2 weeks (while on doxy), her infection has returned with increased drainage and tenderness of medial malleolar wound as well as rising inflammatory markers (CRP: 3 ->100). Per [**Last Name (un) **] plan is to return to the OR with Dr. [**Last Name (STitle) **] for a repeat wash out in effort to treat this infection. After she no longer has an infectious source and she is no longer as deconditioned, then she may be considered for MVR to prevent her recurrent CHF. . On arrival, initial vital signs were 98.8 118/57 87 18 3L NC. Overall patient in no distress. Reports persistent wet cough but denies SOB, PND, orthopnea, peripheral edema. Complains of left ankle pain as well as pain in right hip (at baseline). Reports abdominal pain, blaoting and minimal nausea (again baseline sx). Denies any fevers, chills, weight loss or gain. Denies chest pain, palp. Denies diarrhea, constipation, dysuria. Past Medical History: PAST MEDICAL HISTORY: # CAD and MI, s/p CABG: - LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal occluded # Diastolic Heart Failure # Peripheral vascular disease c/b chronic heel ulcers # Hypertension # Diabetes Mellitus-type I c/b retinopathy (legally blind) and neuropathy, gastroparesis # osteoporosis # Sarcoid, reported lung nodule # depression # s/p right tibial fracture # s/p right leg fracture (cast), [**2147**] # s/p left wrist fracture, [**2147**] # s/p fall and intracranial bleed, [**2147**] # Blood group specific substance. Blood products (red cells and platelets) should be leukoreduced. Past Surgical History . Cardiovascular: # CABG [**5-1**]- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal occluded # s/p right femoropopliteal bypass and left SFA drug-eluting [**Last Name (LF) **], [**2147-5-2**] RENAL: # s/p living-related kidney transplant [**2140-10-31**] (baseline Cr 1.2-1.3 over the last year) [**Year (4 digits) **]: # s/p Open Reduction Internal Fixation of Left Bimalleolar Fracture ([**2148-10-15**]) # s/p left patella open reduction and fixation, [**2147**]. Hardware removed [**2148-10-15**] # s/p left ankle washout and hardware removal ([**3-/2149**]) GI: # s/p cholecystectomy Social History: Patient lives with her mother who is her primary care giver. Ambulates with assistance -Tobacco history: smokes half a [**4-3**] cig/day -ETOH: none -Illicit drugs: smokes marijuana several times per week to help with nausea and appetite Family History: There is no history of diabetes or kidney disease. Her father had an MI at 74 and mother has hypertension. Grandfather had leukemia and hypertension. Physical Exam: Vitals: 97.9 151/69 (primarily: 120-130s/50-80s) 69 (70s) 99% RA FS: 91, 108, 118, 126 General: Chronically-ill appearing, sitting upright in bed, NAD. HEENT: Legally blind. Scleral anicetric. Moist mucous membranes. OP without exudates or lesions Neck: supple, no LAD Heart: RRR, II/VI systolic ejection murmur best heard at LSB, no appreciable carotid bruit, no peripheral edema Lungs: CTA-B, no wheezes, no crackles, good aeration b/l, no accessory muscle use Abdomen: soft, NT, ND +BS, no guarding Extremities: warm, well perfused, no clubbing, cyanosis. #Left ankle: medial and lateral ankle with gauze: dressing with serosangious drainage; non-tender, FROM, # Right toe: quarter size eschar on tip of toe with mild erythema, non-tender, no drainage. Neuro: Alert and oriented x3; moving all extremities with no focal deficits, decreased sensation on b /l LE. T/L/D - PICC line: R arm: dressing c/d/i, no surrounding tenderness or erythemia Pertinent Results: OSH labs and imaging: Trop negx3. [**10-6**] BMP: 134/4.698/17/31/1.4 . Imaging: CXR ([**10-5**]) OSH Minimal interstitial edema compatible with mild CHF, no focal alveolar opacity or pleural effusion . [**Hospital1 18**] labs: Trop neg CRP: 15.3 ESR: 57 . CBC at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 4.7 3.17* 9.5* 28.7* 91 29.9 33.1 14.5 467* BMP at discharge: Glucose UreaN Creat Na K Cl HCO3 AnGap 152 23* 1.9* 134 4.2 98 27 13 . IMAGING: . RENAL US ([**10-8**]) RENAL TRANSPLANT ULTRASOUND: The right lower quadrant renal transplant is identified. There is no hydronephrosis or perinephric fluid. The urinary bladder is decompressed around a Foley catheter, and therefore not well visualized. DOPPLER EXAMINATION: The main renal artery and vein are patent with appropriate waveforms. Resistive indices of the upper, mid, and lower pole of the transplant kidney are 0.64, 0.71 and 0.60 respectively. Arterial waveforms are appropriate, with sharp systolic upstrokes and preserved flow through diastole. IMPRESSION: 1. Normal renal transplant ultrasound. 2. Normal renal transplant Doppler examination . TTE ([**10-10**]) The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with inferolateral hypokinesis. The remaining segments contract normally (LVEF = 45%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No vegetations seen (adequate-quality study). Mild regional left ventricular systolic dysfunction, c/w CAD. Normal global and regional biventricular systolic function. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. . CXR ([**10-16**]) FINDINGS: Interval removal of endotracheal and nasogastric tube. Right PICC position stable with tip in the mid SVC. No pneumothorax. Sternotomy sutures are midline and intact. Improved aeration of the left retrocardiac space. The three faint rounded opacities first demonstrated in the left lung on [**2149-10-9**] chest x-ray are less conspicuous than prior. The cardiac silhouette is top normal. The mediastinal and hilar contours are unremarkable. IMPRESSION: Improved aeration of retrocardiac space. Less conspicuous rounded opacities in left lung, recommend continued radiographic followup. . Cardiac Cath ([**10-17**]) **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 8- 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 DISCRETE 90 11) INTERMEDIUS NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL 16) OBTUSE MARGINAL-3 NORMAL 17) LEFT PDA NORMAL 17A) POSTERIOR LV NORMAL **ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS LOCATION **BYPASS GRAFT 28) SVBG #1 NORMAL 29) SVBG #2 NORMAL 30) SVBG #3 NORMAL 31) SVBG #4 NORMAL 32) LIMA NORMAL 33) RIMA NORMAL . COMMENTS: 1. Coronary angiography in this right dominant system revealed diffuse multivessel multivessel disease. The LMCA had no angiographically significant disease. The LAD had an 80% proximal stenosis. The large D1 had no angiographically apparent disease. The small D2 had 90% stenosis, as in prior angiographic images. The prior PTCA site in the Cx was patent with normal flow. THe RCA was known to be occluded. The SVG-RCA was patent. THE LIMA-LAD was patent. 2. Resting hemodynamics revealed normal right-sided filling pressures and pulmonary capillary wedge pressures. The cariac index was preserved. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with patent SVG to PDA, LIMA to LAD and patent PTCA site to the LCx. 2. Normal right-sided filling pressures. . MICRO: [**2149-10-9**] 10:55 pm URINE Source: Catheter. **FINAL REPORT [**2149-10-11**]** URINE CULTURE (Final [**2149-10-11**]): NO GROWTH. . [**2149-10-14**] 11:30 am TISSUE Site: ANKLE LT LATERAL ANKLE. GRAM STAIN (Final [**2149-10-14**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2149-10-17**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2149-10-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]): NO FUNGAL ELEMENTS SEEN. [**2149-10-14**] 11:30 am TISSUE Site: ANKLE MEDIAL LEFT ANKLE TISSUE. GRAM STAIN (Final [**2149-10-14**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2149-10-17**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2149-10-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]): NO FUNGAL ELEMENTS SEEN. . Blood Cx ([**10-8**], [**10-9**]): NGTD Brief Hospital Course: Ms [**Known lastname 19419**] is a 46yo female with h/o poorly controlled diabetes type 1, CAD, MI status post CABG and PCI, end-stage renal disease status post living-related renal transplant in [**2140-10-31**] on tacrolimus and prednisone immunosuppression, transferred from OSH for continued treatment of URI/atypical PNA and CHF exacerbation; hospital course c/b aspiration event requiring intubation, transferred back to the floor for continued mgmt of CHF, chronic osteo of L. ankle and coronary artery disease. . # CHF. Patient with multiple prior admissions to [**Hospital1 **] and OSH with CHF exacerbations. On this admission to it was thought that possible URI/atypical PNA/bronchitis triggered mild CHF exacerbation. Initial presentation at OSH notable for low-grade fever, leukocytosis to 10.6. CXRs from OSH consistent with pulmonary edema: interstitial edema and Kerley B lines, no focal consolidations noted. On admission to [**Hospital1 **] patient afebrile with normal WBC. She was diuresised with improvement in respiratory symptoms. Finished 7day course of levofloxacin for coverage of atypical PNA. Initially, patients underlying CAD causing ischemia in setting of hypertension thought to account for tendency to flash. However, patient was taken for cardiac catherization on [**10-17**] which was clean. Question if recurrent flashes simply resulted from med and diet noncompliance. At time of discharge patient hemodynamically stable, without need for supplemental oxygen. Lasix dose at time of discharge 80mg PO daily with blood pressures and fluid status well controlled. . # Episode of respiratory failure thought to be secondary to an aspiration event. Patient was found cyanotic on floor with evidence of recent emesis. A code blue was called, patient intubated and transferred to ICU. Of note patient was never pulseless. The patient was able to be extubated after one day in the unit. She rapidly improved and was able to tolerate nasal cannula oxygen without difficulty. A speech and swallow eval was done and she passed without difficulty. She was restarted on her home meds, full diet and transferred back the floor with no further aspiration events. . # Wall motion abnormality. After the episode of respiratory distress requiring intubation TTE was ordered to assess for any cardiac cause. TTE demonstrated a new inferior wall motion abnormality when compared to most recent echo in [**Month (only) 958**]. Trops cycled and neg. Initially, no further cards work-up was performed prior to orthopedic wash-out of left ankle. Cardiac cath performed later in hospitalization was clean. . # Medial malleolus osteomyelitis - On admission oral suppressant regimen of doxycyline stopped per ID request to optimize yield of bone biopsy. Due to increasing concern over recurrent infection, evident by increased inflammatory markers, patient started on IV vancomycin. She was taken to OR on [**10-14**] for Left ankle wash-out. Tissue and bone biopsies were obtained during the procedure: no growth to date. Patient to follow-up with ID and [**Month/Year (2) **] as outpatient. Plan to continue likely 6wk course of IV antibiotics. Will follow-up in [**Month/Year (2) **] clinic in 2-3wk for suture removal. At time of discharge, medial and lateral incision sites clean, dry, intact with no surrounding erythema or stigmata of infection. Patient discharged on vancomycin 750mg IV QD. Regarding pain patient discharged on outpatient percocet regimen as well as lidocaine patch and small supple (30tablets) of dilaudid 2mg PO for breakthru pain in the post-operative period. . # Diabetes Mellitus with gastroparesis - Blood sugars difficult to control in house. Initial hyperglycemia likely aggravated by stress dose steriods that were received at outpatient hospital and again in our ICU, Insulin was dosed as [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. At time of discharge lantus 10u [**Hospital1 **], ISS. Metoclopramide and Zofran used to control nausea secondary to gastroparesis while hospitalized. . # ESRD s/p post living-related renal transplant in [**2140-10-31**] on tacrolimus and prednisone immunosuppression. Baseline creatinine in recent months: 1.2 - 1.8. [**10-7**] OSH labs: creatinine 2.0. Concern for acute on chronic kidney failure as admission creatinine elevated slightly above base at 2.2. Renal ultrasound ordered to assess transplant kidney; dopplers were normal with no sign of rejection. Tacrolimus levels were monitored daily and at time of discharge patient on 2.5mg PO BID with plan to follow level with outpatient labs. Patient continued on prednisone 4mg daily. Creatinine at time of discharge 1.9. Elevated creatinine at time of discharge thought secondary to both elevated tacrolimus level as well as recent dye insult from cardiac cath (though patient pre-hydrated and received mucomyst pre and post procedure) . # HTN: Patient with history of labile BP. During this admission pressures oscilated between asymptomatic hyper and hypotension. Most accurate read taken in left thigh. Patient continued on home regimen with strict holding parameters. In days leading up to discharge, blood pressures well controlled on labetalol, lasix, nifidipine; deferred re-initiation of ACEI to PCP and cardiologist. . # PVD/CAD s/p MI, s/p CABG. Trops negx3 at OSH, neg x5 at [**Hospital1 **]. Plavix and ASA continued in house, held in peri-operative period. Cardiac catherization performed due to concern of worsening of CAD, valvular disease. Cardiac cath clean. No intervention required. Patient discharged on Plavix; ASA dose decreased from 325 -> 81 to decrease risk of bleed. . # Normocytic Anemia: Likely secondary to chronic kidney disease and iron deficiency. Patient received 1u pRBC with appropriate bump in HCT. Stable at time of discharge. Iron supplementation continued . # Depresssion. Appropriate affect in house. Continued Bupropion, Citalopram . # Insomnia. Continue Trazadone 100mg qhs . Code: Full Medications on Admission: Active Medication list as of [**2149-10-3**]: . Medications - Prescription ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a day BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth daily CITALOPRAM - 40 mg Tablet - one and one half Tablet(s) by mouth in a.m. CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 (One) Tablet(s) by mouth once a day COMPAZINE - 25 mg Suppository - 1 Suppository(s) rectally three times a day as needed for nausea DOXYCYCLINE MONOHYDRATE - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth twice a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times a day GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit - ASDIR once as needed for for hypoglycemia PATIENT USES 2 PER MONTH HEPARIN FLUSH (PORCINE) IN NS - 100 unit/mL Kit - 3cc heparin once a day per protocol post infusion INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider: [**Name Initial (NameIs) 10088**]) - 100 unit/mL Cartridge - 9 units Twice a Day INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider: [**Name Initial (NameIs) 20522**]) - 100 unit/mL Cartridge - per sliding scale IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA Aerosol Inhaler - 2 puffs inh q6 hours as needed for coughing LABETALOL - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 200 mg Tablet - 2 Tablet(s) by mouth three times a day hold for SBP<100 or HR<60 LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - ASDIR once apply 15 min before drawing blood METOCLOPRAMIDE - 10 mg Tablet - 1 (One) Tablet(s) by mouth daily do not take more than 5 - 6 times per week NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**2-1**] Tablet(s) by mouth q8hr as needed for ankle pain PANTOPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth qeday POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17 gram/dose Powder - by mouth PRN PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth daily SODIUM CHLORIDE 0.9 % [SALINE FLUSH] - 0.9 % Syringe - as directed once a day 3-5cc saline flush pre and post infusion TACROLIMUS [PROGRAF] - 1 mg Capsule - 3 Capsule(s) by mouth twice a day brand name medically necessary, no substitution TALKING SCALE - - Use once daily for use with CHF protocol TRAZODONE - 100 mg Tablet - one Tablet by mouth at bedtime VANCOMYCIN - 750 mg Recon Soln - infuse 750 mg once a day . Medications - OTC ASPIRIN - (OTC) - 325 mg Tablet - One Tablet(s) by mouth daily BLOOD SUGAR DIAGNOSTIC [PRECISION XTRA TEST] - Strip - use to monitor your blood sugar up to 10 times per day or as directed CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day DOCUSATE SODIUM [COLACE] - 100 mg Capsule - [**2-1**] Capsule(s) by mouth twice a day FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth twice a day NUT.TX.GLUC.INTOL,LAC-FREE,SOY [GLUCERNA] - Liquid - 1 can by mouth six times per day Diabetes Mellitus Type I Gastroperisis POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC; Dose adjustment - no beverage and drink daily as needed for as needed for constipation . Discharge Medications: 1. Outpatient Lab Work REQUIRED LABORATORY MONITORING: LAB TESTS: CBC, BUN, Crea, ESR, CRP, Vanco trough FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 13. Tacrolimus 1 mg Capsule Sig: 2.5 Capsules PO Q12H (every 12 hours). Disp:*150 Capsule(s)* Refills:*2* 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. Disp:*1 bottle* Refills:*2* 15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) u subQ Subcutaneous twice a day. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Sig: Three (3) ml every eight (8) hours: Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush . Disp:*30 flush* Refills:*2* 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Sig: Heparin Flush (10 units/ml) 2 mL IV PRN line flush flush Qday and prn. Disp:*30 flush* Refills:*2* 20. Humalog 100 unit/mL Solution Sig: per sliding scale u/mL Subcutaneous with meals, at bedtime: PLEASE HOLD AM HUMALOG UNTIL AFTER BREAKFAST - if able to eat, dose per AM scale; if nausea prevents eating, dose per BEDTIME SCALE. 21. SLIDING SCALE Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-150mg/dL 0u 0u 0u 0Units 151-250mg/dL 6u 6u 6u 0Units 251-300 mg/dL 8u 8u 8u 4Units 301-350mg/dL 10u 10u 10u 6units 351-400mg/dL 12u 12u 12u 8Units 22. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 23. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 25. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 26. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 27. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a day: Do not take more than 5-6x/week. 28. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO once a day. 29. Citalopram 40 mg Tablet Sig: one and one half tablet Tablet PO QAM. 30. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every six (6) hours as needed for cough. 31. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous once a day: Will complete 6 week course of vancomycin. tentative stop date: [**11-25**]. Disp:*30 bags* Refills:*2* 32. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 33. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: PRIMARY: CHF exacerbation Chronic osteomyelitis . SECONDARY: End-stage kidney disease Diabetes Mellitus Coronary Artery Disease Peripheral Vascular Disease Discharge Condition: Mental status: clear and coherent Ambulates with assistance' weight bearing activity as tolerated. Discharge Instructions: Dear Ms [**Known lastname 19419**] it was a pleasure taking care of you. . You were initially transferred to [**Hospital1 18**] for continued treatment of an upper respiratory infection and CHF exacerbation. During your stay you were actively diuresised, continued on antibiotics and your respiratory symptoms improved. . Unfortunately you had an episode of respiratory distress necessitating ICU transfer and intubation. The episode was thought secondary to an aspiration event. Shortly after transfer to the ICU you were extubated, your respiratory status improved and you were transferred back to the floor. . While hospitalized the infectious disease, orthopedic, renal, and cardiology services participated in your care. There was concern for recurrent osteomyelitis of your left ankle. Your doxycyline was stopped and you were restarted on IV vancomycin to complete a 6wk course. On [**10-14**] you were taken to the OR by Dr. [**Last Name (STitle) **] for a wash-out of your left ankle. Biopsies were taken of bone and soft tissue during the procedure and at time of discharge had demonstrated no bacterial growth. You will need to follow-up with both infectious disease and [**Last Name (STitle) **] for continued care of this infection as an outpatient. Until follow-up you will continue taking IV vancomycin 750mg daily for likely 6wk course. Your sutures will be removed in [**Last Name (STitle) **] clinic in 2-3wks. Until that time be sure to keep incision sites, clean and dry. You may ambulate with assistance with weight bearing activities as tolerated. . While hospitalized your underlying coronary artery disease was evaluated. You had a cardiac catherization done on [**10-17**] which was clean with no interventions necessary. You will follow-up with Dr. [**Last Name (STitle) 20523**] as an outpatient. . Regarding your renal function, you were followed by the renal service. An ultrsound of your transplanted kidney was obtained which was negative for any signs of rejection. You were continued on tacrolimus and prednisone to prevent rejection. . CHANGES TO YOUR MEDICATIONS: --We DECREASED your Aspirin from 325mg -> 81mg by mouth daily --We DECREASED your LASIX to 80u by mouth to once daily --We STOPPED your DOXYCYLINE. --We STARTED VANCOMYCIN , 750mg IV every day (6week course: Start date: [**2149-10-14**] Stop date: [**2149-11-25**]) You levels will be checked with weekly lab draws. --We DECREASED your dose of TACROLIMUS to 2.5mg twice daily. --YOUR HOME INSULIN REGIMEN WAS CHANGED TO THE FOLLOWING: LANTUS 10u twice daily with insulin sliding scales with meals and bedtime. Regarding sliding scale: Check sugar and administer AM humalog AFTER breakfast - if you have eaten full meal use AM sliding scale, if nausea has made it difficult to eat use BEDTIME sliding scale to avoid hypoglycemia. --PAIN REGIMEN: We continued your PERCOCET; We added daily LIDOCAINE patchs, we discharged you with 30 pills of DILAUDID 2mg for breakthough pain as needed every 4-6hrs (please do not take more than 4 pills daily to avoid over-sedation) --We also added an albuterol inhaler to use as needed to help with your breathing. . Followup Instructions: [**Last Name (un) **] FOLLOW-UP Wednesday @ 9am with Dr [**Last Name (STitle) 10088**] [**Name (STitle) **] Center [**Location (un) **], [**Location (un) **] . Department: [**Hospital3 249**] When: TUESDAY [**2149-10-28**] at 10:00 AM With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . DEPT: ORTHOPEDICS - suture removal Tuesday [**10-28**] at 1120 [**Location (un) **] [**Hospital Ward Name 23**] Center [**Location (un) **] . Department: INFECTIOUS DISEASE When: MONDAY [**2149-11-3**] at 9:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2149-12-1**] at 9:30 AM With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], 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: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2149-11-19**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2149-10-21**]

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icd9pcs

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44889+58766

Discharge summary

report+addendum

Admission Date: [**2184-10-5**] Discharge Date: [**2184-10-15**] Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 1162**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Nasogastric [**First Name3 (LF) **] History of Present Illness: Mr. [**Known lastname 11455**] is an 84 y/o man with PMH notable for CAD, PVD, and chronic atrial fibrillation on coumadin who presents to the ED from [**Hospital 100**] Rehab due to hypotension in setting of UTI. The patient has been at rehab since discharge from [**Hospital1 18**] on [**2184-6-20**]. The patient was diagnosed with UTI on [**9-30**] and started on ciprofloxacin at that time. . On [**10-3**], the patient was noted to have hematuria with temp to 99.6 with BPs 80s/50s and HRs in the 90s. At that time, he was given NS at 75 cc/hour with multiple boluses and marginal improvement in BPs to 100s systolic. Labs at that time demonstrated WBC 25.2 (up from 19.7) with Hct 34.8 . INR at rehab on [**10-4**] found to be 5; given vit K 2.5 mg X 1. On [**10-5**], the patient's blood pressure was again low at 70/40 with HR 100 (afebrile at that time). He was given 250 cc NS with subsequent blood pressure 74/50. At that time, decision was made to transfer patient to [**Hospital1 18**] ED for further management. . In in the ambulance, the patient's blood pressures ranged from 68-80 systolic with HRs 120s-130s. Initial vitals in the ED were T 98, HR 140, BP 127/32, RR 22 with O2 sats 97% on 2L nc. Given 6 L NS in the ED. For rapid a fib, he received 20 mg IV diltiazem and BPs decreased to 80s systolic. HR improved to 90s-110s at best. UA demonstrated > 50 WBCs, > 50 RBCs, moderate bacteria and 0 epis. Blood and urine cultures were sent, and the patient was given 1 g IV vancomycin, flagyl 500 mg IV, and ciprofloxacin 400 mg IV X 1. KUB was performed due to abdominal tenderness which demonstrated diffusely dilated loops of small bowel. CT scan was then performed to further evaluate for a transition point. CT demonstrated a suggestion of transition at RLQ; there is some stranding adjacent to the bladder. Urology was consulted due to concern for bladder perforation; it was determined that there was no bladder perforation after the surgeons looked at the scan with the radiologist. . On arrival to the [**Hospital Unit Name 153**], the patient denied abdominal pain, chest pain, shortness of breath, palpitations, dizziness, and lightheadedness. He tells me that all of this began with his "8 or 9 surgeries" though cannot elaborate. He reported blood in his urine several days ago. He denied vomiting but reported poor PO intake for several days. Per nurse [**First Name (Titles) 767**] [**Last Name (Titles) 100**], patient's appetite was poor yesterday but has been adequate in days prior. The patient has not had any diarrhea or abdominal pain per the nurse. Past Medical History: CAD HTN Hypercholesterolemia DM2 MI'[**74**] Peripheral arterial disease post-polio contractures Social History: Prior to hospitalization in [**Month (only) 547**], patient was living at home with wife. [**Name (NI) **] been at [**Hospital 100**] Rehab since discharge in the spring. Prior smoker. Drinks 1 glass wine/nightly prior to recent hospitalization and rehab stay. Has two sons. Previously worked at Dept. of Public Health. Family History: non-contributory Physical Exam: T: 96.6 BP: 116/68 HR: 117 RR: 25 O2 99% 3L NC Gen: Pleasant, elderly male in NAD. Talkative. HEENT: No conjunctival pallor. Keeping eyes closed throughout conversation. PERRL. Tongue dry. NECK: Supple, JVD 8 cm. No thyromegaly or palpable lymphadenopathy. CV: irregularly irregular with nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: clear to auscultation bilaterally, no wheezes or crackles heard ABD: Distended but nontender to palpation. + tympany with percussion. No organomegaly noted. EXT: DP pulses 2+ bilaterally. Bandage covering R great toe. No peripheral edema. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Gait not assessed. PSYCH: Listens and responds to questions appropriately though tangential, pleasant Pertinent Results: Admit Labs: [**2184-10-5**] 02:50AM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 [**2184-10-5**] 02:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2184-10-5**] 02:50AM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2184-10-5**] 02:50AM PT-31.4* PTT-42.8* INR(PT)-3.3* [**2184-10-5**] 02:50AM PLT SMR-NORMAL PLT COUNT-407 [**2184-10-5**] 02:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2184-10-5**] 02:50AM NEUTS-87.0* BANDS-0 LYMPHS-9.0* MONOS-3.2 EOS-0.8 BASOS-0.1 [**2184-10-5**] 02:50AM WBC-13.2* RBC-3.33* HGB-10.2* HCT-28.9* MCV-87 MCH-30.5 MCHC-35.2* RDW-14.5 [**2184-10-5**] 02:50AM ALBUMIN-2.0* [**2184-10-5**] 02:50AM CK-MB-NotDone [**2184-10-5**] 02:50AM cTropnT-0.06* [**2184-10-5**] 02:50AM ALT(SGPT)-20 AST(SGOT)-41* CK(CPK)-80 ALK PHOS-76 AMYLASE-42 TOT BILI-0.4 [**2184-10-5**] 02:50AM estGFR-Using this [**2184-10-5**] 02:50AM GLUCOSE-149* UREA N-63* CREAT-1.0 SODIUM-137 POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-16* ANION GAP-16 [**2184-10-5**] 02:59AM LACTATE-1.3 [**2184-10-5**] 02:59AM COMMENTS-GREEN TOP [**2184-10-5**] 10:40AM CK-MB-NotDone cTropnT-0.08* [**2184-10-5**] 10:40AM CK(CPK)-95 [**2184-10-5**] 08:49PM HCT-31.5* [**2184-10-5**] 08:49PM MAGNESIUM-1.9 [**2184-10-5**] 08:49PM CK-MB-11* MB INDX-11.7* cTropnT-0.05* [**2184-10-5**] 08:49PM CK(CPK)-94 [**2184-10-5**] 08:49PM GLUCOSE-149* UREA N-39* CREAT-0.7 SODIUM-134 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-12* ANION GAP-15 [**2184-10-5**] 11:53PM LACTATE-1.2 [**2184-10-5**] 11:53PM TYPE-ART PO2-84* PCO2-23* PH-7.46* TOTAL CO2-17* BASE XS--4 INTUBATED-NOT INTUBA Studies: KUB ([**10-5**]): Dilated loops of small bowel with a paucity of air within large bowel consistent with small bowel obstruction as seen on the recently performed CT. CT Abdomen/Pelvis ([**10-5**]): 1. Diffusely dilated small bowel, as described above, with a suggestion of a transition point in the right lower quadrant. Sigmoid diverticulosis with mild fat stranding, likely chronic, with loops of bowel somewhat tethering to the area of diverticulosis. 2. Elongated appearance of the urinary bladder with Foley catheter, with surrounding extensive fat stranding, associated with free fluid. The elongated appearance is consistent within reason to the prior examination and is presumed to prior infection or surgery (reportedly had prior inguinal hernia repair.) 3. Wall thickening of the rectum, decreased since prior study. 4. Bronchiectasis with patchy opacities in the lingula, which could be due to aspiration, in the presence of large hiatal hernia. CXR ([**10-5**]): Large hiatal hernia. Basilar atelectasis. Unchanged left apical pleural thickening. Otherwise, no acute cardiopulmonary process Other Labs: [**2184-10-9**] 11:56AM BLOOD Type-ART O2 Flow-2 pO2-114* pCO2-25* pH-7.44 calTCO2-18* Base XS--4 Intubat-NOT INTUBA [**2184-10-7**] 07:29AM BLOOD Type-ART pO2-85 pCO2-28* pH-7.44 calTCO2-20* Base XS--3 Intubat-NOT INTUBA [**2184-10-9**] 01:15PM BLOOD Acetone-MODERATE [**2184-10-9**] 11:56AM BLOOD Glucose-96 Lactate-0.8 Na-135 K-3.0* Cl-115* Micro: Urine Cultures ([**10-5**], [**10-8**], [**10-9**]) - No Growth Stool ([**10-7**]) - Positive for C. Diff. Cx negative Blood Cx ([**10-5**]) - NGTD x 2 set CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2184-10-8**]): REPORTED BY PHONE TO [**Last Name (LF) 24449**],[**First Name3 (LF) 24448**]-11R- @ 10:10 [**2184-10-8**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). Brief Hospital Course: 1) Hypotension/Urinary Tract Infection/Partial SBO Likely a combination of dehydration in setting of decreased PO intake with concern for sepsis given + UA, despite 5 day treatment with Ciprofloxacin (U Cx positive for proteus, sensitive to Cipro) or abdominal pathology given partial SBO. Pt. was started on broad abx. coverage with Vancomycin/Zosyn. His blood pressure normalized and his vital signs remained stabled. Vancomycin was later discontinued. Pt initially had abdominal tenderness with KUB as above. Later had CT scan with results as above. Surgery was consulted. SBO was treated medically with NGT and NPO for diet. The patient's bowel was successfully decompressed and he began having BMs. His diet was slowly advanced. Patient was maintained on IVF and eventually, Lopressor was added back because of ectopy. His blood pressure tolerated this. He was continued on Zosyn until [**10-10**], when he was changed to Bactrim (given Urine Cx showed sensitivity to this and fluoroquinolones have caused C. Diff in the past). Unfortunately, the patient developed a significant drug rash to bactrim with skin manifestations only and should never receive this drug in the future. He was subsequently placed back on cipro po for presumed UTI (no positive cultures here) to complete a course on [**10-18**]. Patient and wife refused to have foley removed as this is clearly a concern for future infections and they understand the risks associated with long-term foley use. Please see urinary retention below. 2) Diarrhea Patient was being presumptively treated for C. diff at his rehab facility. Last positive cultures were from previous hospitalization in [**2184-5-2**]. Flagyl was continued during this hospitalization. Pt began having soft bowel movements on [**10-7**]. Sample was sent for C. Diff and was positive. Pt was continued on Flagyl, which should be continued for at least 2 weeks after all antibiotics have been stopped. Pt will need to have toxin re-sent after completion of antibiotics. He can continue on lactobacillus while receiving the flagyl. If patient continues to have positive c. diff toxins after this extended course, it is recommended that he be treated with po vancomycin. 3) Atrial fibrillation with RVR On presentation, HRs to the 130s, presumably while off of lopressor. Cardiac enzymes were cycled and negative. The patient was maintained initially on IV Lopressor PRN for tachycardia and ectopy. He eventually was then placed on a standing PO regimen, which was titrated up as tolerated, once BP became stable. Anti-coagulation was held initially because of supratherapeutic INR and possibility of surgical correction of SBO. As surgery was later deemed unnecessary and once INR became therapeutic, the patient was restarted on his outpatient dose of Coumadin. INR was supertherapeutic on [**10-9**], so coumadin was held. This was felt to be realted to his concomitant antibiotic use. Once the INR trended down to 2.7 he was restarted on warfarin 1mg po daily. He will need to have his INR level checked intermittently while on coumadin and antibiotics. 4) Hypertension After patient's blood pressure stabilized, he was restarted on Lopressor and Lisinopril. The Lopressor is at 25 [**Hospital1 **], instead of the 50 [**Hospital1 **] he had been on at [**Hospital 100**] rehab. 5) Renal/Electrolytes On [**10-9**], he was noted to have an increased AG w/ a bicarb of 13 and elevated glucose. He also had severely depressed potassium and magnesium. ABG was above, which was more consistent with an alkalemia. The patient was covered with Regular insulin SC and given IV fluids. Electrolytes were repleted. Repeat labs showed resolution of this AG and his electrolytes have been stable since. 6) DM-2 The patient was initially covered with SSI. However due to elevated blood glucose as above, Lantus 5U qhs was added with subsequent early morning BG of 63. Given the risk of hypogylcemia, this was stopped and the patient was maintained on a sliding scale. 7) Nutrition The patient was held NPO for several days due to the SBO. He was slowly started on clear liquids. His albumin was as low as 1.7. Nutrition was consulted. Given his poor appetite, his diet was liberalized to a regular diet (as opposed to diabetic/cardiac) to provide him with more options for food. 8) Hypothyroid The patient was maintained on his outpatient Synthroid dose (12.5mcg). Given how low this dose is and the fact that last TSH from several months back was elevated, repeat was obtained at 16. The patient's dose was increased to 25mcg daily and will need repeat TFTs in approximately three month's time. 9) Urinary Retention The patient was seen in the ED by urology due to hematuria. Has inflammatory process next to bladder. Has chronic indwelling foley catheter. Urology service changed catheter to 18Fr Coude, which should be changed every 6-8 weeks. Pt had been on Tamsulosin 0.4mg, however this was not given during this admission. He will need to call urology for follow up and likely urodynamics upon leaving the rehab. Medications on Admission: Flagyl 500 PO TID (start [**10-3**]) Dulcolax Suppositories PRN Cipro 250 mg [**Hospital1 **] (start [**9-30**]) Tylenol PRN Trazodone 50 mg QHS PRN (stopped [**10-2**]) Coumadin 1.5 mg daily (held [**10-3**] for INR 3.4) Plavix 75 mg daily Regular SSI Lactobacillus 2 tabs TID Synthroid 12.5 mcg daily lisinopril 20 mg daily Mg oxide 400 mg [**Hospital1 **] Lopressor 50 mg [**Hospital1 **] (held [**10-3**] for BP 98/50) Remeron 7.5 mg daily (d/c'd on [**9-30**]) Protonix 40 mg [**Hospital1 **] Simvastatin 5 mg QMWF Tamsulosin 0.4 mg daily Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 22 days: Continue for 2 weeks beyond completion of cipro. Tablet(s) 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Insulin Lispro 100 unit/mL Solution Sig: As per sliding scale Subcutaneous qAC and qhs: 0-70: [**2-3**] amp d50 71-150: 0 units 151-200: 2 units 201-250: 4 units 251-300: 6 units 301-350: 8 units 351-400: 10 units. 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 12. Lactobacillus Acidophilus Capsule Sig: Two (2) Capsule PO three times a day for 7 days. 13. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO qMWF. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Urinary Tract Infection with Sepsis Atrial Fibrillation with Rapid Ventricular Response Small Bowel Obstruction C. Diff Colitis Secondary: Peripheral Arterial Disease s/p R SFA to AT bypass ([**5-8**]) Prior NSTEM in setting of A-Fib ([**5-8**]) DM-2 Hyperlipidemia Post-Polio weakness/contractures Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Continue Course of Antibiotics: -Ciprofloxacin for UTI until [**10-18**] -Flagyl for C. Diff until [**11-1**] (2 weeks after completion of Ciprofloxacin) Take all other medications as prescribed. Please follow up with the geriatrics service or your PCP [**Name Initial (PRE) 176**] 1 week of leaving [**Hospital 100**] Rehab. Followup Instructions: You have been scheduled for a new appointment with Geriatrics for the following:Provider: [**Name10 (NameIs) **] [**Name (NI) 9329**] [**Name8 (MD) 9328**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2184-10-25**] 2:15 Alternatively can call [**Telephone/Fax (1) 3603**] for an appointment with your existing PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-12-28**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-12-28**] 3:15 Name: [**Known lastname 15249**],[**Known firstname 651**] Unit No: [**Numeric Identifier 15250**] Admission Date: [**2184-10-5**] Discharge Date: [**2184-10-15**] Date of Birth: [**2100-3-6**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 12277**] Addendum: A CXR was obtained on the day of discharge which showed new pleural effusions, felt likely to be attributed to the massive amounts of fluid the patient received on admission. His hiatal hernia seen on admission is still present. Given that the patient has no respiratory distress and with no oxygen requirement for 1 week and oxygen saturation of 99% on RA, we recommend a follow up CXR upon discharge from rehab or if new symptoms present. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 12279**] MD [**MD Number(2) 12280**] Completed by:[**2184-10-15**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17412, 17641

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8044

Discharge summary

report

[** **] Date: [**2128-3-1**] Discharge Date: [**2128-3-9**] Date of Birth: [**2051-4-18**] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[**First Name3 (LF) 1115**] Chief Complaint: hematochezia Major Surgical or Invasive Procedure: capsule endoscopy History of Present Illness: Mr [**Known lastname 28747**] is a 76 year old man with extensive PMHx including CAD s/p CABG with stents, HTN, HLD, St. [**Male First Name (un) 923**] Mechanical AV (on anticoagulation), prostate ca and recent high grade MSSA bacteremia now on cefazolin, presenting from rehab facility ([**Hospital1 **]) with melenotic stools for the past four days. . Patient reports he was doing well with rehabilitation, able to ambulate with the use of a cane and without any shortness of breath of chest pain. About 4 days prior to [**Hospital1 **], he reports he started to notice very dark, tarry stools whenever he moved his bowels. He also noted these became more frequent and that he has getting increasingly more fatigued with minimal activity. Patient reports he has had similar episodes in the past, however never associated with shortness of breath or fatigue. . In the ED, vital signs were initially: 98.2 72 130/44 18 100. Blood pressures were checked at thigh due to concerns about pacemaker and PICC line. Patient received 2 units of FFP, Pantoprazole IV and 2L NS. GI was consulted and patient was admitted to MICU for further monitoring. At time of transfer, HR 81 138/59 21 98% 3L . MICU COURSE: Was HD stable, never on pressors. Got total of 7 units of pRBCs. Got 5 units of FFP to attempt endoscopy but never performed due to logistical issues and relative clinical stability. Last BM 2 days ago. Melenic. Last transfusion yesterday, Hct bumped appropriately 24-->28. Most recent VS: 97.0 148/59 75 (Vpaced) 24 100% 2L. Access: PICC and 1 18g PIV. EP aware of him, no need to see here, f/u as outpatient. Remains on cefazolin. INR 5.9 today. chronic neck pain from post-herpetic neuralgia. Getting morphine prn. DNR/I. . REVIEW OF SYSTEMS: No fevers, chills, weight loss, diaphoresis, headache, visual changes, sore throat, chest pain, shortness of breath, nausea, vomiting, abdominal pain, constipation, pruritis, easy bruising, dysuria, skin changes, pruritis. Past Medical History: # CAD s/p CABG [**2106**] (LIMA-LAD, SVG-OM, SVG-D, SVG-RCA) ; stented 3DES [**2126**] to SVG-OM graft) # Diastolic heart failure with hypertension and hyperlipidemia # Recurrent GIB - [**1-21**] [**Month/Year (2) **] / colonoscopy:erosive gastritis, while colonoscopy showed diverticulosis, ectasias in rectum, mild radiation proctitis, and grade one hemorrhoids. 2nd [**3-20**] episode: [**Month/Year (2) **] showed gastritis and ulcers with unremarkable biopsy. 3rd episode: [**Month/Year (2) **] show gastritis. Patient suppose to get capsule study but never followed up. # St. [**Male First Name (un) 923**] Mechanical AVR in [**2106**] # Endocarditis -- c/b complete heart block -- s/p PPM implantation [**12-23**] # Atrial Fibrillation s/p cardioversion # Prostate ca s/p lupron tx # Gout # 4.4 cm AAA, last imaged [**7-19**] # Prior ETOH abuse (a case of beer a day). He stopped drinking heavily about [**2116**] GIB after drinking an excess amount of alcohol, endoscopy revealing several stomach ulcers, requiring 6 units PRBC. # Cataracts, s/p surgery bilaterally # Borderline glaucoma # Hematuria approximately 6-7 months ago (currently consulting with a urologist and oncologist). Patient reports having a cystoscopy that was unremarkable.) # Hx of Cellulitis of right leg # Hx of mild hepatitis # Recent shingles Social History: Now at rehab from endocarditis [**Year (4 digits) **], regularly lives at home with his wife and daughter, does not smoke or drink, quit smoking ~20 years ago, has about 20 years of 4ppd history. Family History: Father died of CAD at age 65. Physical Exam: VS: 97.0, 166/95, 78, 16, 92 RA GEN: no acute distress SKIN: pale, No rashes or skin changes noted HEENT: JVP 7 cm, distended neck veins, neck supple, no LAD CHEST: Lungs with soft bibasilar crackles CARDIAC: Irregularly irregular, loud crisp sounding S2 over RUSB, [**3-20**] holosystolic murmur at left sternal border ABDOMEN: Non-distended, and soft without tenderness EXTREMITIES: no edema, warm without cyanosis NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE [**5-19**], and BLE [**5-19**] both proximally and distally. No pronator drift. Reflexes were symmetric. Downward going toes. Pertinent Results: LABS ON [**Month/Day (1) **]: [**2128-3-1**] 03:00PM BLOOD WBC-8.7 RBC-1.92*# Hgb-5.4*# Hct-16.9*# MCV-88 MCH-28.3 MCHC-32.2 RDW-16.6* Plt Ct-341# [**2128-3-1**] 03:00PM BLOOD Neuts-87.9* Bands-0 Lymphs-8.5* Monos-2.3 Eos-0.9 Baso-0.4 [**2128-3-1**] 03:00PM BLOOD PT-103.8* PTT-36.4* INR(PT)-13.0* [**2128-3-4**] 08:00AM BLOOD Fibrino-399 [**2128-3-1**] 03:00PM BLOOD Glucose-123* UreaN-74* Creat-1.3* Na-142 K-4.0 Cl-107 HCO3-21* AnGap-18 [**2128-3-1**] 03:00PM BLOOD CK(CPK)-14* [**2128-3-2**] 03:33AM BLOOD CK(CPK)-20* [**2128-3-1**] 03:00PM BLOOD CK-MB-NotDone [**2128-3-2**] 03:33AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.0 [**2128-3-2**] 04:15AM BLOOD Lactate-1.3 [**2128-3-2**] 10:36AM BLOOD freeCa-0.98* . LABS ON DISCHARGE: [**2128-3-9**] 06:14AM BLOOD WBC-8.2 RBC-3.16* Hgb-8.7* Hct-27.2* MCV-86 MCH-27.7 MCHC-32.1 RDW-15.3 Plt Ct-269 [**2128-3-5**] 02:35PM BLOOD Neuts-86.3* Lymphs-7.3* Monos-2.8 Eos-3.2 Baso-0.4 [**2128-3-9**] 06:14AM BLOOD Plt Ct-269 [**2128-3-9**] 06:14AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-142 K-3.4 Cl-107 HCO3-28 AnGap-10 [**2128-3-9**] 06:14AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.1 . Tagged RBC scan: IMPRESSION: No GI bleeding identified, though study is limited for evaluation of the stomach and small [**Last Name (un) 12376**] by the presence of free pertechnetate. . Capsule study: pending at time of discharge Brief Hospital Course: Mr. [**Known lastname 28747**] is a 76 year old man with multiple medical problems, including external pacemaker, prosthetic aortic valve (on coumadin), and recent MSSA bacteremia, presenting with supratherapeutic INR and GI bleeding. . # GI BLEED: Patient with prior episodes of erosive gastritis and GI Bleed, also with known diverticulosis, AAA and history of paroxysmal atrial fibrillation. DDx would therefore also include aorto-enteric fistula, mesenteric ischemia, ischemic colitis, etc. Concerning in setting of elevated INR as well. Patient received 7 units of pRBC and 7 units FFP in total during [**Known lastname **]. A tagged red cell scan was done and no site of bleeding was found. GI recommended [**Known lastname **]/capsule study. Patient declined [**Known lastname **], but was amenable to capsule study, which he completed prior to discharge. These results will be reviewed with patient on GI follow-up appointment. Hct had been stable for >5 days prior to discharge, and ranged from Hct 26-28. Discharge Hct 27. Patient informed to seek medical attention immediately for any signs/symptoms of bleeding from rectum. . # VALVULAR HEART DISEASE/PROSTHETIC VALVE ENDOCARDITIS: Patient with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] mechanical valve in aortic position, also with Moderate MR/TR. Patient has had prior prolonged hospitalization with prosthetic valve endocarditis, on treatment with IV cefazolin. His antibiotics were discussed with infectious disease physicians, and it was determined that patient had completed a sufficient IV antibiotic course; he was discharged on suppressive Doxycycline 100 mg [**Hospital1 **] until f/u with [**Hospital **] clinic. . # SUPRATHERAPEUTIC INR: Unclear etiology of significantly elevated INR, although patient has been on IV antibiotics for a prolonged course and has likely erradicated intestinal Vitamin K metabolizers. No other clear drug interactions noted. Warfarin was held on [**Hospital **] for INR 13, and patient was given FFP as noted above. Goal INR 2.5 to 3.5 given mechanical valve at aortic position with atrial fibrillation. INR on discharge was 3.8 prior to discharge. On date of discharge, coumadin was held. Patient was discharged on new regimen of 3 mg coumadin daily, and this will be adjusted by primary care physician. [**Name10 (NameIs) **] INR check will be [**2128-3-11**] with results faxed to PCP. . # EXTERNAL PACEMAKER: patient with external pacemaker, placed in setting of complete heart block from prior endocarditis. Patient met with cardiology physicians to discuss potential internalization of external pacer. However, given acute GI bleed and concerns for active Abx regimen for prosthetic valve endocarditis, this was deferred until separate [**Month/Day/Year **]. Patient was informed to discuss this separate [**Month/Day/Year **] for internalization with his primary care doctor, and he was provided the number for cardiology whereby he can arrange an appropriate time and date for this procedure. Patient informed to keep this area dry, as he has been. . # DIASTOLIC HEART FAILURE: Appeared slightly hypervolemic after GI bleeding issue resolved. He was placed on his home regimen of lasix and will continue this on discharge. Of note, patient was started on ACEi on discharge, given normal renal function and for improved BP control. . # NECK PAIN: Chronic pain secondary to shingles. He continued his home regimen of oxycodone. . # Dispo: discharge to home, now off IV antibiotics and on PO doxycycline. Has follow-up arranged with ID, GI, and PCP. Medications on [**Month/Day/Year **]: Cefazolin 2gm q8h (last dose at 14:00) Atorvastatin 40mg Amlodipine 5mg daily Aspirin 81mg daily Famotidine 20mg daily Metoprolol 50mg [**Hospital1 **] Oxycodone 5mg PRN Warfarin 5mg daily Furosemide 60mg daily Bisacodyl Docusate Senna Ascorbic acid Eucerin cream Ferrous sulfate 325mg Multivitamin Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient [**Hospital1 **] Work Please have PT/INR blood-work drawn on [**2128-3-11**] and have results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 28761**] 16. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. lower gastrointestinal bleeding . SECONDARY: 1. hypertension 2. St. [**Male First Name (un) 923**] Mechanical aortic valve, on coumadin Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital with bleeding, felt to be from a lower gastrointestinal bleeding source. Your INR level was also very high. You received 7 units of red blood cell transfusion and 7 units of fresh frozen plasma in total. You initially had a GI bleeding study which did not show a brisk bleed. You met with the GI doctors who recommended [**Name5 (PTitle) **] and capsule study. You declined the former but accepted the capsule study. The capsule will be passed in the stool in the next several days. Transmitted results will be reviewed by the GI doctors [**First Name (Titles) **] [**Last Name (Titles) 28762**] with you at GI follow-up. On discharge, your blood counts and hematocrit were stable. You will be on a lower dose of coumadin on discharge, and this will be titrated by your primary care doctor. . In addition, you met with the infectious disease doctors to discuss your antibiotic regimen on discharge. It was determined that you may discontinue your IV antibiotics. You will continue an oral antibiotic called DOXYCYCLINE until your next infectious disease appointment. . You also met with the cardiology doctors during your [**Name5 (PTitle) **]. They did not recommend internalization of your pacemaker on this [**Name5 (PTitle) **]. Please discuss this with your primary care doctor, and he can likely arrange an appropriate time and date for this procedure. Please keep this area dry, as you have been. . MEDICATION CHANGES/NEW MEDICATIONS: - DECREASE coumadin to 3 mg daily. Please have results [**Name5 (PTitle) 28762**] to Dr. [**Last Name (STitle) **] for management of coumadin dosing. - START lisinopril 5 mg daily for blood pressure control - STOP IV cefazolin - START doxycycline 100 mg twice a day. This will continue until your next infectious disease appointment. . Please seek medical attention for chest pain, shortness of breath, difficulty breathing, palpitations, abdominal pain, fevers, bleeding from the rectum, or any other concerns. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: An appointment has been made with your primary care doctor, Dr. [**Last Name (STitle) **], on [**2128-3-24**] at 1:45 PM. His office will be contacting you directly if this appointment can be moved up. Please call [**Telephone/Fax (1) 8725**] if you do not hear from his office. . An appointment with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1356**] (GI) has been scheduled for [**2128-3-23**] at 11:40 AM. Please call [**Telephone/Fax (1) 463**] for any questions. . Please call [**Hospital **] clinic at [**Telephone/Fax (1) 457**] to schedule an appointment with the ID doctors [**Last Name (NamePattern4) **] [**4-20**] weeks time. Please contact them earlier if any additional questions arise. . Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-3-25**] 9:00 . Please have your INR drawn on Thursday, [**3-11**], and fax results to Dr.[**Name (NI) 8716**] office at [**Telephone/Fax (1) 28761**]. Completed by:[**2128-3-9**]

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

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279, 298

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12,834

104,784

7099

Discharge summary

report

Admission Date: [**2100-12-13**] Discharge Date: [**2101-1-2**] Date of Birth: [**2048-1-28**] Sex: F Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: This is a 52-year-old female with a history of hypertension, hypercholesterolemia, and alcoholic cirrhosis, fibrosis, who was admitted for hypotension with systolic blood pressure down to the 60s during therapeutic paracentesis (5 liters total removed). The patient states that she was completely asymptomatic, denying any lightheadedness, dizziness, or chest pain. Since her diagnosis, she has been following up with the liver service, undergoing multiple paracenteses (7 liters removed on [**2100-10-19**] and 9 liters on [**2100-11-22**]) which she tolerated well in the past. The patient states that since her father died last week she has had some stomach upset with cramping and diarrhea as well as poor p.o. intake. The patient states that this is a common reaction to stress. She denied any recent course of antibiotics. She states that she may have gotten food poisoning from a church meal. Her diarrhea has now stopped. Her stomach cramps improved with the medication called in by Dr. [**Last Name (STitle) 497**], her gastroenterologist. The patient has been drinking Pedialyte at home for the past two days. She denied any recent abdominal pain, fever, or [**Male First Name (un) 1658**]-colored stools. Following the procedure, the patient received albumin 50 grams and was started on normal saline wide open with improvement in her systolic blood pressure to 89. The patient was noted to have baseline hypotension with the systolic blood pressure normally in the 90s. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis and fibrosis, diagnosed in [**2100-8-30**], complicated by IVC stenosis, status post stent placement in [**9-2**]. 2. Hypertension. 3. Hypercholesterolemia. 4. Status post breast reduction surgery. 5. History of anemia of chronic disease. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Folic acid one q.d. 2. Thiamine 100 p.o. q.d. 3. Pantoprazole 40 q.d. 4. Compazine 10 p.o. q. six hours p.r.n. 5. Trazodone 50 mg p.o. q.h.s. p.r.n. 6. Spironolactone 100 p.o. q.d. 7. Furosemide 20 p.o. q.d. 8. Bupropion 75 q.d. 9. Aspirin 325 q.d. 10. Nepro p.o. q.i.d. SOCIAL HISTORY: Former alcoholic. Denied recent alcohol use. Smokes a half pack per day times 30 years. She denied IV drug use. Her father recently died after a difficult death. She lives with her son, [**Name (NI) **]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.2, blood pressure 61/41, increased to 89/60 with IV fluids, heart rate 110, respiratory rate 20, saturating 95% on room air. General: She is awake and alert, in no acute distress, upset, answering questions curtly but generally cooperative with examination. She appeared jaundice. Head and neck: Scleral icterus. The mucous membranes were moist. Spider nevi noted on face. Chest clear to auscultation bilaterally with bilateral breast reduction scars noted. Cardiovascular: Regular rhythm, tachycardiac, no murmurs. Abdomen: Distended, with visibly distended bands on the surface of the abdomen. The patient declined palpation secondary to recent paracentesis. The patient was noted to have hypoactive bowel sounds. Extremities: There was 2+ pitting edema in the bilateral lower extremities. Neurologic: The patient was alert and oriented times three. LABORATORY/RADIOLOGIC DATA: White blood cell count 18, hematocrit 28.9 (35.5 on [**2100-11-22**]), platelets 373,000. Sodium 133, potassium 4.2, chloride 94, bicarbonate 23, BUN 51, creatinine 2.3 (prior 1.4), glucose 94. The INR was 1.4 with PT 14.3, PTT 34.2. ALT 23, AST 70, alkaline phosphatase 407, total bilirubin 5.6 (prior 2.4), albumin 2.4. Peritoneal fluid revealed white blood cells 95, red blood cells [**Pager number **], polys 2, lymphocytes 5, monos 20. HOSPITAL COURSE: The patient was transferred to the Intensive Care Unit on [**2100-12-14**] secondary to hypotension as well as hematocrit down to 23.8. She was stabilized in the unit with blood pressures maintained with systolic in the 80s to 90s and hematocrit up to 31.4 and then transferred back to the floor on [**2100-12-15**]. She was then transferred back to the unit on [**2100-12-23**] after worsening renal failure with a creatinine of 3.3 and decreased urine output. There, she was given aggressive IV fluids and placed on Levophed for increased blood pressure and increased urine output. Her urine output initially improved with a decrease in creatinine but has since dropped back down to 0-60 milliliters per hour of urine output off of the Levophed. Her systolic blood pressure, however, has been maintained greater than 100. She was also with encephalopathy and receiving Lactulose. She was diagnosed with a UTI and received Cipro times seven days and then started on ceftriaxone on [**2100-12-24**]. She was pan cultured for recurrent temperature spikes including a repeat paracentesis and was started on empiric vancomycin and Diflucan for yeast noted in her urine. A NG tube was placed and the patient was started on tube feeds but this was subsequently held secondary to increased residuals. On [**2100-12-29**], a meeting was held with the patient's son, [**Name (NI) **], to discuss the fact that there were no realistic therapeutic interventions available for her worsening sources and oliguria. The decision at that point was to take the patient home with hospice care. While hospice arrangements were being made, the patient was maintained on antibiotics of ceftriaxone and Diflucan. Her vancomycin was discontinued. She received free water IV fluid for hypernatremia and her sodium went down from 155 to 150. She was intermittently confused and required redirection; however, this appeared to be improving as her sodium decreased. She was also given standing Lactulose as well as p.r.n. Lactulose and had a rectal Foley in place. Her urine output remained minimal. However, her blood pressure has remained stable with systolic blood pressures in the 90s. A repeat therapeutic paracentesis was done on [**2100-12-31**] with 2 liters removed and 50 grams of albumin infusion following. The patient will be discharge home with hospice. DISCHARGE DIAGNOSIS: 1. End-stage alcohol cirrhosis. 2. Renal failure. 3. Hypernatremia. 4. Urinary tract infection. CONDITION ON DISCHARGE: Poor. DISCHARGE MEDICATIONS: 1. Compazine 10 mg p.o. q. six hours p.r.n. 2. Acetaminophen 325 to 650 mg p.o. q. eight to ten as needed. 3. Lactulose 45 milliliters p.o. q. four hours. 4. Lactulose 30 milliliters p.o. q. four hours p.r.n. confusion. 5. Prevacid 30 mg p.o. q.d. 6. Ativan 0.5 mg p.o. q. six to eight hours p.r.n. (as per hospice arrangements). 7. Morphine 5-20 mg p.o. q. one to two p.r.n. (as per hospice arrangements). 8. Oxygen continuous 2-4 liters via nasal cannula. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By:[**Last Name (NamePattern1) 9296**] MEDQUIST36 D: [**2101-1-2**] 11:36 T: [**2101-1-2**] 12:30 JOB#: [**Job Number 26463**]

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icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "96.6", "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

6506, 7251

6350, 6451

3968, 6329

2034, 2318

2581, 3950

1689, 2011

2335, 2566

6476, 6483

17,122

194,573

6495

Discharge summary

report

Admission Date: [**2140-1-31**] Discharge Date: [**2140-2-5**] Service: MEDICINE Allergies: Ciprofloxacin / Ambien / Trazodone Attending:[**First Name3 (LF) 663**] Chief Complaint: intertrochanteric femur fracture status-post fall Major Surgical or Invasive Procedure: -Open reduction internal fixation of left hip [**2140-2-1**] -Intubation History of Present Illness: Ms [**Known lastname 24834**] is an 88yo with a history of HTN, diastolic CHF, aortic stenosis (valve area .8-1cm), osteoporosis and afib not on anticoagulation now presenting after landing on her left side after a fall. She was in a [**Doctor Last Name **] about to get out to go to church when the [**Doctor Last Name **] continued to roll a few inches while she was standing inside causing her to fall on to her left side. She says this was purely mechanical and denied any preceding prodrome of dizziness, chest pain, sob, or palpitations. She denied loss of conciousness. She notes the pain was immediate and [**10-3**]. At no point does she recall losing sensation in her left leg/foot, and does have motor function which is limited from pain. . In the ED, initial vs were: 98.5, 63, 103/87, 18, 97% RA. EKG unchanged from prior. Patient was given 6mg IV morphine for pain control. Radiographs of her, L elbow, shoulder, hip and knee were obtained, demonstrating a minimally displaced intertrochanteric L femur fracture. Ortho saw the pt and say she will need surgical repair but would like her medically optimized before this. . On the floor, VS were: T: 97.1 BP: 122/70 HR: 56 RR: 16 O2 95% RA She reports being in [**10-3**] pain currently but does not look visibly distressed . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: # CAD s/p PCI of prox LAD in [**2-23**], NSTEMI and in-stent restenosis treated with PTCA and DESx2 to mid-LAD in [**6-28**] # Paroxysmal atrial fibrillation on amiodarone and BB, not on coumadin [**1-27**] h/o GIBs # Diastolic dysfunction (LVEF >55%) # Moderate-to-Severe aortic stenosis ([**Location (un) 109**] 0.8-1.0 cm2) # HTN # Hypercholesterolemia # Gout # Diverticulosis # OSA # s/p CCY # Spinal stenosis # Obesity # CKD (baseline Cr 1.7) Social History: Social History: Lives independently, uses the ride for transportation. Gets food through meals on wheels. Denies tobacco, EtOH, recreational drug use. Family History: Family History: Father, mother and 5 siblings all had or have heart disease. Physical Exam: ADMISSION EXAM . Vitals: T: 97.1 BP: 122/70 P: 56 R: 16 O2:95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to 2cm below angle of jaw, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic ejection murmur heard best at the left upper sternal border Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: deformity from gouty tophi on bilateral index fingers, left foot externally rotated, left foot colder than right, DP pulses palpable bilaterally, PT pulses dopperlable bilaterally, symmetric sensation to light touch . DISCHARGE EXAM . Tmax 98.7 Tcurrent 95.3 P 75 BP 103/54 R 20 O2sat 97%RA GEN: Awake, CPAP machine in place HEENT: oropharnyx clear, JVP not elevated Lungs: CTAB Heart: RRR, nlS1S2 III/VI systolic ejection murmur heard at the LUSB Abd: soft, + BS, non-tender, non-distended, no rebound tenderness or guarding Ext: WWP, DP pulses palpable bilaterally, sensation intact to light touch bilaterally Wound: incisions on L hip, c/d/i, dressing on L olcranon c/i Pertinent Results: ADMISSION [**Location (un) **]: . [**2140-1-31**] 02:45PM BLOOD WBC-10.9# RBC-4.40 Hgb-12.6 Hct-38.1 MCV-87 MCH-28.8 MCHC-33.2 RDW-14.8 Plt Ct-203 [**2140-1-31**] 02:45PM BLOOD Neuts-80.4* Lymphs-13.6* Monos-3.0 Eos-2.4 Baso-0.6 [**2140-1-31**] 02:45PM BLOOD PT-12.6 PTT-22.7 INR(PT)-1.1 [**2140-1-31**] 02:45PM BLOOD Glucose-113* UreaN-56* Creat-1.5* Na-139 K-5.3* Cl-103 HCO3-21* AnGap-20 [**2140-2-1**] 07:40AM BLOOD Calcium-9.7 Phos-4.6* Mg-2.8* . DISCHARGE [**Year/Month/Day **]: . Hct: 25.7 [**2140-2-5**] 10:50AM BLOOD Glucose-123* UreaN-76* Creat-1.8* Na-140 K-4.4 Cl-103 HCO3-24 AnGap-17 . STUDIES: . Left hip xray [**1-31**]: IMPRESSION: 1. Left minimally displaced intertrochanteric femoral fracture. 2. Possible irregularity at the left tibial plateau, for which dedicated knee radiographs should be performed. 3. Vascular calcifications. . Shoulder/elbow xray [**1-31**]: IMPRESSION: 1. Minimal shoulder degenerative changes with unchanged calcific tendinitits. 2. Possible small left elbow joint effusion, although no fracture is definitely identified. . EKG [**1-31**]: Sinus bradycardia with A-V conduction delay. Intra-atrial conduction delay. Probable left ventricular hypertrophy. Lateral lead ST-T wave abnormalities with borderline [**Month/Day (4) 5937**] interval may be due to left ventricular hypertrophy but clinical correlation is suggested. Since the previous tracing of [**2138-7-23**] there is probably no significant change. . Post-op hip xray [**2-1**]: FINDINGS AND IMPRESSION: Multiple intraoperative fluoroscopic images of the left hip. Status post ORIF of the left hip with short intramedullary nail and hip screw. The hardware appears intact. Improved alignment of the intertrochanteric fracture. No definite dislocation. Total intraoperative fluoroscopic imaging time 119.1 seconds. Please see operative report for further details. Brief Hospital Course: 88 yo female with PMH of CAD, CHF, PAF, AS, presenting s/p mechanical fall with subsequent left intertroch fracture s/p ORIF, transferred back to medicine for management of medical issues. . # Left hip fracture s/p ORIF: The description of the fall seems to be mechanical as there was no preceding prodrome to suggest syncope and no loss of conciousness or cardiac symptoms to suggest arrhythmia. Left femur XR in the ED showed intertrochanteric fracture. Pt was admitted to medicine prior to surgical repair given her comorbidities of a.fib, CHF, and severe AS. She was deemd high-risk for surgery, but given the high morbidity/mortality from immobility of an unrepaired hip fracture, the decision was made to procede to ORIF. On [**2-1**] she underwent open reduction internal fixation of her left femur fracture. She tolerated the procedure and anesthesia well without intraoperative complication. After the procedure she remained intubated and was monitored in the ICU as prophylaxis due to concern of possible flash pulmonary edema due to interoperative fluids. At 11pm on [**2-1**], she was extubated and she was transfered back to the medical floor on [**2-2**]. She received routine post op care and pain was controlled with standing tylenol and IV morphine which was eventually weaned to a PO regimen, and eventually just standing tylenol. She was started on lovenox 30mg SC daily which should be continued for 1 month. She worked with PT and progressed quite well and this should be continued at rehab. . #Hct drop: Pt with steady Hct drop from 38.1 on admission to 25.7 on discharge. No sign of bleed and surgical site does not appear to have hematoma. We recommend trending this at rehab until it stabilizes. . # A fib: Pt with history of PAF, rhythm controlled on amiodarone. Of note, she has not anticoagulated given history of GIB. She was continued on home amiodarone as well as asa-81 and remained in NSR throughout admission . # Severe AS: Pt with sever AS, valve area 0.8-1.0 cm2 and aortic valve gradient 56 mmhg on Echo in 4/[**2138**]. Symptomatically she denied any CP or SOB, however does have persistent fatigue which has been her baseline. Given her severe AS she is preload dependent and BPs were closely watched throughout admission. However, given her history of CHF, we avoided excess IVF (with the exception of intraoperatively). She remained relatively euvolemic throughout admission. . # Diastolic CHF: Pt noted have diastolic CHF with preserved EF on echo from 4/[**2138**]. Pt was euvolemic throughout admission and excessive IVF was avoided as above given her propensity to go into CHF. She was continued on home toprol-xl 25mg daily, and home lasix regimen 40mg 4x/week, 60mg 3x/week. Valsartan was held after Cr trended up to 2.0 but was 1.8 on discharge. Valsartan should be restarted on discharge. . # CAD: S/p PCI of prox LAD in [**2-23**], NSTEMI and in-stent restenosis treated with PTCA and DESx2 to mid-LAD in [**6-28**]. No signs or symptoms to suggest her fall is cardiac in nature. EKG on admission was unchanged from prior. Of note, she received a repeat EKG during episode of abdominal pain (see below) which was significant for ST depressions TWI I/aVL which were possibly increased from baseline. However, it was thought that this was more likely to be rate related given her tachycardia at the time and she did not seem to have any signs or symptoms of ischemia. She was continued on home asa, simva, and toprol-xl 25mg daily . # Abdominal Pain: On the floor postoperatively, her pain was well controlled and she had no shortness of breath or chest pain. She did experience an episode of right upper quardant abdominal pain. An ECG was obtained and as above was notable for mild ST changes as compared to prior, but it was thought this was rate related and there did not appear to be any cardiac signs or symptoms. The pain was most consistent with consipation/gas pain. She was given simethicone and an aggressive bowel regimen with resolution of pain. However she remained constipated requiring manual disimpaction. She subsequently was discharged on colace/senna/miralax, and PRN dulcolax suppository. . # CKD: Recent baseline 1.6-1.8. She was 1.5 on admission but trended up to 2.0 post operatively. This was likely prerenal but we did not aggressively rehydrate with IVF given her CHF history. We did hold her lasix the morning of [**2-4**] and allowed her to rehydrate PO. Cr trended down to 1.8 on discharge. We also held her valsartan in house which should be restarted on discharge . # Gout: Continued home allopurinol . # Code: Pt is a confirmed DNR/DNI Medications on Admission: -allopurinol 100mg PO QOD -amiodarone 200mg PO QOD -Cholestyramine 4g pack once daily -codeine-guaifenesin 100mg-10mg/5mL 1tsp qhs -colchicine 0.6mg [**Hospital1 **] PRN gout flare -Lasix 40mg po 4x/week, 60 mg PO 3x/week -Toprol-xl 25 mg po daily -prn SL nitro -simvastatin 80mg PO daily -Valsartan 40mg PO daily -aspirin 81mg po daily -Vit D3 400U daily Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO QOD (). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 4. furosemide 20 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-27**] Sprays Nasal TID (3 times a day) as needed for congestion. 13. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q24H (every 24 hours): for 1 month, to be completed [**2140-2-29**]. 15. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 17. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal pain/gas. 18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 19. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for gout flare: only during gout flare. 20. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. cholestyramine-sucrose 4 gram Packet Sig: One (1) PO once a day. 22. Outpatient Lab Work Please check hematocrit over the next 2 days to ensure stabilization given slow downtrend over admission. Was 25.7 on discharge Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: Primary: Left Hip Fracture Constipation Secondary: Aortic stenosis Paroxysmal Atrial Fibrillation Congestive Heart Failure Coronary Artery Disease Osteoperosis 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 24834**], You were admitted to the hospital because you fell and fractured your hip. You had surgery to repair the fracture and did quite well. We also carefully monitored your other health issues in the hospital and you remained stable. You were constipated but this improved by the time of discharge. We feel you are ready for discharge to rehab. We made the following changes to your medications: STARTED: lovenox (enoxaprin) 30mg injected once daily for 1 month through [**2140-2-29**]. STARTED: Maalox 15-30ml by mouth every 6 hours as needed for gas STARTED: Colace (docusate) 100mg by mouth twice daily STARTED: Senna 1-2 tabs by mouth twice daily STARTED: Miralax 17g by mouth daily STARTED: Dulcolax suppository once daily as needed for constipation STARTED: Tylenol 625mg by mouth every 6 hours as needed for pain You should continue all medications as you were previously taking. You should have your hematocrit (blood count) followed for the next 2-3 days at rehab to ensure that it stabilizes We also have set you up with follow up with the orthopedic surgeron. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2140-2-16**] at 8:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2140-2-16**] at 8:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PODIATRY When: WEDNESDAY [**2140-3-16**] at 2:30 PM With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "78.55" ]

icd9pcs

[ [ [] ] ]

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13432, 13432

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49091

Discharge summary

report

Admission Date: [**2173-12-7**] Discharge Date: [**2173-12-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 84yo male with alzheimer's, HTN, Prostate Ca, CAD s/p CABG c/o altered mental status. Family reports several months of increasing confusion. Wife (who is also suffering from dementia) reports that patient has become acutely more agitated last 24-48 hours. Reportedly unwilling to get out of tub, acutely confused, not c/o pain. Patient states that he was worried about falling when he got up. Patient denies any c/p, SOB, orthopnea, PND, light headedness, diaphoresis, focal weakness, bleeding, nausea, vomiting, diarrhea, constipation or any other complaints on ROS. Further history from family however suggests b/l le edema of several months duration, and ?shortness of breath in past. . In ED, 97.6, 84, 140/80, RR 18. Exam notable for crackles at bases, 2+ LE edema. EKG showed pseudonormalization of T-waves in precoridal leads. CXR +moderate bilateral effusions. Cards recommended admit to medicine, and follow on consult service. Patient given ASA 325, lopressor 5mg IV, lasix 20mg IV x1. . In the MICU pt's respiratory status improved dramatically with diuresis. He was transiently placed on nitro gtt and heparin gtt and transitioned to PO medications. He was stable on transfer to the floor. Past Medical History: CAD s/p CABG 4-vessel in [**2156**], records not available Hypercholesterolemia Hypertension Chronic Renal Insufficiency, baseline Cr 1.6-2.2 Prostate Ca, s/p TURP and radiation in [**2161**], w/ radiation cystitis Gout Alzheimer's Dementia Bilateral cataracts . Surgical History - CABG x4 in '[**56**] - cystoscopy and TURP in '[**61**] - cystoscopy TURP in '[**63**] - cystoscopy in '[**68**] Social History: Lives with wife, denies tobacco, Etoh, retired [**University/College **] professor . Family History: Mother with diabetes and prior [**Name (NI) 27141**]. Father deceased from a "clot" and pneumonia. Physical Exam: T97.4, BP 128/72, HR 86, RR22 O2 94% 1L NC Gen: Elderly man appearing younger than stated age, mildly tachypneic using abdomen and accessory muscles to breath HEENT: NCAT, PERRL, EOMI, mmm Neck: JVP elevated, with venous distension when fully upright Chest: No deformities, lungs with decreased breathsounds bilaterally at lower third with mild crackles, and occasional wheezes Heart: Occasional premature beat, II/VI systolic murmur at erb's point. Abd: NTND, +BS, no hepatosplenomegaly, Ext: wwp, 2+ pitting edema b/l to knee, no asterixis Pulses: 2+ DP pulses, 2+ popliteal pulses, no carotid or aortic bruits. Neuro: AOx3, mild facial asymmetry of lips, no dysarthria, CNII-XII otherwise intact, motor [**5-15**] upper, [**4-15**] lower bilaterally. Pertinent Results: LABS: [**2173-12-7**] 03:00AM BLOOD WBC-10.1 RBC-5.01 Hgb-15.7 Hct-47.5 MCV-95 MCH-31.4 MCHC-33.2 RDW-15.1 Plt Ct-173 [**2173-12-21**] 06:30AM BLOOD WBC-9.7 RBC-3.59* Hgb-11.4* Hct-35.3* MCV-98 MCH-31.6 MCHC-32.2 RDW-16.4* Plt Ct-182 [**2173-12-7**] 03:00AM BLOOD Neuts-83.2* Lymphs-6.7* Monos-9.2 Eos-0.7 Baso-0.2 [**2173-12-17**] 08:20PM BLOOD Neuts-89.7* Lymphs-5.0* Monos-4.9 Eos-0.3 Baso-0 [**2173-12-7**] 07:40PM BLOOD PT-14.1* PTT-35.2* INR(PT)-1.2* [**2173-12-20**] 06:25AM BLOOD PT-13.9* PTT-35.0 INR(PT)-1.2* [**2173-12-19**] 02:40PM BLOOD Ret Aut-2.2 [**2173-12-7**] 03:00AM BLOOD Glucose-122* UreaN-87* Creat-4.1*# Na-137 K-4.2 Cl-102 HCO3-19* AnGap-20 [**2173-12-21**] 06:30AM BLOOD Glucose-119* UreaN-102* Creat-4.1* Na-145 K-4.2 Cl-106 HCO3-28 AnGap-15 [**2173-12-7**] 03:00AM BLOOD ALT-64* AST-56* LD(LDH)-423* CK(CPK)-297* AlkPhos-117 TotBili-1.1 [**2173-12-17**] 08:20PM BLOOD ALT-27 AST-24 LD(LDH)-351* AlkPhos-91 Amylase-67 TotBili-0.5 [**2173-12-19**] 02:40PM BLOOD LD(LDH)-316* TotBili-0.5 DirBili-0.2 IndBili-0.3 [**2173-12-7**] 03:00AM BLOOD Lipase-72* [**2173-12-17**] 08:20PM BLOOD Lipase-40 [**2173-12-7**] 03:00AM BLOOD CK-MB-16* MB Indx-5.4 cTropnT-5.30* [**2173-12-7**] 05:20PM BLOOD CK-MB-14* MB Indx-6.5* [**2173-12-7**] 05:20PM BLOOD cTropnT-6.75* [**2173-12-8**] 12:33AM BLOOD CK-MB-12* cTropnT-6.36* [**2173-12-8**] 05:40AM BLOOD CK-MB-11* MB Indx-6.3* cTropnT-5.75* proBNP-[**Numeric Identifier 103008**]* [**2173-12-8**] 08:02PM BLOOD CK-MB-12* MB Indx-5.5 cTropnT-6.16* [**2173-12-8**] 10:19PM BLOOD CK-MB-12* MB Indx-4.5 cTropnT-6.17* [**2173-12-9**] 04:42AM BLOOD CK-MB-13* MB Indx-3.9 cTropnT-5.73* [**2173-12-10**] 01:22AM BLOOD CK-MB-8 cTropnT-5.77* [**2173-12-8**] 05:40AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.5 [**2173-12-21**] 06:30AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.6 [**2173-12-17**] 08:20PM BLOOD Albumin-3.6 [**2173-12-19**] 02:40PM BLOOD calTIBC-237* Hapto-238* Ferritn-135 TRF-182* [**2173-12-9**] 04:42AM BLOOD Triglyc-91 HDL-67 CHOL/HD-2.1 LDLcalc-55 [**2173-12-7**] 03:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-LESS THAN Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2173-12-19**] 11:58AM BLOOD Type-[**Last Name (un) **] pO2-97 pCO2-32* pH-7.49* calTCO2-25 Base XS-1 [**2173-12-8**] 09:25AM BLOOD Lactate-2.8* [**2173-12-10**] 01:47AM BLOOD Lactate-1.2 [**2173-12-15**] 09:45AM BLOOD Lactate-2.9* [**2173-12-16**] 07:00AM BLOOD Lactate-1.9 calHCO3-24 [**2173-12-16**] 08:15AM BLOOD Lactate-1.7 [**2173-12-19**] 07:44AM BLOOD Lactate-1.7 [**2173-12-19**] 11:58AM BLOOD Lactate-2.9* [**2173-12-7**] 05:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2173-12-15**] 03:10PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2173-12-7**] 05:20AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2173-12-15**] 03:10PM URINE Blood-LGE Nitrite-NEG Protein-500 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2173-12-7**] 05:20AM URINE RBC-[**6-20**]* WBC-[**3-15**] Bacteri-OCC Yeast-NONE Epi-0-2 [**2173-12-15**] 03:10PM URINE RBC->1000* WBC-134* Bacteri-MOD Yeast-FEW Epi-14 [**2173-12-7**] 04:50PM URINE Hours-RANDOM UreaN-993 Creat-171 Na-39 [**2173-12-21**] 08:38AM URINE Hours-RANDOM UreaN-895 Creat-113 Na-37 TotProt-39 Prot/Cr-0.3* [**2173-12-12**] 01:16PM URINE Osmolal-443 [**2173-12-21**] 08:38AM URINE Osmolal-510 . MICRO: Urine Cx ([**12-7**]): no growth Urine Cx ([**12-15**]): no growth . IMAGING: . Renal U/S ([**12-7**]): RENAL ULTRASOUND: The right kidney measures 8.4 cm. The left kidney measures 9.8 cm. The corticomedullary differentiation is preserved. There are no stones or hydronephrosis. A Foley catheter is seen within a collapsed bladder. IMPRESSION: Unremarkable renal ultrasound. . CXR ([**12-7**]): FINDINGS: The lung volumes are low limiting detailed evaluation. There are bilateral moderate pleural effusions. There is prominent cephalization of the pulmonary veins. The patient is status post median sternotomy and multiple surgical clips project over the silhouette of the aorta. The upper lungs are clear. The visualized soft tissues and osseous structures are grossly unremarkable. IMPRESSION: Moderate bilateral pleural effusions most consistent with congestive heart failure. Repeat radiography following appropriate diuresis recommended to assess for underlying infection. . ECG ([**12-7**]): Sinus rhythm with ventricular premature beats. Since the previous tracing of [**2168-1-1**] the rate is faster and the ventricular premature beats are new. QRS voltage has decreased. The Q-T interval is shorter and lateral T wave inversions are no longer present. . TTE ([**12-8**]): The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract well (LVEF = 35%). [Intrinsic function may be more depressed given the severity of mitral regurgitation.] No intraventricular thrombus is seen. Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. An eccentric, inferolaterally directed jet of at least moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Left ventricular cavity enlargement with regional systolic dysfunction c/w CAD. At leasst moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. . ECG ([**12-9**]): Sinus rhythm. Ventricular trigeminy. Long QTc interval. Possible left atrial abnormality. Consider prior inferior myocardial infarction. Non-specific lateral T wave flattening. Compared to tracing of [**2173-12-8**] sinus tachycardia is absent. The QTc interval is longer. Ventricular trigeminy is present. . CT Abd/Pelvis ([**12-17**]): CT ABDOMEN: Moderate cardiomegaly and trace pericardial effusion are noted. Marked coronary atherosclerosis was not seen on [**2173-10-16**]. Large bilateral pleural effusions are associated with moderate relaxation atelectasis. The pancreas, liver, gallbladder, spleen, adrenals, and kidneys are unremarkable. There is no evidence of obstruction or kidney stone. The large and small bowel are unremarkable without evidence of obstruction, free air or pneumatosis. CT PELVIS: The rectum, sigmoid, prostate and seminal vessicles are unremarkable. A Foley is noted within a distended bladder. There is no free fluid or free air in the pelvis. Bone windows demonstrate no suspicious blastic or lytic lesions. Moderate degenerative changes of thoracolumbar spine are unchanged since [**76**]/[**2167**]. IMPRESSION: 1. Cardiomegaly and large bilateral pleural effusions consistent with CHF. 2. No evidence of obstruction, infection or other abdominal pathology. . CXR ([**12-18**]): Comparison to [**2173-12-17**] chest radiograph. The appearance of the chest radiograph is virtually unchanged. There is obvious cardiomegaly with bilateral pleural effusions and evidence of bilateral hypoventilation. Mild cardiac edema. No newly appeared parenchymal opacities. IMPRESSION: No relevant radiographic changes as compared to [**2173-12-17**]. Brief Hospital Course: # Acute on chronic systolic heart failure: The patient became tacypnic and hypoxic upon admission, and CXR showed worsened moderately severe pulmonary edema, large left pleural effusion, increased moderate right pleural effusion. BNP on admission was [**Numeric Identifier 103008**]. He was sent to the MICU he was diuresed with Lasix 40-80 IV dosed by UOP and Diuril x1. For LOS in MICU he was -3868 Liters. A TTE showed mild to moderate regional LV systolic dysfunction with near akinesis of the basal half of the inferior and inferolateral walls, EF 35%, and moderate (2+) MR. [**Name13 (STitle) **] was transferred back to the floor, where he received occasional Lasix 40-80 IV doses when Is/Os were positive for the day. Further diuresis was held as he appeared euvolemic on exam. Repeat CXRs showed stable CHF. Heart Failure waws consulted and recommended converting metoprolol to Toprol XL, 1500 cc fluid restriction, and low sodium diet. He was also placed on hydralazine 10 mg PO q6hr for afterload reduction, but it was often held for SBP 100-110. His ACE-I was held in the setting of ARF. Upon discharge, he did not have lower extremity edema and was satting 97% on room air. The cause of his CHF exacerbation remained uncertain: it may have been secondary to cardiac ischemia, renal insult, less likely infection (urine Cx showed no growth and WBC 10.1 on admission). The patient can be restarted on Lasix 40 PO daily in [**2-13**] days when his renal function further improves, or if he becomes volume overloaded. His Hydralazine can be restarted for afterload reduction if his SBP increases. Continue 1500 cc fluid restriction. . # Respiratory Distress: On the day after admission, the patient triggered for tachypnea into the 30s and SaO2 88% on RA. He was placed on a NRB, ABG showed 7.42/38/57. CXR showed worsening congestive failure with persistent bilateral pleural effusions. He was given nebs, Lasix 40 IV, and Morphine 2 mg IV; and transferred to the MICU. In the MICU, the patient's respiratory status improved dramatically with diuresis with Lasix 40-80 IV dosed by UOP, Diuril x1, and he did not require non-invasive ventilation. pO2 improved to 64 -> 107 on ABG. He was transferred back to the medicine floor, and denied any SOB. CXR [**12-18**] showed bilateral pleural effusions and evidence of bilateral hypoventilation, mild cardiac edema, and no newly appeared parenchymal opacities. Diuresis was being held upon discharge as the patient appeared euvolemic and was satting 97% on room air. . # Acute Coronary Syndrome/CAD. He has a history of 4 vessel CABG in [**2156**]. The patient was found to have elevated Trop T, with 8 values over 3 days ranging 5.30-6.75. Large component of renal failure in the troponin elevation. CK ranged from [**Telephone/Fax (1) 103009**], and CK-MB was [**8-26**]. ECG showed sinus tachycardia with a VPB, possible left atrial abnormality, non-diagnostic inferior Q waves-cannot exclude a prior inferior myocardial infarction, non-specific lateral ST-T wave changes. Cardiology was consulted, and the patient was transiently placed on a heparin gtt. He was monitored on telemetry. TTE showed near akenesis of the basal half of inferior and inferolateral walls, but it was determined that he would not require long-term anti-coagulation for this. The patientw as continued on ASA, Atorvastatin, and Toprol XL. He was placed on Isosorbide Dinitrate 10 mg PO tid, but this was often held for SBP parameters. This can be added back on if his SBP incrases. As an outpatient, consider changing nitrate to long acting (isosorbide mononitrate) vs. starting Bidil (combination Isosorbide mononitrate and Hydralazine). . # Acute on Chronic Renal Failure: The patient has a history of CRI with a baseline Cr of 1.6-2.2. He has seen an outpatient nephrologist once at [**Hospital1 18**], and his CRI was thought to be due to an injury to his kidneys around thetime of his CABG. His Cr on admission was 4.1. On admission, FeNa 0.56%, FeUrea 24.2%. Renal ultrasound showed no evidence of hydronephrosis, calculi or masses. Renal was consulted and thought this was a primary cardiac event causing ischemic stiffening and pulmonary edema and ARF vs. a primary renal event causing CHF and demand ischemia. He was given Lasix 40-80 IV in the MICU for volume overload, but the patient then began to auto-diurese which suggested recovery from possibly ATN. He was started on Calcium Carbonate 500 mg PO tid with meals. His Cr decreased down to 3.0 on the medicne floor, then peaked again at 5.3 on [**12-18**]. A repeat renal ultrasound showed no evidence of hydronephrosis. Renal was re-consulted and further diuresis was held as he was likely at his intravascular limit for diuresis. Urine sediment showed few granular casts, no significant hyaline casts, many nondysmorphic RBCs. Therefore, his ARF was then thought to be prerenal azotemia in the setting of overdiuresis. Creatine was 4.1 at the time of discharge. Repeat urine lytes showed FeNa 0.98% and FeUrea 31.8%. He will follow up with renal as an outpatient in [**2-13**] weeks to continue the workup of his chronic kidney disease and to monitor his creatinine. A UPEP and SPEP were ordered, and need to be followed up after his discharge. His ACE-I was held through the hospitalization. He can restart Lasix 40 PO daily in [**2-13**] days, or as his volume status warrants. . # Altered mental status. Patient presented with several months of increased confusion, was found acutely confuesed and unwilling to get out of the tub. His mental status improved during the hospitalization, and he was alert and oriented x3 at the time of discharge. He was restarted on Aricept 10 mg PO qhs on [**12-11**]. He required soft wrist restraints prn and Haldol IV prn agitation. . # Hematuria: The patient pulled out his Foley on [**12-13**], with resulting hematuria. A 3 way Foley as reinserted, and the patient was put on continuous bladder irrigation, with clearing of his urine within 2 days. Foley was pulled out. However, on [**12-16**] the patient was found to have a clot at his penis tip, and a bladder scan showed 250 cc. Foley was reinserted and continuous bladder irrigation was restarted. His urine cleared 3 days later, and the Foley was discontinued. The patient is currently incontinent of urine. . # Anemia: Hct 47.5 on admission, trended down to 31.8, up to 35.3 at the time of discharge. Patient did not require any PRBCs. His last colonoscopy on [**6-/2166**] showed localized discontinuous abnormal vascularity with contact bleeding was noted in the rectum c/w radiation proctitis. His stools were guaiac positive. Hemolysis labs: hepto 238, LDH 316, t bili 0.5, d bili 0.2. Iron studies showed Fe 27, TIBC 237 (transferrin sat 11.6), ferritin 135 (nl), so he was put on Fe Gluconate IV, and transferred to PO at the time of discharge. . # Leukocytosis: WBC 10.1 on admission, and peaked at 18.9 on [**12-18**]. The patient remained afebrile. UA showed 134 WBC (but >1000 RBC), sm leuk, neg nitrite, mod bacteria. Urine Cx had no growth, but patient was started on Cipro 250 PO q12 hr (Day 1 = [**12-16**]) for empiric treatment of possible UTI. No decubitus ulcers on exam. His lactate fluctuated between 1.2-2.9. WBC at the time of discharge was 9.7 . # Abdominal pain: On [**12-17**], the patient complained of diffuse abdominal pain, and was noted to have a firm abdomen. His LFTs showed ressolving transaminitis with ALT 41, AST 44, T bili 0.5l. He had persistently elevated LDH. Amylase/lipase WNL. A noncontrast abdominal/pelvic CT showed no evidence of obstruction, infection or other abdominal pathology. His LFTs returned to [**Location 213**] at the time of discharge. (ALT 27, AST 24). . # Hypertension: Patient briefly on nitro gtt in MICU. Patient was started on Toprol XL 50 daily, Isosorbide Dinitrate 10 mg PO tid, and Hydralazine 10 PO q6 hr. The nitrate and hydralazine were generally held as his SBP was in the 100s. They can be restarted if his blood pressure increases as an outpatient. The patient may have been on an ACE-I as an outpatient, and that is being held in the setting of ARF. . # Hypercholesterolemia: Lipid panel [**12-9**] showed cholesterol 140, HDL 67, LDL 55, TG 91. He was continued on Atorvastatin 40 daily. . # Thrombocytopenia. Presented with plt 173, nadired at 140, back up to 182 at time of discharge. . # Prostate Cancer: No current issues. . # Gout: His outpatient allopurinol was held throughout the admission in the setting of ARF. As an outpatient, his allopurinol should be restarted as his creatinine allows to avoid a gout flare. . # FEN. Low sodium heart healthy diet, lactose-free, 1500 free water restriction. . # Contact: [**Name (NI) **] [**Name (NI) 103010**] (son-in-law) [**Telephone/Fax (1) 103011**] (c), [**Telephone/Fax (1) 103012**] (home); daughter (power-of-attorney) [**Name (NI) **] [**Name (NI) 103010**] [**Telephone/Fax (1) 103013**] (cell); patient's home (wife has dementia, where daughter is staying) [**Telephone/Fax (1) 103014**] . # Code: DNI, BUT TRIAL OF RESUSCITATION (Spoke with family on [**12-11**] and they were very clear about this) Medications on Admission: Atorvastatin 10mg daily Aspirin 325mg daily HCTZ 12.5mg daily Metoprolol 12.5mg [**Hospital1 **] Discharge Medications: 1. Metoprolol Succinate 50 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* 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). Disp:*300 mL* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/ MEALS (). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 doses. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: PRIMARY: Altered Mental Status Acute on chronic heart failure Acute on chronic renal failure Acute Coronary Syndrome/Non-ST elevation myocardial infarction Respiratory Distress Hematuria Anemia Thrombocytopenia Bacteria on Urinalysis . SECONDARY: Hypertension Hypercholesterolemia Alzheimer's Dementia History of Prostate Cancer Gout Discharge Condition: Stable, SaO2 97% on RA, Euvolemic, Alert to person, place, and date Discharge Instructions: 1. If you develop shortness of breath, chest pain, decreased urine output, mental status changes, increased lower extremity edema, fever >101.5, shaking chills, or any other symptoms that concern you, call your primary care physician or return to the emergency department. 2. Take all medications as prescribed. 3. Attend all follow up appointments. 4. The patient is currently euvolemic, and has not required diuresis for the past 4 days. Per renal recommendations, restart Lasix 40 PO daily in [**2-13**] days. 5. He will eventually need to be on a CHF regimen. Start Lasix in [**2-13**] days of based on his volume status. In the hospital, he received Hydralazine 10 mg PO q6 hr for afterload reduction and Isosorbid Dinitrate 10 mg PO tid (but they were often held as his SBP was in the 100s). These can be added on after discharge if his SBP increases (or can consider Bidil). 6. The patient's allopurinol was held during this hospitalization for his ARF. Add back as his renal failure improves to avoid a gout flare. 7. An SPEP/UPEP were ordered upon discharge for the work up of his chronic kidney disease. These will need to followed up on after discharge. 8. Continue fluid restriction of 1500cc, especially while the patient is off Lasix. 9. Continue to hold his ACE-I until his ARF ressolves. Followup Instructions: You will need to make a follow up appointment with a new primary care physician in gerontology ([**Telephone/Fax (1) 719**]) once you are discharged from rehab. . You will need a follow up appointment with Dr. [**Last Name (STitle) 4090**] in the nephrology clinic ([**Telephone/Fax (1) 60**]) within the next 2-3 weeks. The nephrology secretary will contact [**Name (NI) **] (daughter) within the next week re: date/time of appointment.

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Discharge summary

report

Admission Date: [**2163-6-23**] Discharge Date: [**2163-7-7**] Date of Birth: [**2079-1-17**] Sex: M Service: SURGERY Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol / Torsemide Attending:[**First Name3 (LF) 1390**] Chief Complaint: Fall down stairs Major Surgical or Invasive Procedure: Chest tube placement ([**2163-6-26**]) Intubation ([**2163-6-27**]) Failed extubation and reintubation ([**2163-6-30**]) Trach and PEG ([**2163-7-1**]) History of Present Illness: Mr. [**Known lastname 108855**] is an 84 yo M with history of atrial fibrillation on coumadin, ventricular tachycardia, and systolic CHF (ejection fraction 35-40%), and baseline rhythm complete heart block status post pacer placements who presents after a fall down stairs with loss of consciousness. At around 2am the morning of admission, Mr. [**Known lastname 108855**] got up from bed and went into the kitchen to drink scotch. He drank "[**1-16**] cup." Immediately after, he attempted to go down the stairs to the bedroom and this was the last thing he remembered before being in the ED. Per wife, she heard "thumps" and immediately went to the stairs, where she found the patient unconscious with blood behind his head. He was completely still and she [**Month/Day (2) **] any shaking, tongue biting, or incontinence. She immediately called 911. Upon EMT arriving, the patient became somewhat interactive. . The patient [**Month/Day (2) **] feeling shortness of breath, chest pain, or lightheaded before the fall. He does not recall tripping. He did not feel any different than usual yesterday evening and [**Month/Day (2) **] any recent viral illness. Of note, two days before admission the patient did have one episode of light headedness after getting out of bed in the morning, requiring him to lean against the wall. He felt much better after drinking [**Location (un) 2452**] juice and felt completely improved after lunch that day. He now complains of chest pain since the fall. . Mr. [**Known lastname 108855**] [**Last Name (Titles) **] fever, chills, night sweats, headache, vision changes, sore throat, abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, dysuria, hematuria. Past Medical History: PMH: ventricular tachycardia, dilated cardiomyopathy with EF 35-40%,- CAD s/p stenting; chronic systolic CHF, atrial tachycardia, atrial fibrillation, rectal cancer s/p chemo radiation and surgery in [**2157**], GI bleed [**2-16**] angiectasia in the duodenum [**1-/2162**], CVA in [**2150**] with right hand dysthesia, prior mechanical falls, depression PSH: CAD s/p stenting of the OM in [**2-/2159**] following cardiac arrest, - s/p dual chamber [**Year (4 digits) 3941**] in [**2-/2159**] Social History: Mr. [**Known lastname 108855**] lives in [**Location 745**] with his wife. They are currently in the process of moving to an apartment. Per wife, Mr. [**Known lastname 108855**] has been feeling stress/depressed about moving out of their 42 year home. They have 2 children. He is a retired computer science professor. [**First Name (Titles) **] [**Last Name (Titles) 22381**] smoked 5 cigars a day for 30 years and quit in [**2150**] after his CVA. He drinks once or twice a week. His wife says that even just a little alcohol 'affects him quite a bit' in changing his mood and makes 'him sick' Family History: Father died in 80s from MI. Mother died in 80s from PE. No family history of colon, breast, uterine, or ovarian cancer. No family history of seizures. Physical Exam: Admission Physical Exam VS: T 98 BP 118/56 HR 66 RR 32 O2 Sat 95% 3L GENERAL: Man laying still in bed. NAD. Sleeping but easily arousable. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, JVP 11cm. no carotid bruits. LUNGS: No increased work of breathing. Diffuse wheezes and rhonci with crackles at the bases. HEART: RRR, III/VI holosystolic murmer at the lower right sternal border. Chest is tender to palpation. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle strength 5/5 throughout but patient has pain in moving them. sensation intact at distal extremities. Pertinent Results: CXR ([**2163-6-23**]) - There is moderate cardiomegaly, mild vascular congestion, slightly increased compared to [**2162-11-20**]. Severe pulmonary artery dilatation indicating pulmonary arterial hypertension has worsened. Transvenous pacemaker/defibrillator leads end in the right atrium and right ventricle respectively. There is no pleural effusion and no pneumothorax. No displaced fractures. CT head ([**2163-6-23**]) - No acute intracranial process. CT cspine ([**2163-6-23**]) - No fractures and no malalignment. Moderate denerative changes. CT A/P ([**2163-6-23**]) - No acute process of the abdomen and pelvis including no evidence of retroperitoneal hematoma. No splenic injury and no left lower rib fractures. Small left pleural effusion. Tiny small right pneumothorax and focus of mediastinal air which could be explained by attempted line placement. Echo ([**2163-6-24**]) - Poor image quality. The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably mildly depressed (LVEF= 40-45 %). There is no ventricular septal defect. The right ventricular cavity is dilated 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 mild bileaflet mitral valve prolapse. An eccentric, posteriorly directed jet of mild to moderate ([**1-16**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. At least mild pulmonary hypertension is detected.There is no pericardial effusion. CTA chest ([**2163-6-24**]) - Acute fractures of the left first through tenth ribs, with some fracture displacement, with subjacent moderate-sized left pleural fluid collection,likely containing blood layering in the dependent portion. There is left lower lobe collapse, and mild left upper lobe atelectasis. No pneumothorax. No pulmonary embolus detected to the subsegmental levels. No dissection. Equivocal right 5th-7th rib injuries. The right lung is clear. CT torso ([**2163-6-25**]) - No evidence of active bleeding in the chest or abdomen. Innumerable left-sided rib fractures and questionable, right rib fractures as previously described. In addition, there is a non-displaced fracture of the left clavicle near the sternoclavicular junction. There is a lytic lesion in the distal left clavicle adjacent to the aromioclavicular joint which appears new from a radiograph in [**2163-5-15**] and is concerning for a metastatic focus. Decreased attenuation in the T4 vertebral body on the right may represent a second lytic lesion. Continued atelectasis involving the left lower lobe with left pleural effusion, not significantly increased from prior and other, additionally described, chronic findings in the abdomen, unchanged. L shoulder R|XR ([**2163-6-26**]) - There is an acute fracture involving the left distal clavicle extending into the AC joint. This was not present on the prior study from [**2163-6-7**]. There is also severe degenerative changes of the left humeral head with spurring. There is a left-sided pacemaker. Moreover, there is increased density to the left lung which may be due to hemorrhage or pleural effusion which has increased since the Chest CT scan Brief Hospital Course: [**6-23**]: Initial trauma workup in the ED including CXR, CT head, CT c-spine, CT abdomen/pelvis did not show significant trauma and the patient was admitted to medicine for workup for syncope. On the SIRS team, the patient was noted to have an increasing oxygen requirement and was initially diuresed for a potential CHF exacerbation. [**6-24**]: CTA to r/o PE and showed left-sided pleural effusion concerning for a hemothorax in the context of the down-trending hct 30 on initial presentation ([**6-23**])->28 ([**6-24**])-> 26 ([**6-25**])->24 ([**6-25**])->21 ([**6-25**]) between w/increasing hypoxia. [**6-25**]: Repeat CT torso showed [**10-26**] left-sided rib fractures, up to 3 questionable right rib fractures, atelectasis vs scarring at the posterior right lung base, and stable left pleural effusion. Received 2 units FFP and 1 unit PRBC [**6-26**]: Increasing O2 requirement with PO2 in the low 90's on 4-5L NC. 1 additional unit PRBC, diuresing with Lasix 40mg IV x3 with the transfusions. IV Morphine and pain regimen was up-titrated for splinting. Repeat CXR showed large left pleural effusion and Thoracic surgery and IP were consulted for the concern of hemothorax. IP placed a pigtail catheter, which drained 750cc of red blood on insertion, and the patient developed hypotension to the 80's systolic from a prior range of SBP 90's-120's. Triggered for hypotension and received 250cc bolus. PO2 was noted to be 98% on 6L NC with decreasing UOP. [**6-27**]: He was transferred to the MICU for hypoxia. The Trauma Surgery service was consulted and assumed care of the patient. He was transferred to the Trauma ICU. He was placed on a facemask. The Acute Pain Service was consulted and an epidural was placed for improved pain control. On imaging a white out of the right lung was placed and the patient became increasingly hypoxemic and dyspneic. He was intubated and bronch with copious secrections throughout the left lung. Left lung pneumonia was demonstrated on CT chest. He was treated with vanco and cefepime. [**6-28**]: A right subclavian central line was placed and his pigtail catheter was discontinued. Bronch was repeated with additional BAL. Ciprofloxacin was added to antibiotic regimen. [**6-29**]: Bronch was repeated this time with thin secretions. He remained on pressors. [**6-30**]: He was tranfused one unit of PRBC and started on solumedrol. He was extubated but immediately failed and was reintubated. His epidural was discontinued. [**7-1**]: Patient underwent bedside trach and PEG. Upper GI endoscopy done at the time was negative for any abnormal findings. [**7-2**]: Patient remained on ventilator. [**7-3**]: He was weaned to trach mask and remained stable off the vent all day. He was put back on the vent on CPAP settings at night. BAL demonstrated MSSA and his antibiotics were narrowed to just vanco/cipro. Home antihypertensives and lasix were restarted. [**7-4**]: He tolerated trach mask all day. Steroid taper was started. Started prednisone taper with plans to taper by 10mg every 48hours. Remaining antibiotics were dc'ed. [**Date range (1) 40196**]: Tube feedings were adjusted to correct sodium levels. He was initially hypernatremic to 154. His tube feeds were changed from Novasource Renal to Replete with Fiber at 70cc/hr with 250cc q4hr free water flushes. His lasix was held and he was put on D5W at 100cc/hr. His sodium decreased to 148 on the morning of [**7-7**] and he was felt to be stable for discharge. His free water flushes were continued and his D5W was dc'ed. Medications on Admission: CITALOPRAM -10 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 40 mg Tablet - 1(One) Tablet(s) by mouth twice a day GABAPENTIN - 100 mg Capsule - one Capsule(s) by mouth daily at bedtime LISINOPRIL - 2.5 mg Tablet - one Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - one Tablet(s) by mouth once a day PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day PHYSICAL THERAPY-LEFT SHOULDER PAIN - - Evaluate and treat . POTASSIUM CHLORIDE [KLOR-CON M20] - 20 mEq Tablet, ER Particles/Crystals - 1 Tab(s) by mouth daily SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily TEDS STOCKINGS - 1 PAIR - WEAR DAILY TO PREVENT ANKLE SWELLING WARFARIN - (med list update) - 2.5 mg Tablet - one Tablet(s) by mouth 2 tabs on MWF, daily as directed by MD FERROUS SULFATE - 325 mg Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day PRAMOXINE-ZINC ACETATE [ITCH RELIEF] - 0.5 %-0.5 % Lotion - [**Hospital1 **] Discharge Medications: 1. citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 2. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q12H (every 12 hours). 3. carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 7. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 8. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mL PO Q4H (every 4 hours) as needed for pain. 10. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: 2-4 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing. 12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Four (4) Puff Inhalation Q4H (every 4 hours). 13. prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: please wean to 10mg qday on [**7-9**] and then discontinue on [**7-9**]. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital -[**Hospital1 8**] Discharge Diagnosis: Multiple bilateral rib fractures Respiratory failure Left clavicular fracture 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: 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 are NOT being restarted on your home medication of COUMADIN which you take for atrial fibrillation. Once you are discharged from rehab please follow-up with your primary care provider to discuss restarting this medication. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please follow up in the Acute Care Surgery Clinic in two weeks. Call ([**Telephone/Fax (1) 2537**] for an appointment. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] IM (NHB) Date/Time:[**2163-7-19**] 2:00 Provider: [**Name10 (NameIs) 13953**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2163-7-28**] 2:45 Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2163-8-8**] 12:00

[ "E880.9", "V15.88", "255.41", "V55.3", "810.02", "599.0", "285.1", "507.0", "850.11", "995.91", "276.0", "V53.32", "518.81", "V58.61", "860.2", "584.9", "305.00", "427.31", "V10.06", "V45.82", "807.08", "038.9", "041.6", "873.8", "E947.8", "428.0", "041.11", "428.43" ]

icd9cm

[ [ [] ] ]

[ "31.1", "03.90", "96.6", "86.59", "43.11", "33.24", "96.72", "33.22", "34.04" ]

icd9pcs

[ [ [] ] ]

14158, 14228

7969, 11540

359, 512

14349, 14349

4357, 7946

15801, 16340

3401, 3553

12624, 14135

14249, 14328

11566, 12601

14527, 15778

3568, 4338

303, 321

540, 2255

14364, 14503

2277, 2773

2789, 3385

55,963

160,989

40577

Discharge summary

report

Admission Date: [**2146-6-13**] Discharge Date: [**2146-6-14**] Date of Birth: [**2079-5-21**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: IPH Major Surgical or Invasive Procedure: none History of Present Illness: 67 RHW with PMH of DVT on coumadin, Ca Vagina and rectum s/p chemo presented from OSH with a large Right frontal IPH. HPI provided by notes, and family. Her family members spoke with her on [**Name (NI) 1017**] night and she was at her normal self. She lives alone. This am, when her brother's wife went to see her to go for a routine doctors follow up [**Name5 (PTitle) **], she was noted to be confused. She was irritable, was talking non sense. She was able to walk but was walking into things. She was taken to OSh where BP was 180/100. She rapidly became drowsy and started vomiting. She was intubated and CT head showed large IPH. She was shifted to [**Hospital1 18**]. She was given vitamin K and factor 9. INR on presentation was 2.1 which became 1.7 after above. Neurourgery saw her and defd surgical intervention. Next, Neurology was called. Past Medical History: - DVT on coumadin - Left carotid endarterectomy - Ca Vagina and Rectum s/p surgery and resection Social History: Ex smoker, Ex alcoholic, No drugs Family History: nc Physical Exam: Physical Examination; Gen; lying in bed, intubated HEENT; NC/AT, mucous membranes moist, oropharynx clear CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; MS;Intubated and sedated CN; PERRL 1mm BL non reactive, other Cr nerve exam limited Motor;some spontaneus movement on right side Sensory; withdraws to pain on right side, not on left Coordination;defd Gait; deferred Pertinent Results: [**2146-6-13**] 12:15PM BLOOD WBC-12.4* RBC-4.25 Hgb-12.1 Hct-37.0 MCV-87 MCH-28.4 MCHC-32.6 RDW-14.2 Plt Ct-269 [**2146-6-13**] 12:15PM BLOOD Neuts-86.4* Lymphs-10.2* Monos-2.8 Eos-0.2 Baso-0.4 [**2146-6-13**] 12:15PM BLOOD PT-18.6* PTT-25.4 INR(PT)-1.7* [**2146-6-13**] 12:15PM BLOOD Glucose-251* UreaN-15 Creat-0.9 Na-141 K-3.5 Cl-99 HCO3-26 AnGap-20 CT brain on [**2146-6-13**]: IMPRESSION: 1. Large right frontal parenchymal hematoma with 2 cm of leftward subfalcine herniation and early downward transtentorial herniation. 2. Left posterior frontal gyral hyperdensity is seen and small amount of subarachnoid hemorrhage cannot be excluded. Brief Hospital Course: Patient was admitted with large IPH with midline shift and hernation. Given the severity of the hemorrhage, it was felt that the injury was not compatible with life and that no surgical intervention would be beneficial. After discussion with her family, she was made CMO. She was extubated upon arrival to the ICU, and passed away [**2146-6-14**]. Medications on Admission: - Simvastatin - coumadin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "V49.86", "431", "V70.7", "V10.44", "V12.51", "V58.61", "V10.06", "348.4" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

2968, 2977

2511, 2860

317, 323

3028, 3037

1838, 2488

3093, 3103

1394, 1398

2936, 2945

2998, 3007

2886, 2913

3061, 3070

1413, 1819

274, 279

351, 1205

1227, 1326

1342, 1378

2,034

187,734

970

Discharge summary

report

Admission Date: [**2195-8-17**] Discharge Date: [**2195-8-20**] Date of Birth: [**2135-2-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 60-year-old gentlemen who was in previously good health until [**8-15**] when he felt weak and fell to the ground and also had one episode of hematemesis. In retrospect, the patient recalls that one week prior to admission he had an episode of melena. Patient was evaluated at [**Hospital3 3765**] and was found to have a hematocrit of 25.5. An nasogastric tube lavage at that time revealed maroon fluid coffee grounds. The patient on that day underwent an esophagogastroduodenoscopy which showed 2+ varices and erosions in the cardiac antrum. The patient was transfused four units of packed red blood cells to stabilize his hematocrit at 29-30%. The patient underwent a repeat esophagogastroduodenoscopy on [**8-17**] which again showed 2+ varices and gastritis with no evidence of active bleeding. At that point, the patient was transferred to the [**Hospital6 1760**] where his hematocrit was found to be 28.2. The patient was admitted directly to the Medical Intensive Care Unit. The patient underwent a repeat esophagogastroduodenoscopy on [**8-18**] which showed Grade III varices in the lower one third of the esophagus and also stigmata of recent bleeding. Four bands were placed around these varices. In addition, the esophagogastroduodenoscopy showed some evidence of gastritis and portal hypertensive gastropathy with nonbleeding varices in the cardia. In the Medical Intensive Care Unit, his creatinine dropped further to 26 and the patient was given an additional one unit of packed blood cells to increase his hematocrit to 29.8. At the time of transfer out of Medical Intensive Care Unit, the patient no longer had reported any more episodes of hematemesis. He denied any abdominal pain but still noted tarry stools. PAST MEDICAL HISTORY: Insulin dependent diabetes times 15 years, macular degenerative, chronic urinary tract infections, no coronary artery disease, left nephrectomy 40 years ago with blood transfusion at that time. MEDICATIONS PRIOR TO ADMISSION: NPH 50 in the a.m. and 58 in the p.m., regular insulin 15 in the a.m. and 7 in the p.m., Bactrim as needed for his recurrent urinary tract infections and he is on a macular degeneration study medication. While in the hospital, the patient was placed on levofloxacin when there was a question to treat a possible community acquired pneumonia. In addition, the patient was placed on Protonix, propanolol, Lasix and spironolactone. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Negative for any tobacco or alcohol or injection drug use. He thinks he may have received transfusions 40 years ago at the time of his nephrectomy. The patient has no tatoos. Is in a monogamous relationship with his wife and he denies any common history of liver disease or liver disease. EXAMINATION ON ADMISSION: He is afebrile. Blood pressure 125/70. Pulse of 84. Respirations 24. 02 saturation of 92% on two liters. He has [**2-3**] left systolic murmur, heard best at the left sternal border. He had no palpable hepatomegaly and a well-healed nephrectomy scar. Abdomen was distended but was not tense. He had no lymphadenopathy. He had palpable distal pulses and trace to 1+ bilateral lower extremity edema. He had no asterixes and is alert and oriented. He had no spider angiomata, no gynecomastia. Of note were occasional scattered cherry angiomata in his trunk. LABORATORY STUDIES ON TRANSFER OUT OF THE MEDICAL INTENSIVE CARE UNIT ARE AS FOLLOWS: CBC: White blood cell count 12.3, hemoglobin and hematocrit of 9.8 and 28.1, platelets of 151,000. Chemistry panel: Sodium 142, potassium 3.4, chloride 115, bicarbonate 20, BUN and creatinine of 19 and 0.8 and glucose of 73. His calcium was 7.1, his magnesium is 1.6, phosphorus is 2.4. HOSPITAL COURSE: The patient was hemodynamically stabilized in the Medical Intensive Care Unit and transferred to the General Medical Service on the regular floor. Numerous hepatology studies were sent off including hepatitis B, hepatitis C and an autoimmune work-up. In addition, iron and ferritin were also sent. His hepatitis B studies are currently pending. His hepatitis C is negative. His H. Pylori negative. His autoimmune antibody studies are all pending. His iron is 63 and his ferritin is 41. An ultrasound on hospital day number three showed the following results: 1. Small liver with coarse echogenicity. 2. Massive ascites. 3. No intrahepatic ductal dilatation. 4. Splenomegaly. 5. Gallstones with no evidence of cholecystitis. 6. Common bile duct of [**1-4**] mm. 7. SMV and a splenic vein patent. Patent hepatic artery. 8. Hepatic vein and portal vein that were patent. The patient's hematocrit continued to improve over the course of the hospitalization and on discharge ([**8-20**]), his hematocrit had stabilized to 31.5. The patient's phosphorus was low most of the course of admission and at 2.0 to 2.4 and the patient was given one packet of Neutra-Phos. The patient will be discharged to home with no visiting nurse follow-up. The patient will however be followed up by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**], within one week of discharge. In addition, the patient will follow-up with Dr. [**Last Name (STitle) **] of the Gastrointestinal Service for re-scoping, re-evaluation and re-banding of his varices. The patient will see Dr. [**Last Name (STitle) **] within three weeks of discharge. The patient will be discharged home on the following medications: DISCHARGE MEDICATIONS: 1. Spironolactone 25 mg q.d. 2. Lasix 20 mg q.d. 3. Propanolol 10 mg t.i.d. 4. Protonix 40 mg q.d. 5. Neutra-Phos 1 packet q.d. times two days. CONDITION ON DISCHARGE: Stable and patient will be discharged to home. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 4872**] MEDQUIST36 D: [**2195-8-24**] 22:13 T: [**2195-8-24**] 22:13 JOB#: [**Job Number 6456**]

[ "362.50", "535.50", "456.8", "250.00", "571.8", "789.5", "456.20", "537.89", "486" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

5712, 5862

3950, 5689

2163, 2649

156, 1912

2985, 3932

1935, 2130

2666, 2970

5887, 6232

51,716

192,084

54054

Discharge summary

report

Admission Date: [**2154-4-16**] Discharge Date: [**2154-4-23**] Date of Birth: [**2100-4-6**] Sex: M Service: CARDIOTHORACIC Allergies: Hytrin / niaspan Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: CABG x 4(LIMA-LAD; SVG to diag; SVG to OM; SVG to RCA)[**2154-4-16**] History of Present Illness: This is a 53 year old male with known coronary artery disease. Cardiac catheterization dating back to [**2145**] showed total occlusion of right coronary and left anterior descending arteries. Currently, he remains relatively asymptomatic and has a decent functional status. He performs routine ADLs without difficulty, and remains very active. He denies history of chest pain, dyspnea, orthopnea, PND, pedal edema and syncope. Recent SPECT showed viable myocardium with normal LV function. He is now referred for surgical revascularization but has yet to undergo repeat cardiac catheterization. Past Medical History: - Coronary Artery Disease - Hypertension - Dyslipidemia - Diabetes Mellitus Type II - Fatty Liver - History of Pyelonephritis - GE reflux disease Social History: SOCIAL HISTORY : Lives with: Wife in [**Location (un) 110799**] Occupation: Glass Industry Cigarettes: Denies Other Tobacco use: Quit cigars over 6 yrs ago, smoked a cigar a day for 25 yrs ETOH: Quit [**2153-12-9**], previously [**1-15**] drinks/week Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse: 100 Resp: 16 O2 sat: 98% room air B/P Right: 180/104 Left: 147/100 General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none. Normal s1s2 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], small ventral hernia noted Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None Neuro: Grossly intact [x] 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 bilaterally Pertinent Results: Imaging Cardiac Cath [**4-16**]: 1. Selective coronary angiography of this right dominant system demonstrated two vessel and left main coronary artery disease. The LMCA had an 80% distal stenosis. The LAD had a total occlusion at the mid-vessel. The LCx is a large vessel without angiographically apparent flow-limiting stenosis. The RCA is occluded. 2. Limited resting hemodynamics revealed systemic arterial normotension with a central aortic pressure of 105/67 mmHg. Left-sided filling pressures are mildly elevated with LVEDP of 15mmHg. FINAL DIAGNOSIS: 1. Two vessel and left main coronary artery disease. 2. Aspirin daily. 3. Start heparin drip. 4. Cardiac surgery evaluation, email sent and Dr. [**Last Name (STitle) **] is aware. Carotid Series [**4-16**]: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is no plaque seen in the ICA . On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 65/21, 68/24, 76/29, cm/sec. CCA peak systolic velocity is 106 cm/sec. ECA peak systolic velocity is 148 cm/sec. The ICA/CCA ratio is .71 These findings are consistent with no stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 65/26, 77/35, 54/24, cm/sec. CCA peak systolic velocity is 109 cm/sec. ECA peak systolic velocity is 163 cm/sec. The ICA/CCA ratio is .70. These findings are consistent <40% stenosis. There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA no stenosis. Left ICA <40% stenosis. CXR [**4-17**]: FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is normal. There is no evidence of pulmonary edema. There are no acute skeletal abnormalities. IMPRESSION: No acute cardiopulmonary process. . [**2154-4-18**] Intra-op TEE Conclusions PRE-CPB: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-10**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. [**2154-4-23**] 04:51AM BLOOD WBC-9.2 RBC-3.48* Hgb-9.8* Hct-30.8* MCV-88 MCH-28.1 MCHC-31.7 RDW-13.5 Plt Ct-320# [**2154-4-21**] 07:00AM BLOOD WBC-10.9 RBC-3.59* Hgb-10.2* Hct-31.7* MCV-88 MCH-28.4 MCHC-32.1 RDW-13.6 Plt Ct-202 [**2154-4-23**] 04:51AM BLOOD UreaN-16 Creat-0.7 Na-136 K-4.5 Cl-97 [**2154-4-20**] 06:55AM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-99 HCO3-30 AnGap-13 Brief Hospital Course: The patient was brought to the Operating Room on [**2154-4-18**] where the patient underwent CABG x 4 LIMA-LAD; SVG to diag; SVG to OM; SVG to RCA)[**2154-4-16**] with Dr. [**Last Name (STitle) **]. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued. He did develop a tiny left apical pneumothorax which remained stable on CXR. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He did have some minimal erythema surrounding left knee saphenectomy site without associated pain or drainage. He was afebrile and WBC count was normal at the time of discharge. He was instructed to call with any increasing erythema, pain, drainage or temperature >100.4. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: ATORVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 8 units bedtime METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day NICOTINE [NICOTROL] - (Prescribed by Other Provider) - 10 mg Cartridge - 1 puff inh prn QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day RANITIDINE HCL - (Prescribed by Other Provider) - 300 mg Capsule - 1 Capsule(s) by mouth as needed for prn SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day VITAMIN D - (Prescribed by Other Provider) - Dosage uncertain ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - Dosage uncertain ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule - 1 Capsule(s) by mouth once a day CINNAMON BARK [CINNAMON] - (Prescribed by Other Provider) - 500 mg Capsule - 2 Capsule(s) by mouth twice a day FLAXSEED OIL - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE 1500 COMPLEX] - (Prescribed by Other Provider) - 500 mg-400 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain NICOTINE (POLACRILEX) - (Prescribed by Other Provider) - 4 mg Gum - as needed Discharge Medications: 1. nicotine (polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q2H (every 2 hours) as needed for cravings. Disp:*qs Gum(s)* Refills:*0* 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily (). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 11. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 13. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 7 days. Disp:*7 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease, Hypertension, Dyslipidemia, Diabetes Mellitus Type II, Fatty Liver, History of Pyelonephritis, GE reflux disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2154-5-29**] 1:00pm in the [**Hospital **] Medical office building, [**Doctor First Name **] [**Hospital Unit Name **] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2154-5-2**] 10:00 [**Hospital **] Medical office building, [**Doctor First Name **] [**Hospital Unit Name **] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2154-5-7**] 11:15a Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 104406**] in [**3-14**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2154-4-23**]

[ "250.00", "272.4", "512.1", "327.23", "571.8", "V58.66", "530.81", "414.01", "V70.7", "V13.02", "V15.82", "414.2", "401.9", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "37.22", "39.61", "36.15", "88.56", "36.13" ]

icd9pcs

[ [ [] ] ]

10104, 10179

5402, 6888

290, 362

10361, 10596

2259, 2803

11438, 12304

1443, 1558

8818, 10081

10200, 10340

6914, 8795

2820, 5379

10620, 11415

1573, 2240

243, 252

390, 988

1010, 1158

1174, 1427

10,072

109,339

26419

Discharge summary

report

Admission Date: [**2141-4-7**] Discharge Date: [**2141-4-19**] Date of Birth: [**2087-4-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: esophageal cancer t3, N1 s/p neoadjuvent chemo -presents for resection Major Surgical or Invasive Procedure: lap esophagectomy and feeding J-tube History of Present Illness: Mr. [**Known lastname 23306**] is a 53-year-old gentleman who has a T3 N1 adenocarcinoma of the distal esophagus. He was treated with chemotherapy and radiation in the neoadjuvant fashion and this had stable to improving disease and, therefore, presents for resection. Past Medical History: Hypertension Hypercholesterolemia Bilateral knee arthritis esophgeal cancer T3, N1 Social History: Real Estate broker, divorced, two kids- son is HCP. [**Name (NI) **] smoking history, 44 pack years, stopped [**1-4**]. No EtOH for 23 years. Family History: Mother with breast cancer, father with emphysema, lung cancer and older brother had metastatic melanoma. Physical Exam: PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3, pulse 92, blood pressure 138/74, respiratory rate 16, oxygen saturation 99% on room air, weight 203.7 pounds. GENERAL: Slightly ill-appearing gentleman, alert and oriented x3. HEENT: There is no cervical or supraclavicular lymphadenopathy. NECK: Supple and nontender. LUNGS: Clear to auscultation and percussion. CHEST: Chest excursion is symmetric and good. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended, without mass or hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-4-16**] 05:20PM 11.2* 3.44* 11.4* 32.6* 95 33.1* 35.0 15.7* 349 BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2141-4-16**] 05:20PM 349 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-4-16**] 05:20PM 110* 25* 0.7 133 4.9 93* 30 15 barium swallow [**2141-4-12**] IMPRESSION: 1. Status post esophagectomy with gastric pull-through. Small contained leak is seen posteriorly along the likely inferior margin of the cervical anastomosis. Extraluminal contrast most likely tracks intramurally, and then forms a small collection posteriorly, but does not extend farther into the mediastinum. 2. Nasogastric tube, with sideport located in the middle of the gastric pull- through, tube could be advanced approximately [**4-6**] cm for more optimal positioning. Brief Hospital Course: pt admitted and atken tot he OR for Minimally invasive esophagectomy; mediastinal lymph node dissection, tube jejunostomy. OR course was uneventful. Epidural was placed and PCa was also used for pain control. Admitted to the SICU for post op management. Chest tube was to sxn , anastomotic JP to bulb sxn and J-tube initially to gravity. POD#2 passage of flatus. Trophic tube feeds were started and advance when passing stool and flatus. chest tube was placed to water seal. Transfused 2UPRBC for post op anemia. Pt restarted on fent patch which he had been on PTA. POD#4 chest tube d/c'd. Epidural d/c'd and mainatined on roxicet elixir w/ PCA for breakthru. POD# 6 barium swallow done revealing contained cervical anastomic leak. JP drainage sent for trigylcerides which was minimal not consistent w/ a chyle leak. Maintained NPO status and TF increased to goal. NGT output remained high 700-1000cc. POD#9 attempted NGT to gavity but pt became nauseous and sxn was resumed. POD#10 KUB was done - no ileus. POD#11 - NGT was d/c'd and pt. started on sips 30 cc/hr - he tolerated this well POD#12 - pt. d/c to home Post op course was complicated by slow return of GI function w/ high NGT output. Medications on Admission: Lisinopril 20', toprol xl 25', nicotine patch, wellbutrin 150" . Discharge Medications: 1. tube feeding replete w/ fiber at 90cc/hr continuous 2. feeding pump feeding pump and supplies 3. flushes J-tube flushes 50cc every eight hours and before and after tube feed hook-up and disconnect 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*400 ML(s)* Refills:*0* 5. Famotidine 20 mg IV Q12H 6. Metoprolol 7.5 mg IV Q6H Hold for SBP < 100, HR <55 Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: esophageal cancer s/p esophagectomy and feeding J-tube Discharge Condition: good Discharge Instructions: call Dr.[**Name (NI) 2347**] [**Telephone/Fax (1) 170**] office if you develop chest pain, fever, chills, redness or drainage from your incision sites. Call if you have difficulty swallowing, nausea, vomiting or diarrhea. If your feeding tube sutures become loose or break, please tape tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Followup Instructions: Provider: [**Name10 (NameIs) 326**] UPPER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-4-25**] 10:00 Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2141-4-25**] 11:30

[ "151.0", "272.0", "401.9", "E878.8", "V15.82", "285.9", "715.36", "530.85" ]

icd9cm

[ [ [] ] ]

[ "43.5", "96.6", "40.29", "46.39", "42.41", "45.41" ]

icd9pcs

[ [ [] ] ]

4357, 4418

2599, 3799

391, 430

4517, 4524

1723, 2576

5295, 5542

1013, 1120

3915, 4334

4439, 4496

3825, 3892

4548, 5272

1135, 1135

1157, 1704

281, 353

459, 730

752, 837

853, 997

47,907

196,782

35346

Discharge summary

report

Admission Date: [**2194-1-23**] Discharge Date: [**2194-1-30**] Date of Birth: [**2116-5-12**] Sex: F Service: EMERGENCY Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / Cozaar / Captopril Attending:[**First Name3 (LF) 2565**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Mechanical ventilation Blood transfusion History of Present Illness: 77 y/o lady with CHF, AF, HTN was discharged from Trauma service yesterday after she was admitted here with C7 fracure secondary to fall. She initially presented to an outside hospital prior to the recent admission and was intubated for ? respiratory distress vs glottic swelling. Her course here was complicated by unable to wean her off of vent and she eventually underwent a trach/PEG placement on [**2194-1-10**]. Patient was discharged to [**Hospital3 **]. . Patient states that she has felt tired and sleepy in the last two days. Otherwise denies any symptoms. Patient has had episodes of tachycardia to 150s at rehab facility yesterday. CXR this morning there was concerning for CHF. She recieved 40 mg of furosemide IVP, cardizem 30 mg PGT (1444) and 1 mg of ativan (1255). Her BP dropped to 60s/40s. She received some fluid boluses. Her vent setting there was ACMV PEEP 5, rate 12, Volume 500 FiO2 40%. She was taken to [**Hospital6 **]. She recieved 500 mg of levofloxacin. She was transfered here given recent hospitalization. . In [**Hospital1 18**] ED her vitals were T 99.5 HR 79 BP 84/50 RR 18 100% O2sat. Patient received 1.5 L NS, 1 gram IV vancomycin and started on 1 u PRBC. Currently she is asymptomatic. . She denies any chest pain, shortness of breath, fever, chills, nightsweats, abdominal pain, headache, acute change in vision, hearing, new weakness, change in sensation. No diarrhea, constipation, hematuria, dysuria, or blood in stool. She occasionally feels nauseous. Past Medical History: - CHF, unclear history - AF - HTN - NHL - ? radiation treatment to thyroid, ? hypothyroidism - anxiety - intermittent diarrhea - trach/PEG [**2194-1-10**] - C7 fx 2/4/009 s/p fall - vent dependent respiratory failure [**2194-1-1**] - multiple pleural taps; right-sided thoracentesis [**2194-1-3**], left-sided thoracentesis [**2194-1-4**], ? R PTX, s/p right chest tube placement [**2194-1-6**] - s/p trach/PEG [**2194-1-10**] Social History: Patient is coming from rehab. Denies ever using tobacco/ETOH/street drugs. Family History: HTN, CAD Physical Exam: Gen: alert and awake, pleasant lady in NAD, following commands HEENT: EOM-I, MMM, OP clear, trach in place Heart: S1S2 holosystolic murmur audible throughout precordial area best heard at apex radiating to axilla Lungs: wheezes R>L Abdomen: BS present, soft NTND Ext: WWP, no edema Neuro: strenght [**4-1**] in R ext and 3+/5 in L ext Guaic negative in ED Pertinent Results: [**2194-1-24**] 05:20AM BLOOD PT-40.8* PTT-30.8 INR(PT)-4.5* . [**2194-1-24**] 05:20AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 . [**2194-1-23**] 12:23AM BLOOD Lactate-1.4 . [**2194-1-23**] 08:16AM BLOOD WBC-9.8 RBC-2.94* Hgb-9.3* Hct-26.6* MCV-91 MCH-31.7 MCHC-35.0 RDW-14.5 Plt Ct-296 [**2194-1-23**] 05:00PM BLOOD Hct-28.3* . MICROBIOLOGY: [**2194-1-23**] 9:33 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2194-1-23**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2194-1-26**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. SPARSE GROWTH. CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S . RADIOLOGY: [**2194-1-23**] CT C-SPINE: The alignment is normal. There is a depressed fracture of the endplate of the C7 vertebra. There is no significant canal stenosis at this level. There is a posterior endplate fracture of the T2 vertebral body, without significant canal stenosis at this level. There is again multilevel degenerative disc and facet disease on the left at C2-3. There is scarring at the lung apex. The right pleural effusion is again noted. No significant canal stenosis at these levels. Multilevel degenerative change is similar to prior. IMPRESSION: No change in the appearances of C7 and T2 fractures. No significant new abnormality. . [**2194-1-22**] CXR: In the interval the amount of hazy opacity projecting over the right hemithorax with regions of lucency within it has significantly increased causing obscuration of the right hemidiaphragm. Mild blunting of the left costophrenic angle persists. The pulmonary vasculature appears distinct without any significant Kerley B lines noted. There is continued opacity in the retrocardiac region. Right-sided PICC, tracheostomy, and calcifications within the aorta are unchanged. IMPRESSION: Increased effusions, moderate-to-large on right and small-to- moderate on left. Persistent adjacent opacities, probably compressive atelectasis, although infection cannot be excluded within these regions. No edema is noted. . [**2194-1-24**] CT HEAD: CONCLUSION: No definite new intracranial abnormality. Bilateral mastoid and right middle ear abnormality, raising question of an ongoing inflammatory process, also involving the right sphenoid sinus air cell. NOTE: Please note that the present study was obtained only with a soft tissue algorithm. Therefore, maximum bone detail was not depicted at this time. Finally, MR scanning of the brain, if feasible, offers far greater sensitivity in the detection of acute brain ischemia, compared with the present CT scan . KUB [**2194-1-25**]: FINDINGS: Unchanged position of the access line. No gastric or intestinal distention. Visible psoas opacity. Gas in the rectum. No evidence of pathological air-fluid levels. . CXR [**2194-1-28**]: Since [**2194-1-25**], there is no overall change. Tubes and catheters are in unchanged position, including a right PICC ending in the right brachiocephalic vein. Moderate-to-large right pleural effusion, small left pleural effusion and moderate-to-large bibasilar atelectasis are unchanged. There are no signs of volume overload. The study and the report were reviewed by the staff radiologist. . EKG [**1-25**]: Atrial fibrillation Low limb lead QRS voltages Delayed R wave progression with late precordial QRS transition Modest low amplitude lateral T wave changes Findings are nonspecific Since previous tracing of [**2194-1-22**], T wave abnormalities decreased and Q-Tc interval appears shorter . EKG [**1-22**]: Atrial fibrillation. Low voltage in the standard leads. Decreased R wave and T wave inversion in leads V2-V3. Occasional ventricular premature beats. T wave inversion in leads V4-V6. Consider anterior wall myocardial infarction of undetermined age. Compared to the previous tracing of [**2194-1-17**], when there was left and right arm lead reversal, the precordial T wave inversions are new and may represent acute ischemia. In addition, anterior voltage is decreased which may be related to lead placement. Clinical correlation is suggested. Brief Hospital Course: 77 y/o lady with CHF, AF, HTN was discharged from Trauma service yesterday after she was admitted here with C7 fracure secondary to fall now presents with hypotension. # Hypotension: Initial differential was that this was secondary hypovolemia in the setting of aggressive diuresis and diastolic heart failure vs. autonomic instability vs. medication effect. Patient underwent an infectious work-up which revealed only MSSA in sputum, presumed colonization given lack of fevers and leukocytosis. Patient was noted to have episodes of low systolic BP's (high 60's), but BP improved after discontinuing clonidine as there was no clear indication for her to be on this medication. She continues to have episodes of hypotension while sleeping, but no changes in mentation. She was started on Coreg for management of her heart failure, which BP tolerated. Midodrine administration was changed to 10 mg qHS. Patient should not return to hospital for low BP's unless accompanied by alteration in mental status. # Chronic vent dependence: Patient was trached on [**2194-1-10**] during previous admission following 3 failed extubation attempts. Her son at that time gave the Surgical team a vague history of a possible prior tracheostomy, and radiation to her neck -- perhaps causing some tracheal stenosis. On bronchoscopy, close evaluation demonstrated upper airway edema, with no leak when the cuff was down. She was placed on steroids, but given these findings, the decision was made to proceed with a trach/peg for ? glottic swelling. Vent settings at time of this ICU were AC 15/5/50%. Of note, a thoracentesis was also performed during previous admission for evaluation of her pleural effusion, with results consistent with a transudative process. Her PCP was [**Name (NI) 653**] by the ICU team and confirmed that her pleural effusions were chronic. Patient also appears to have weakened diaphragm as indicated by low NIF. She was gently diuresed during this hospitalization, with vent settings successfully reduced to Pressure Support ventilation at [**9-1**]. Scarce MSSA was cultured from sputum, but given radio in the absence of leukocytosis, fever, radiographic changes, or hemodynamic instability, antibiotic therapy was deferred. CXR on the morning of discharge showed a chronic right pleural effusion but overall improvement. # Diastolic heart failure: Has chronic transudative right pleural effusion. She has a documented AceI and [**Last Name (un) **] allergy. She was started on beta-blockade with Coreg 6.5 mg [**Hospital1 **]. She was discharged on a standing dose of Lasix 40 mg PO daily. She also responds to PRN dosing of Lasix 40 mg IV PRN. # Atrial fibrillation: Patient had episodes of rapid afib with HR 150's - 180's, triggered by suctioning, manipulations in the bed, and interactions with the healthcare team. She received Lopressor 5 mg IV for these epidodes, with resolution. She was started on Carvedilol for rate control. She is anticoagulated on Coumadin with a target INR [**12-31**]. Her coumadin dose was adjusted for both supratherapeutic INR and subtherapeutic INR. INR on the morning of discharge was 1.8. Coumadin dose was readjusted to 2 mg daily. # Anemia: Normocytic, most likely secondary to recent admission and frequent phlebotomy. She received 1 unit PRBC's on arrival to [**Hospital1 18**] for hematocrit of 24 in the setting of hypotension. Hct 29.7 on day of discharge following diuresis and 1 unit PRBC's. Normal Vit B12 nd folate in [**1-6**]. # Thyroid disease: Thyroid CA s/p surgery and radiation. TFT's previously consistent with sick thyroid with elevated TSH but normal free T4. She was continued on thyroid replacement therapy with Levothyroxine 200 mcg daily. TFT's should be rechecked in one month following resolution of acute illness. # C7-T2 fractures: No clear history of stroke after comparing PCP??????s note. CT of her c-spine was repeated during this hospitalization at the request of the Ortho Spine service, demonstrating no interval changes of C7/T2 fractures. Per Ortho, she was scheduled for follow-up with Dr. [**Last Name (STitle) 363**] in late [**Month (only) 958**]. She has been instructed to continue wearing the c-collar for a total of 8 weeks (end date [**2194-2-26**]). # Low-grade fever: On [**1-29**] patient was documented to have a low-grade fever to 100.3. Her PICC line was discontinued. Patient had no subsequent fevers and WBC on morning of discharge was 6K. Her only positive culture data from this hospitalization revealed scarce MSSA in sputum culture from sample collected on [**1-23**]. # FEN: Continued tube feeds via PEG tube with Replete with fiber at goal 60 ml/hour. # Contact: [**Name (NI) **] [**Name (NI) 44143**] [**Telephone/Fax (1) 80582**]. # Code status: Full Code. Medications on Admission: Warfarin 2.5 mg PG daily Docusate Sodium 50mg Liquid PGT [**Hospital1 **] Albuterol Sulfate 90 mcg 6 Puffs Inhalation Q4H prn Bisacodyl 10 mg PR daily prn Insulin sliding scale Camphor-Menthol 0.5-0.5 % Lotion TID prn Acetaminophen 325 mg PG Q4H prn Senna 8.6 mg PO BID prn Lansoprazole 30 mg PG DAILY Clonidine 0.1 mg PG TID Midodrine 10 mg PG TID Quetiapine 50 mg PG QHS Levothyroxine 200mcg PG daily Chlorhexidine mouthwash Discharge Medications: 1. Levothyroxine 200 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ea Mucous membrane [**Hospital1 **] (2 times a day). 4. Midodrine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 5. Quetiapine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 6. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO Q6H (every 6 hours). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Coreg 6.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 12. Coumadin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: Goal INR [**12-31**]. 13. Lasix 40 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Hypotension Anemia C7 fracture Atrial fibrillation Respiratory failure Discharge Condition: BP 117/50, HR 90-100 (afib), SpO2 94% on Pressure Support 10/5/50% INR 1.8 Discharge Instructions: You were admitted to the hospital with hypotension. You were evaluated for infection, but none was identified. You were noted to have episodes of hypotension while sleeping, during which you were asymptomatic. Your Clonidine was discontinued with improvement. You were started on Coreg for heart rate control. You should return to the hospital for fevers, persistent hypotension with altered mental status, or other concerning symptoms. Followup Instructions: You have been advised to wear your c-collar for a total of 8 weeks (start date was [**1-1**]). You are scheduled to follow-up with Dr. [**Last Name (STitle) 363**] in the Department of Orthopaedics on [**2-20**] at 11 AM. His office is located on [**Location (un) **] of the [**Hospital Ward Name 23**] Building on [**Hospital1 18**] [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 34107**] if you need to reschedule. You should follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] following your discharge from rehabilitation.

[ "V10.87", "518.81", "V15.3", "511.9", "E929.3", "V44.1", "293.0", "805.07", "427.31", "428.0", "428.30", "458.9", "244.0", "285.8", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

13928, 14008

7253, 12078

336, 379

14123, 14200

2890, 5216

14690, 15329

2483, 2493

12556, 13905

14029, 14102

12104, 12533

14224, 14667

2508, 2871

285, 298

407, 1924

5225, 7230

1946, 2374

2390, 2467

17,205

126,280

22657

Discharge summary

report

Admission Date: [**2144-2-17**] Discharge Date: [**2144-3-7**] Date of Birth: [**2068-1-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: inability to wean from the ventilator at [**Hospital1 **] Major Surgical or Invasive Procedure: CT MRI Bronchoscopy with BAL and tracheostomy change Muscle Bx LP Transbronchial bx VATS History of Present Illness: 76 yo RH woman with h/o HTN, hypercholesterolemia, PVD, B12 deficiency who now has anti-[**Doctor Last Name **] antibody positive bulbar neuropathy and respiratory muscle weakness with no carcinoma found. Hospitalization course at [**Hospital3 **] is as follows: Was in usual state of health, including going to gym, living independently until early [**Month (only) 359**]. Initially admitted [**2143-11-4**] for a sense of movement in her vision, + nausea, gait instability due to vision problems. [**Name (NI) **] to have upbeat nystagmus in all directions. Dx'd with dizziness with oscillopsia, which can be seen in posterior circulation ischemia, wernickes, paraneoplastic syndromes, sarcoid or atypically in peripheral vestibulopathy. MRI with gad on [**2143-11-6**] showed no acute stroke, but did have chronic small vessel ischemic disease and right A-1 hypoplasia. On that admission, had Na 125 and diagnosed with SIADH. Also noted to have hematocrit 30. LP showed lymphocytic meningitis. Unclear what treatment was done at this point. Then ~[**11-13**], pt had difficulty with neck extension, saying its "too heavy to hold up head". By dinner that evening, she was having difficulty swallowing, and family brought her back to [**Hospital3 10959**] ED. Seen again by neurology on [**2143-11-16**] for neck weakness and difficulty swallowing, no choking. Per their notes, nystagmus was worst on awakening in the morning, improved through the day. Denied fatiguability. Exam still with nystagmus, found to have neck extensor weakness 3/5, wide based gait, subtle ataxia. Medicine team also noted decreased reflexes and difficulty with sharp/dull discrimination in the legs. Patient underwent a total of 4 LPs, and anti-[**Doctor Last Name **] antibodies were found to be positive with a titer of 1:640 ([**2143-11-19**]). Workup for carcinoma included torso CT showing an ovarian cyst (not further explored surgically), and bronchoscopy. Bronch revealed atypical squamous cells per d/c summary but no overt mass. Prior to the anti-[**Doctor Last Name **] antibodies turning positive, she was empirically treated for tuberculosis meningitis with rifampin, ethambutol, INH, PZA and pyridoxime as her father had TB when she was a child. Tx'd for 10 days without clinical change. PPD negative. She was also treated with high dose steroids for the bulk of her admission for the possibility of TB meningitis and "immune mediated disorders." She was discharged on prednisone. By [**11-20**] her weakness had progressed to involve respiratory muscles, and she was on BiPAP for intermittent hypercarbia. By [**11-23**] she was in respiratory failure with waxing and [**Doctor Last Name 688**] mental status and required intubation and mechanical ventilation. At that time she had no documented arm or leg weakness. Trach placed [**12-3**], PEG also placed. Found to have labile BP. Added norvasc and cont'd lisinopril. Seen by psych who deemded her incompetant to make decisions for herself. Thus her daughter, [**Name (NI) **] [**Name (NI) 16844**] became her health care proxy. Started on risperdal 0.5mg [**Hospital1 **] to calm her while on the vent. And fluoxetine 20mg daily for possible depression. She was discharged to rehab ([**Hospital1 **]) on [**2143-12-6**]. Family notes the start of bilateral hand action tremor in [**2143-11-25**], which has improved. While at [**Hospital1 **] in [**11/2143**], developed left leg swelling and DVT found. She was started on coumadin. On [**2144-1-4**] while at [**Hospital1 **] family reports she had respiratory failure/arrest, though no cardiac arrest. Thought secondary to mucous plug. Was transferred to [**Hospital 8**] Hospital for a short time. Family reports they repeated chest CT which was still negative for mass. She did well and returned to [**Hospital1 **] after ~3 days. She was able to be rapidly weaned, and spent ~8hr per day on a trach collar for 3 days. Since then, she has been unable to tolerate the trach collar and is currently ventilator dependent. Profound neck muscle weakness has continued, and she remains difficult to wean. She is now transferred to [**Hospital1 18**] for further workup and management. ROS: Recent PNA/bronchitis with increased cough, secretions, fever. Treated with antibiotics at [**Hospital1 **], family thinks augmentin. Has improved, with decreased suctioning needed. Otherwise, no fever, chills, chest pain, difficulty breathing on vent, abdominal pain, diarrhea or constipation. Past Medical History: - Paraneoplastic disease as above with cranial neuropathy and respiratory failure - Respiratory failure, trach and vented - HTN and bilateral renal artery stenosis - High cholesterol - PVD - eye surgery? - Hyponatremia/SIADH - Depression - Iron deficiency anemia - B12 deficiency - DVT left leg, [**11/2143**], on coumadin - S/p PEG tube - perivascular white matter changes on MRI consistent with small vessel disease. - adenexal cyct seen on CT at OSH, not further explored surgically Social History: currently at [**Hospital1 **], had been living independently previously. No tobacco, rare EtOH. Supportive family. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16844**] is HCP, phone [**Telephone/Fax (1) 58711**] Family History: No stroke, seizure, neurological disease. No DM. +MI in sister age 79. [**Name2 (NI) **] cancer in sister, age 16. Physical Exam: ADMISSION PHYSICAL EXAM: Afebrile 125/41 56 14 100% on SIMV 500x12, FiO2 0.40, PS5, PEEP 5 Gen: Pleasant elderly woman in NAD HEENT: Sclera anicteric. +thrush. TMs with cerumen bilaterally. Neck: Supple, floppy, FROM, trach in place Cardiac: RRR, S1, S2 no murmur Lungs: Slightly coarse BS, especially R base Abd: Soft, NT, +BS. G tube inplace, no tenderness or erythema Extr: Trace edema bilateral ankles. R heel ulcer wrapped. Back: Sacral decub with duoderm dressing Neurologic Exam: MS: Awake and alert. Oriented to person, place, "[**Month (only) 956**]" and did not know year. DOW backward intact. Naming and repetition intact. Mouths words given trach/vent so unable to assess voice. CN: PERRL, VFF to finger motion. EOMs intact, with mild right-beating nystagmus on rightward gaze. Intact to LT, cold. Face symmetric and strength full. Decreased hearing to finger rub bilaterally. Tongue and palate midline. Trapezius full strength. ~0-1 bilateral SCM, neck extension and flexion. Motor: Tone normal. Mild bilateral tremor of hands with action or posture, disappears at rest. No fasciculations noted. No pronator drift. Overall strength mild to moderately decreased throughout, neck flexor/extensor weakness presents. Bilateral IP severely decreased, and quads/plantar flexion which were full: Strength: D T B WE FiF [**Last Name (un) **] FiAb IP Q H AF AE TE Right 4+ 4 4+ 4+ 4 4+ 4+ ~1 5 4+ 5 4+ 4 Left 4 4 4+ 4+ 4 4+ 4 ~1 5 4+ 5 3 3 Sensation: Intact to LT, cold, PP. Decreased vibration to knees and decreased proprioception at toes bilaterally. Reflexes: DTRs 3+ and symmetric throughout, except 1+ at ankles. Toes down bilaterally. No grasp. Coordination: Slight dysmetria on FNF, proportional to weakness. [**Doctor First Name **] slightly decreased rhythm. FFM intact. Gait: Unable to assess Pertinent Results: Lans on D/C [**2144-3-7**] WBC 23 Hct 30 (stable, baseline 30-33) Plt 304 BUN/Cr 26/0.2 Na 132 INR 1.6 PTT 81.3 WBC 7.5, Hct 36.1, Plt 355, MCV 88 Hct nadired at 30.5 INR 1.5 upon admission ESR 63 Glucose-78 UreaN-12 Creat-0.2* Na-135 K-5.3* Cl-99 HCO3-31* AnGap-10 BLOOD CK(CPK)-17* Calcium-8.6 Phos-3.6 Mg-2.1 Initial TSH-5.3*, upon repeat: TSH-3.0 T3-64* (slightly low) Free T4-1.1 (normal) Anti thyroid antibodies: Anti-Tg-normal/neg, antiTPO-89* (slightly elevated) CXR [**2-17**]: 1) Overdistention of tracheostomy tube cuff as communicated to clinical service caring for the patient. 2) Left lower lobe pneumonia and adjacent small pleural effusion. CT torso [**2144-2-18**]: 1) No primary malignancy identified to account for the patient's condition. 2) Extensive coronary artery calcifications. 3) Small left pleural effusion with associated consolidation of the left lower lobe. Right basilar atelectasis. 4) Isolated subcarinal lymphadenopathy. 5) Focal hypodensities within the right lobe of the liver are incompletely characterized, but likely represent cysts. 6) A 4 cm left renal cyst. 7) A 2 cm left adnexal cyst. 8) Prominent perirectal and presacral soft tissue as above. This is a nonspecific finding which could represent underlying inflammation or infection. MRI c-spine: In the upper cervical spine on the axial images, no evidence of spinal cord compression or intrinsic spinal cord signal abnormalities are seen. No abnormal enhancement is noted. MRI brain: Mild-to-moderate small vessel ischemic infarcts involving the bilateral cerebral hemispheres and brainstem. Mild mucosal thickening involving the ethmoid and left sphenoid sinus. Opacification of bilateral mastoid air cells. EMG: results pending BAL cytology: negative for malignant cells CSF: WBC 2, 3. RBC 19, 37. Protein 79, glucose 70. Gram stain and cx: no growith. Cytology negative for malignant cells. Opening pressure was 5. Muscle bx: pending Transbronchial FNA: nondiagnostic. VATs biopsy: pending, likely neuroendocrine tumor of unknown etiology. Labs from [**Hospital3 2568**]: LP data: Date RBC WBC Polys Lymph Monos Gluc Prot Cx AFB [**2143-11-28**] 47 23 1 21 1 60 88 NG ? 95 11 - 10 [**2143-11-21**] 690 60 - 92 70 114 NG ? 575 45 - 89 [**2143-11-17**] 1168 40 3 93 43 95 NG ? [**0-0-0**] 35 29 2 84 56 88 NG ? 4910 21 6 15 CSF flow cytom: no b cell lymphoproliferative disease seen Crypto neg [**2143-12-10**]: CBC: 4.16/28.6/186, MCV 79 Na 138, K 3.1, Cl 104, bicarb 25, BUN 11, Cr 0.3, gluc 143, cal 7.4, mag 2.3, phos 2.5 [**2143-11-27**]: ESR 52 [**2143-12-4**]: LDH 205 [**2143-11-5**]: Chol 244, TG 64, HDL 46, LDL 186 [**2143-12-3**]: Iron 16, TIBC 239, Ferritin 29 [**2143-11-21**]: ACE 7 (normal [**9-/2106**]) [**2143-11-22**]: CA-125 10 (nl 0-35) [**2143-11-20**]: FTA-ABS NR, syphilis in CSF NR [**2143-11-7**]: [**Doctor First Name **] neg [**2143-10-10**]: ASO neg [**2143-11-20**]: brucella ab not detected [**2143-11-19**]: mitochondrial antibody < 1:20 [**2143-11-21**]: SPEPE neg [**2143-11-21**]: CSF PEP + oligoclonal bands [**11-6**], [**11-16**]: HSV neg CSF [**2143-11-13**]: lyme disease neg [**2143-11-17**]: West Nile Virus IgG<1.3, IgM<0.9 [**2143-11-19**]: RI autoab neg [**2143-11-20**]: C-anca, p-anca neg [**2143-11-21**]: myelin associated glycoprotein (MAG-Ab) - results ?? [**2143-11-19**]: anti-[**Doctor Last Name **] + 1:640 [**2143-11-18**]: EEG - diffuse slowing with bifrontal predominance L>R MRI c/t/l spine with gad: [**2143-11-28**]: degenerative disc disease with osteophyts c3-4, c5-6, without compression of cord. CT torso: Apical lung scarring. Atherosclerotic disease of abdominal aorta with possible mural thrombus, renal and celiac artery stenosis at origins, prominent uterus and ovarian cyst Labs from [**Hospital1 **]: [**2144-2-14**]: C dif negative. INR 1.7 [**2144-2-11**]: Chem7 normal except HCO3 31. Ca 8.5 WBC 9.4 Hct 34.8 Plt 259 CXR [**2144-2-5**]: LLL infiltrate, possible effusion, and R base atelectasis vs early infiltrate Brief Hospital Course: 76 yo woman transferred to [**Hospital1 18**] from [**Hospital **] rehab for workup of inability to wean from ventilator. She developed bulbar, neck and respiratory muscle weakness at the end of [**2143**], and now also has arm/leg weakness of unclear etiology. On prednisone for "immune related disorders." Initial workup at [**Hospital3 **] revealed anti-[**Doctor Last Name **] antibodies, but no cancer found. Here for further workup. For the weakness, ddx includes: myopathy (steroid induced?), NMJ dysfunction, polyradiculopathy, central process. Less likely cortical or brainstem, however does have cranial nerve involvement (SCM is weak, has nystagmus on right gaze, bilateral facial weakness). An official neuromuscular consult was obtained (attending [**Location (un) **] [**Doctor Last Name 557**], fellow [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) and EMG/NCS performed. Neuromuscular junction dysfunction was ruled OUT based on EMG/NCS findings. Dr. [**Last Name (STitle) 557**] suggested further workup: a. MRI brain and spine to r/o central process-> MRI of the brain and cervical cord was obtained with gad and results were unrevealing. No masses or lesions to explain her symptoms. Only perivascular white matter changes. b. LP for cytology done on [**2144-2-27**] -> negative for malignant cells c. Muscle bx of right deltoid: coumadin was stopped and heparin started when INR<2.0 in preparation for procedures. Done on [**2144-2-25**]. Results pending. Prelim results show that there is no inflammation, awaiting special stains per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] (pathologist). d. Wean prednisone: Patient came in on prednisone for unclear reasons. Prednisone was slowly weaned from 20mg daily to off over the course of 2 weeks. Last day of steroids: [**2144-3-3**]. For the possibility of a myopathy, CK was checked and was normal at 17. ESR was 62. For the Anti-[**Doctor Last Name **] Antibody positivity, a cancer workup was initiated. A CT torso showed a 1.4 cm subcarinal node -> interventional pulm did a transbronchial bx on [**2144-2-24**], unfortunately the results were nondiagnostic. CT surgery consulted and recommended VATS, thus she underwent this surgery on [**2144-2-26**] and was found to have a Neuroendocrine tumor of unknown etiology. Final pathology showed a poorly differentiated carcinoma with neuroendocrine features. Oncology was consulted. The onc team (attending Dr. [**First Name (STitle) **] discussed findings with the family and all are in agreement to start chemotherapy (likely carboplatin and taxol, one cycle q 3weeks, to complete [**4-29**] cycles). She was transferred to the [**Hospital Unit Name 153**] for chemotherapy and vent management. She was premedicated with decadron, ativan, anzemet, and benadryl prior to chemo. She then received dosages of Taxol and carbaplatin. She tolerated the chemo well and had minimal side effects. She was started on neupogen for [**Hospital Unit Name 500**] marrow support. After chemo her counts remained stable but will need to be monitored on a weekly basis at rehab and the reults should be sent to Dr. [**Last Name (STitle) 2036**]. Her next chemotherapy will be done in three weeks and can be set up through Dr. [**Last Name (STitle) 2036**]. Her white count increased in 23 on the day of admission secondary to neupogen which had been started 2 days prior. Gyn: CT torso also showed 2cm adenexal cyst. Gynecology was consulted, however patient adamantly refused vaginal ultrasound and gynecologic exam. [**Last Name (un) 58712**] exam was normal. She was also [**First Name9 (NamePattern2) **] [**Male First Name (un) **] metronidazole vaginal gel. Noted to have some vaginal bleeding which will need to be worked up as an outpatient, if patient desires. Patient underwent a bronchoscopy as her trach needed changing (per admission CXR), and no bronchial masses were seen. BAL cytology was negative for malignancy. The CT torso also revealed a LLL infiltrate, likely her resolving pneumonia diagnosed at [**Hospital1 **] s/p antibiotics course. The SICU team placed her on levoquin 750mg qD on [**2-19**] thru [**2144-2-24**] for unclear reasons. She remained afebrile with normal white count and thus levoflox was discontinued. She continued on the ventilator. She was able to be weaned from A/C to CPAP+PS. For the possibility of a myopathy, TSH was checked. It was initially elevated but repeat was normal. Free T4 normal, T3 slightly low, tyroid antibody anti TPO was mildly positive at 89, possibly due to sick euthyroid, or x-reaction with anti-[**Doctor Last Name **]?? Iron deficiency anemia: stools guaiac negative. Continued on iron replacement. Also check B12 wuhich was normal. HTN: She was continued on lisinopril and amlodipine. She has a questionable history of bilateral renal artery stenosis. Her creatinie remained stable throughout the hospital admission. She had some elevated BP's into the 190's so her lisinopril was titrated up. However msut closely monitor her BP has she gets extremely orthostaitsc with massive swings in her BP when going from supine to uprighgt position. This is felt ot be secondary to autonomic dysfunction due to the paraneoplastic syndrome. Goal is to keep BP's around 140-160. Must closely watch patient during PT and transitions in position for hypotensive events. DVT in [**2143-11-25**]: admission INR was subtheraputic, but then became theraputic with several higher doses of coumadin. Coumadin was stopped and heparin gtt started when INR<2.0 for procedures (muscle Bx, transbronchial bx, VATs, LP). Coumadin restarted on [**2144-2-28**], heparin gtt to be continued until INR is between [**2-27**]. Her coumadin was started at 7.5mg, this was then decreased out of concerns of being to high of a dose, but INR did not bump sufficiently thus had to increase coumadin to 10mg qhs. When she reaches goal INR [**2-27**] can then stop the heparin. Depression: prozac 20mg daily was continued. Psychiatry was consulted given her blunted affect and refusal of services. Psychiatry recommended keeping prozac at current dose, and to allow her to use the pessimer valve to speak while on the vent. She was unable to tolerate this valve as she became tachypnic, very uncomfortable. FEN: Tube Feeds, vitamins, H2Blocker PPx: coumadin/heparin gtt, H2B, pneumoboots, proper wound care for pressure ulcers (right heel and coccyx), PT/OT FULL CODE Dispo: back to rehab after patient completes chemotherapy and post-chemo symptoms have been monitored for several days. Medications on Admission: Coumadin 3.5 QHS, nystatin swish and swab qid x8 days, prednisone 20, liinopril 10, amlodipine 10, vitamin C 500 [**Hospital1 **], B12 1000 mcg qmonth (next due [**3-2**]), colace 100 [**Hospital1 **], FeSO4 300, prozac 40, MVI, zantac 150 [**Hospital1 **], senna 10ml hs, bacitracin to G tube site Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 4. Fluoxetine HCl 20 mg/5 mL Solution Sig: Five (5) mL PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Ten (10) ML PO HS (at bedtime). 7. Acetaminophen 160 mg/5 mL Elixir Sig: [**11-12**] mL PO Q4-6H (every 4 to 6 hours) as needed. 8. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution Sig: 0-12 units Injection ASDIR (AS DIRECTED): Please check QAC/HS FSBG and give insulin per sliding scale. 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Filgrastim 300 mcg/mL Solution Sig: One (1) mL Injection Q24H (every 24 hours). 14. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for bloating/gas. 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 16. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**1-26**] mL Injection Q6H (every 6 hours) as needed for nausea. 17. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Seven Hundred (700) units/hour Intravenous ASDIR (AS DIRECTED): Please titrate to goal PTT of 60-80. Can stop when INR between [**2-27**] . 18. Metronidazole 0.75 % Gel Sig: One (1) Appl Vaginal HS (at bedtime). 19. Warfarin Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) mL Injection Q4H (every 4 hours) as needed. 21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: Paraneoplastic syndrome Lung Cancer HTN Respiratory Failure Neuromuscular Disorder DVT Hyperlipidemia Depression Iron Deficiency Anemia Discharge Condition: Pt is stable on ventilatory support with trach in place. She is afebrile, with no signs of active infection. Discharge Instructions: Patient will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**], please see contact info below. She will need chemotherapy in the 3 weeks per Dr. [**Last Name (STitle) 2036**] recommendations. Her heparin can be stopped once her INR is between [**2-27**]. She will need qweekly CBC counts and Chem 10, results should be sent to Dr. [**Last Name (STitle) 2036**]. Followup Instructions: Patient will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**]. He can be reached at the following locations/numbers: Division of Hematology/Oncology [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 13341**] Fax: [**Telephone/Fax (1) 13345**] [**Hospital6 2561**] [**Hospital3 58713**], [**Last Name (un) 5433**] 3 [**Hospital1 8**], [**Numeric Identifier 53049**] Phone: [**Telephone/Fax (1) 58714**] Fax: [**Telephone/Fax (1) 58715**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "253.6", "453.8", "334.9", "197.0", "V58.61", "197.8", "V55.0", "518.83", "199.1", "197.2" ]

icd9cm

[ [ [] ] ]

[ "34.24", "96.05", "96.6", "33.24", "99.25", "04.81", "40.11", "33.21", "83.21", "33.28", "96.72" ]

icd9pcs

[ [ [] ] ]

21111, 21189

11987, 18627

372, 462

21369, 21480

7803, 11964

21940, 22611

5781, 5898

18977, 21088

21210, 21348

18653, 18954

21504, 21917

5939, 6389

275, 334

490, 4999

6406, 7784

5021, 5508

5524, 5765

72,103

119,706

40124

Discharge summary

report

Admission Date: [**2187-1-13**] Discharge Date: [**2187-1-20**] Date of Birth: [**2153-10-2**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 65513**] Chief Complaint: abdominal pain and fever Major Surgical or Invasive Procedure: -CT guided drainage of tuboovarian abscess -repair of right carotid artery and right internal jugular vein -exploratory laparotomy, lysis of adhesions, bilateral salpingo-oophorectomy, repair of cecal enterotomy, rigid proctoscopy, dilation and currettage History of Present Illness: 33 year old G0 with history of endometriosis who originally presented to [**Hospital1 **] [**2187-1-9**] with a two day history of left lower back pain, LLQ pain, fevers and vomiting. An ultrasound showed bilateral endometriomas and she was started on Amp/Gent/Clinda. WBC count on admission 15.4 and Tmax was 103.2 on [**2187-1-11**]. On HD#5 she was transferred to [**Hospital1 18**] for further management. Upon transfer she continued to have sharp/crampy left back pain and LLQ pain, nausea and fevers. Review of imaging was felt consistent with either an infected cyst vs tubo-ovarian abscess in her pelvis. Past Medical History: PSH: LSC right ovarian cystectomy (endometrioma) GynHx: G0, regular menses, +h/o abnormal Pap s/p LEEP 10 years ago. Denies h/o STI's. +severe endometriosis. +infertility Social History: Married. No tob/EtOH/drugs. Originally from [**Country 4194**], came to US with husband for work. Family History: Mother deceased of uterine CA Denies any other family members with breast, ovarian, uterine cancers. Physical Exam: Admission exam: VS on admission: T 100.9 BP 103/69 HR 98 RR 18 sat 98%RA A&O, NARD, lying comfortably on bed Lungs CTAB Heart RRR Abd soft, mildly distended, TTP LLQ>RLQ, no rebound, +BS SSE normal mucosa, moderate discharge from os, no bleeding, GC/CT collected BME no CMT, uterus AV, normal sized, no fundal tenderness, bilateral adnexal fullness and TTP with vol guarding of adnexae, L>R Discharge exam: afebrile, VSS NAD, A/O x 3 RRR CTAB abdomen soft, ND, appropriately tender, incision closed using already in place prolene and staples, no erythema/induration ext NT, ND Pertinent Results: Admission labs: [**2187-1-13**] 03:47PM BLOOD WBC-11.2* RBC-3.59* Hgb-9.5* Hct-28.6* MCV-80* MCH-26.5* MCHC-33.3 RDW-13.5 Plt Ct-273 [**2187-1-13**] 03:47PM BLOOD Neuts-79.9* Lymphs-12.7* Monos-6.2 Eos-1.0 Baso-0.2 [**2187-1-13**] 03:47PM BLOOD PT-14.9* PTT-35.2* INR(PT)-1.3* [**2187-1-13**] 03:47PM BLOOD Glucose-101* UreaN-4* Creat-0.7 Na-139 K-3.8 Cl-101 HCO3-31 AnGap-11 [**2187-1-13**] 03:47PM BLOOD Calcium-8.5 Phos-4.2 Mg-2.1 . Other labs: [**2187-1-15**] 07:15AM BLOOD HCG-<5 [**2187-1-15**] 10:37AM BLOOD CRP-296.8* [**2187-1-13**] 08:34PM BLOOD ESR-95* [**2187-1-13**] 03:47PM BLOOD ALT-15 AST-22. . Microbiology: GC/CT negative UCx [**1-13**], [**1-15**] negative BCx [**1-13**], [**1-15**] negative Abscess cx: _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R CT ABDOMEN/PELVIS W/CONTRAST [**2187-1-13**]: 1. Bilateral adnexal cystic masses. Given prior stated history, right solitary adnexal mass appears most consistent with endometrioma. 2. The more complex left-sided mass is indeterminate in origin. This may represent tubo-ovarian abscess though the absence of surrounding inflammatory change is unusual but might be due to the recent antibiotic treatment. Differential also includes complex endometriotic cysts. 3. The abnormal appearance of the left fallopian tube is difficult to interpret, given the known prior history of left hydrosalpinx. . CT GUIDANCE DRAINAGE [**2187-1-14**]: Status post CT-guided drainage/aspiration of left ovarian complex fluid collection, with aspiration of approximately 20 cc of purulent material, concerning for tubo-ovarian abscess. Drainage catheter was removed, as it appeared to have become clotted, and would not flush. . CHEST PORT. LINE PLACEMENT [**2187-1-15**]: No previous images. Right IJ catheter extends to the upper portion of the SVC. No evidence of pneumothorax. There is prominence of somewhat indistinct pulmonary vessels, suggesting overhydration related to the large amount of fluid given to this patient with sepsis. . ABDOMEN (SUPINE ONLY) IN O.R. [**2187-1-15**]: Two views of the abdomen were obtained. The distal aspect of a nasogastric tube is seen extending into the expected location of the stomach. The patient's known JP drain is seen extending into the left pelvis, crossing midline into the right lower quadrant. The very distal tip of a central venous catheter is seen projecting over the mid SVC, not optimally evaluated. No additional radiopaque foreign body is seen. Brief Hospital Course: Ms. [**Known lastname **] was transferred from an OSH to [**Hospital1 18**] secondary to concern for tubo-ovarian abscess. Once transferred she was started on ampicillin, gentamicin, and clindamycin. Her imaging was reviewed and thought consistent with infected endometrioma or tubo-ovarian abscess. She subsequently had CT guided percutaneous drainage of 20 cc purulent fluid on her left side. Despite IR drainage and triple antibiotic therapy she continued to be febrile. Blood and cultures continued to be negative. On hospital day 3 she became hypotensive and tachycardic consistent with sepsis. She was aggressively fluid resuscitated and transferred to the medical ICU. A central line was placed. The decision was then made to proceed to the OR for exlap given failed medical management. In the operating room, her central line was found to be in the carotid artery. Vascular surgery was called and prior to proceeding with the exploratory laparotomy, her IJ and carotid artery were repaired. On entry into the abdomen there was no frank pus. She was found to have enlarged multicystic ovaries with endometriomas and purulent cavities bilaterally which were densely adherent to uterus and bowel. A bilateral salpingo-oophorectomy was performed and the pelvis was irrigated. She also had repair of a cecal enterotomy. The fascia was closed however the skin was left open. During the case she received 3 units of PRBC's as well as 2.5L crystalloid. Her blood pressure and tachycardia improved significantly. Postoperatively, Ms. [**Known lastname **] recovery was uncomplicated. She was monitored in the ICU postop briefly before being transferred to the floor. Given likely gram negative sepsis,her antibiotics were switched to vanc/meropenem. She remained afebrile and eventually her regimen was tailored to ctx/flagyl based on the culture results. She was discharged with a 10 day course of PO cipro/flagyl. Ms. [**Known lastname **] NG tube was removed on POD 1 and her diet was advanced slowly. By discharge on POD 5, she was tolerating a regular diet, pain was controlled with PO medications, she was voiding spontaneously, and ambulating. Her wound was closed prior to discharge. Discussed briefly need for hormone replacement therapy given bilateral salpingo-oophorectomy. Medications on Admission: Tylenol PRN 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: -tubo-ovarian abscess -sepsis -vascular injury in the neck Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. *You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * Your stitches and staples will be removed at your follow-up visit. Followup Instructions: -please call Dr.[**Name (NI) 86653**] office on Monday [**1-22**] to arrange for follow-up ([**Telephone/Fax (1) 5777**]) -you will need a visit approximately 10 days from today ([**1-30**]) for removal of your sutures and staples [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**] Completed by:[**2187-1-23**]

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icd9cm

[ [ [] ] ]

[ "65.61", "65.89", "69.09", "39.31", "39.32", "46.75", "65.91" ]

icd9pcs

[ [ [] ] ]

8295, 8301

5204, 7515

341, 599

8404, 8404

2290, 2290

9428, 9788

1573, 1676

7577, 8272

8322, 8383

7541, 7554

8555, 9088

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277, 303

627, 1242

2307, 2727

1724, 2083

8419, 8531

1264, 1442

1458, 1557

2740, 5181

5,431

197,175

18118

Discharge summary

report

Admission Date: [**2159-5-1**] Discharge Date: [**2159-5-11**] Date of Birth: [**2092-8-30**] Sex: M Service: MEDICINE Allergies: Motrin Ib Sinus Attending:[**First Name3 (LF) 905**] Chief Complaint: revision of L3-L5 spinal fusion Major Surgical or Invasive Procedure: laminectomy of L2 with L3-L5 fusion and hardware removal with iliac crest autograft History of Present Illness: 66 y/o man with history of HTN, prior history of alcohol abuse, on chronic narcotics for back pain, CAD s/p MI and stenting, admitted to the hospital for laminectomy of L2, fusion of L3-L5, removal of previous instrumentation and iliac crest autograft. His surgery was performed on [**2159-5-1**]. His postoperative course has been complicated by the development of "twitching" overnight as well as difficult to manage pain, fevers, tachycardia, and low urine output. The twitching started around 2400 in his face and limbs, and has progressively gotten worse. At first, there was concern for alcohol withdrawl although the patient denies drinking for over a year, and the patient was given valium on a CIWA scale. the patient denies ever having had a seizure although the interview is limited by his waxing and [**Doctor Last Name 688**] mental status. Over the course of the last 24 hours, the patient had an epidural placed (during surgery) for pain control, which was removed this morning around 7am (it was capped at 10pm yesterday). He was then on dilaudid PCA for pain control. . His surgeries have been complicated by altered mental status in the past in '[**56**] which was attributed to infection of unknown etiology, possibly meningitis, although no cultures were positive. He was treated at that time with 14 days of ceftaz and vancomycin. In '[**57**] he developed postoperative delerium which was treated with Haldol and at that time was seen by psychiatry. His low urine output responded well to fluid boluses overnight, however, his postoperative creatinine was elevated. CXR showed early right lower lobe infiltrate. . The morning of transfer to floor, received total 20mg valium, 2mg ativan IV, and 10 of haldol for agitation, as well as a total of 7mg dilaudid in 1mg increments for pain. Past Medical History: HTN Hyperlipidemia CAD s/p MI, s/p stents placed [**1-5**] and [**4-6**] GERD Chronic LBP LLE radiculopathy Cervical spondylosis C4-C7 fusion surgery [**11-3**] Lumbar laminectomy L3-L5 on [**2157-1-25**] (anterior fusion) COPD Social History: [**11-2**] ppd smoker X 40years 1 and [**1-2**] quart vodka/day according to patient, but family reports they are not aware of any current alcohol use Family History: +CAD hx, mother with MI in 80's + hx rheumatic heart disease NO CVA, DM, HTN hx Physical Exam: Vitals: Tm 101.3/Tc 98.9; BP 118/60; RR 20; 98%RA General: lying in bed, grumbling, says, "You mispronounced my name, so I'm not gonna talk to you" HEENT: NC/AT, moist mucous membranes Neck: supple, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no bruits Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: Refusing to cooperate with exam but also seems inattentive. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation could not be tested, patient not responding to questions, facial strength [**Doctor First Name 81**]: SCM [**5-5**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Full strength throughout. Reflexes: Bic Br Pa Right 2 2 2 Left 2 2 2 Toes downgoing bilaterally. Pertinent Results: [**2159-5-2**] 05:54AM BLOOD WBC-17.2*# RBC-3.47* Hgb-11.1*# Hct-34.1* MCV-98 MCH-31.9 MCHC-32.5 RDW-14.7 Plt Ct-291 [**2159-5-2**] 05:54AM BLOOD Glucose-109* UreaN-14 Creat-1.3* Na-136 K-5.1 Cl-101 HCO3-30 AnGap-10 [**2159-5-2**] 03:43PM BLOOD ALT-11 AST-33 AlkPhos-43 TotBili-0.4 [**2159-5-3**] 01:24AM BLOOD CK-MB-4 cTropnT-<0.01 Head CT: There is no intracranial hemorrhage. There is a focal area of low attenuation within the periventricular white matter in the anterior limb of the left internal capsule. This could be due to a small lacunar infarct. There are periventricular white matter hypodensities consistent with chronic microvascular ischemic change. There is no midline shift, mass effect, or hydrocephalus. There is atherosclerotic disease. There is mild mucosal thickening within the left maxillary sinus. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. AP CXR [**5-2**]: Cardiac size is normal, costophrenic angles are sharp. There is no re-distribution. There is a mild increase in lung markings in the right lower lobe extending to the diaphragm and an early infiltrate in this area is probably present. Some chronic interstitial changes to the right upper lobe are again seen. These have been present on prior chest x-rays dating back to [**2156**]. IMPRESSION: Probable early right lower lobe infiltrates. AP CXR [**5-3**]: Upright frontal AP radiograph, comparison [**2159-5-2**], demonstrates unchanged interstitial opacities throughout the right lung. The apparent airspace consolidation in the lower lung is no longer present and may have represented confluence of vascular shadows. Heart, mediastinum and pleural surfaces are unremarkable. The right CP angle is not included on this study. IMPRESSION: Interstitial opacity throughout right lung, chronic. Brief Hospital Course: 66 y/o man with HTN, prior history of alcohol abuse, on chronic narcotics for back pain, CAD s/p MI and stenting, admitted to the hospital for spinal surgery, course complicated by fever, tachycardia, delirium, also hospital acquired pneumonia and acute renal failure. . # delirium: disoriented after surgery and 48hrs after admission accompanied by tachycardia in a formerly heavy drinker, high suspicion for alcohol withdrawal, although family adamantly deny recent alcohol use. Also considered infection (ie, pneumonia or less likely meningitis) or metabolic derangement but electrolytes wnl. EKG and enzymes x1 were negative to rule out atypical presentation of ischemic disease. Received thiamine and folate IV x3 days and CIWA scale ativan; awoke with clear sensorium and oriented to person, place, and time four days post op. . # pneumonia: RLL infiltrate seen on CXR [**5-2**], less obvious on repeat CXR, along with fevers; treated initially with broad spectrum antibiotics for hospital-acquired organisms. Culture grew Proteus as well as two other morphologies of GNR; narrowed coverage to levofloxacin and flagyl, will complete 10 day course on [**5-15**]. Afebrile with O2 Sats 93-95% on room air at discharge. . # acute renal failure: unclear etiology; urine micro unrevealing per nephrology consult and urine lytes suggested but were not classic for pre-renal azotemia and Cr did not respond to 1L fluid challenge. Avoid nephrotoxins, ie furosemide, lisinopril, gabapentin for now and monitor. Creatinine was down to 1.8 from peak of 2.2 on the day of discharge; will need outpatient creatinine check and can likely restart ACE, diuretic if Creatinine continued to return to baseline. . # s/p laminectomy of L2 with L3-L5 fusion and hardware removal with iliac crest autograft on [**5-1**]: Per Dr[**Name (NI) 12040**] team, pt may ambulate with brace; no brace required while in bed. Breakthrough pain controlled with oxycodone once patient was able to take po, continued home oxycontin; stopped gabapentin because of renal failure. . # HTN: continued metoprolol, nitrates . # CAD: post-op cardiac enzymes were negative and patient had no symptoms of CAD. patient had completed >1 year of plavix for stents the week prior to surgery. Restarted ASA at discharge. Continued beta blocker. ACE held due to renal failure. . # Iron deficiency anemia, compounded by perioperative blood loss anemia: Iron studies showed iron 19, so started iron sulfate 325mg daily. Should have screening colonoscopy as outpatient. . # antibiotic associated diarrhea: C diff toxin negative x3. Imodium prn for symptom control until completes course of antibioics. Medications on Admission: Isosorbide Mononitrate 30 mg PO DAILY Lisinopril 40 mg PO DAILY Acetaminophen 650 mg PO Q8H Lorazepam 1 mg IV Q4-6H:PRN for CIWA scale > 10. Atorvastatin 20 mg PO DAILY Metoprolol XL (Toprol XL) 100 mg PO DAILY Bisacodyl 10 mg PO/PR DAILY:PRN Mirtazapine 7.5 mg PO HS Nitroglycerin SL 0.3 mg SL PRN Oxycodone SR (OxyconTIN) 20 mg PO Q8H Diazepam 5 mg PO Q6H:PRN spasms Oxycodone SR (OxyconTIN) 20 mg PO ONCE Docusate Sodium 100 mg PO BID Thiamine 100mg IV Daily Prochlorperazine 10 mg PO Q6H:PRN Furosemide 20 mg PO DAILY Ranitidine 150 mg PO BID Gabapentin 400 mg PO TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: completes 10 day course on [**5-15**]. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days: completes 10 day course on [**5-15**]. 10. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain: for breakthrough pain. 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stools: while taking antibiotics. 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. Chronic LBP s/p lumbar laminectomy L3-L5 on [**2157-1-25**] (anterior fusion), now s/p laminectomy of L2 with L3-L5 fusion and hardware removal with iliac crest autograft 2. HTN 3. Hyperlipidemia 4. CAD s/p MI, s/p stents placed [**1-5**] and [**4-6**] 5. GERD 6. LLE radiculopathy 7. Cervical spondylosis C4-C7 fusion surgery [**11-3**] 8. COPD 9. Acute renal failure, peak Cr 2.2 Discharge Condition: good Discharge Instructions: You had spine surgery with removal of the previous spine fixation hardware. You should wear the back brace while you are walking until you see Dr [**Last Name (STitle) 363**] in follow-up; you do not need to wear it while sitting or lying in bed. We held the medications lasix and lisinopril because your kidneys were not working well. When you see your doctor at follow-up, you should have your kidney function (BUN/Cr) checked and restart these medicines if the kidneys have improved. Followup Instructions: Call Dr [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] for a follow-up appointment when you get home. The office number is [**Telephone/Fax (1) 40833**]. Needs Cr check and consider restarting lisinopril and furosemide if Cr returned to baseline. Also needs outpatient colonoscopy for iron deficiency anemia. Also call Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a post-op visit when you get home. ([**Telephone/Fax (1) 11061**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2159-9-6**] 11:20 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "77.79", "81.38", "81.62" ]

icd9pcs

[ [ [] ] ]

10399, 10496

5538, 8194

306, 392

10925, 10932

3710, 4044

11468, 12205

2667, 2748

8817, 10376

10517, 10904

8220, 8794

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235, 268

420, 2230

3260, 3691

4053, 5515

3184, 3244

2252, 2482

2498, 2651

3,064

172,794

9236

Discharge summary

report

Admission Date: [**2186-5-30**] Discharge Date: [**2186-6-7**] Date of Birth: [**2141-3-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: cough, shortness of breath Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: HPI: Ms. [**Known lastname **] is a 45 y/o woman with a history of HIV/AIDS (last CD4 of 22, VL [**2181**], 2 weeks ago) who presents with dyspnea on exertion, productive cough, fevers, and malaise x several months, worsening over the past few weeks. She states that she has been in an out of hospitals for this upper respiratory infection at which point she was ruled out for TB and treated for pneumonia. She states that she presented to the ED at the urging of her PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3183**]). The patient also complains of some pleuritic chest tightness, whole body myalgias. No HA, change in vision or hearing, dysphagia, abdominal pain, diarrhea, melena, hematochezia, dysuria, hematuria. She states that she takes her Bactrim faithfully but her PDP doubts this. She stopped taking HAART two months secondary to severe nausea. In the ED, the patient had a CXR with demonstrated multifocal PNA. Given ceftriaxone, azithromycin, and bactrim. No ABG obtained. Pt was resuscitated with 5L of fluids and her blood pressure responded. Past Medical History: 1. HIV/AIDS (CD4 22, VL 2K several weeks ago) Denies opportunistic infections; Neg PPD (6 weeks ago) 2. hx of Hep C positivity, HCV-RNA neg in [**10/2181**] 3. ? ITP Social History: Lives woth mother in [**Name (NI) 1474**] with significant family support. 30-pack-year history. No EtOH. +IVDU, last 20 years ago. No blood transfusions, no tattoos. Family History: DM maternal side Physical Exam: PE: VS: 101.1, HR 120, BP 100/60 R 24 %Sat 88% on RA, 94% ON 3L Gen: Cachetic, NAD, speaking without dyspnea HEENT: oral thrush, dry MM, PERRL Chest: bilateral rales, egophony at bases, R>L, air movement throughout Cor: RRR, no g/m/r Abd: flat, +BS, soft, NTND, no hepatomegaly Ext: no rashes, no edema, 2+ DP Neuro: CN 2-12 intact, strength 5/5 Pertinent Results: [**2186-5-30**] 01:35PM WBC-27.0*# RBC-3.30* HGB-9.2*# HCT-28.6*# MCV-87# MCH-28.0# MCHC-32.3 RDW-16.8* [**2186-5-30**] 01:35PM NEUTS-95.6* BANDS-0 LYMPHS-3.0* MONOS-1.3* EOS-0 BASOS-0.1 [**2186-5-30**] 01:35PM PLT COUNT-281# [**2186-5-30**] 01:35PM GLUCOSE-95 UREA N-22* CREAT-0.4 SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 [**2186-5-30**] 01:35PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.0 [**2186-5-30**] 01:35PM IRON-9* [**2186-5-30**] 01:35PM calTIBC-172* VIT B12-[**2140**]* FOLATE-7.9 FERRITIN-720* TRF-132* [**2186-5-30**] 01:35PM TSH-0.69 [**2186-5-30**] 01:35PM HCG-<5 [**2186-5-30**] 01:46PM LACTATE-1.5 [**2186-5-30**] 07:31PM TYPE-ART TEMP-37.2 RATES-/26 PO2-61* PCO2-33* PH-7.38 TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA VENT-SPONTANEOU . CXR: Multifocal patchy opacities as described above. This is concerning for PCP or multifocal pneumonia. . CT CHEST: 1) Numerous ill-defined patchy nodular opacities in bilateral lungs, associated with underlying mild bronchiectasis and emphysema, and somewhat consolidative opacity at the right lung base. These findings are most likely representing infectious process in this patient with AIDS, including PCP, [**Name10 (NameIs) 1074**] or other viral infection, or fungus including aspergillosis, or bacterial infection. Differential diagnosis include Lymphoma or Kaposi's sarcoma. Please correlate clinically. 2) Bilateral pleural effusion associated with atelectasis. 3) Diffuse anasarca. 4) Small ascites and edematous appearance of peritoneal cavity. . ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Brief Hospital Course: A/P 45 y/o woman with history of AIDS (CD4 of 3) who presents with fevers and SOB . 1. PNA: Pt was initially admitted to the ICU for close observation but then called out to the medical floor after stabilzing on 4L of oxygen. She was started on ceftriaxone and azithromycin empirically to cover community acquired pneumonia. Also, given her CD4 count and her PaO2 of <70, she was started on prednisone and PCP treatment doses of Bactrim. She was ruled out for TB with three negative [**Name10 (NameIs) 11381**] sputums. Pulmonary and ID were consulted. A CT scan of the chest showed numerous ill-defined patchy nodular opacities in bilateral lungs along with a consolidation at the right lung base. A large pleural effusion on the left was tapped and found to be exudative but with a pH of 7.5. A bronchoscopy found copius amounts of purulent sputum which was sent for PCP, [**Name10 (NameIs) 11381**] and culture. PCP was negative and prednisone was stopped and Bactrim was changed to the ppx dose. No fungus or nocardia was isolated from BAL. Urine legionella was negative. Histoplasma, coccidioides and cryptococcal antigen were all negative. The BAL culture grew out pseudomonas sensitive to ciprofloxacin so her ceftriaxone and azithro were stopped and she was started on a 3 week course of cipro. . 2. HIV: Per pt and her PCP, [**Name10 (NameIs) **] has not been taking HAART due to severe side effects. A CD4 count was checked and found to be 3 with a viral load of 47,800. ID was consulted. Once PCP was ruled out, pt was started on ppx Bactrim and Azithromycin doses. Pt was not started on HAART therapy due to her acute illness. She will follow-up in [**Hospital3 6616**]. . 3. Oral Thrush/candidiasis: Pt was given nystatin swish and swallow along with fluconazole for her severe thrush. If she is still having pain on swallowing after a 7-day course of fluconazole, she should have an EGD for further evaluation. . 4. Oral ulcers: Pt developed ulcers on her tongue and lips suspicious for herpers. A swab was positive for herpes but a DFA could not be done due to insufficient cells. She was given a 7-day course of famcyclovir. . 5. + [**Hospital3 1074**]: Pt was found to have a [**Hospital3 1074**] VL of 13,200 copies/ml. Ophthalmology was consulted and ruled out [**Hospital3 1074**] retinitis. ID did not recommend treating her + [**Hospital3 1074**] VL. . 6. Anemia: Pt's hct dropped to 21 during her acute illness and she was transfused one unit of PRBCs. Iron studies showed a very low iron with a low TIBC and high ferritin thought to be secondary to anemia of chronic disease. After her transfusion of one unit, she remained at 27-30. A parvovirus was checked and she was found to have +IgG, negative IgM. She likely has severe bone marrow suppression from her acute illness and her HIV. . 7. Bilateral Hip Pain: Pt has chronic hip pain. She was continued on her vicodin and switched over to oxycontin with oxycodone for breakthrough. . 8. Hyponatremia: Pt was noted to have a low Na during her hospital stay. Urina studies were checked and she was found to have SIADH, likely from her pulmonary process. Na remained stable without treatment. . Medications on Admission: Combivir (not taking) Viracept (not taking) Vicodin Combivent Bactrim Darvocet Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*2* 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*2* 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:*30 Capsule(s)* Refills:*2* 4. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2* 5. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 6. Ciprofloxacin 5 g/100 mL Suspension, Microcapsule Recon Sig: Ten (10) MLs PO twice a day for 17 days. Disp:*500 mL* Refills:*0* 7. Fluconazole 40 mg/mL Suspension for Reconstitution Sig: Five (5) MLs PO once a day for 5 days. Disp:*25 mL* Refills:*0* 8. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*25 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: 1. Pseudomonas Aeruginosa Multilobar Pneumonia. 2. Herpes Virus Stomatitis. 3. Oral-Esophageal Candidiasis. 4. Cachexia - Malnutrition. 5. Disseminated [**Hospital1 1074**]. 6. Parapneumonic Effusion. 7. Hypoproliferative Anemia. 8. SIADH. 9. Odynophagia. 9. HIV-AIDS, non-compliant with HAART Discharge Condition: 93% on room air. Discharge Instructions: Please take all medications as prescribed. You have been given 3 different antibiotics for your pneumonia and your mouth infections. It is very important to go to all follow-up appointments. . If your throat pain does not improve, you will need an EGD (a procedure to look at your throat) Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20302**] MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2186-6-12**] 9:00 am . You have an appointment with Dr. [**Last Name (STitle) **] on [**6-16**] (friday) at 2:00pm. . Please call [**Telephone/Fax (1) 253**] [**Hospital1 18**] Opthamology for an eye exam appointment within one month of discharge.

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Discharge summary

report

Admission Date: [**2124-5-14**] Discharge Date: [**2124-6-11**] Date of Birth: [**2062-3-6**] Sex: M Service: MEDICINE Allergies: amiodarone / lisinopril Attending:[**Doctor First Name 3290**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy Bronchoscopy Tracheostomy placement History of Present Illness: The patient initially presented to [**Hospital1 **] via ambulance following being found by his wife to have melena and hematemesis at home. There, he evidently endorsed generalized weakness, but denied chest/abdominal pain, fever, or dyspnea. Cordis and 18 gauge placed. Initial lactate was 8 and hematocrit 19. The patient was resuscitated with 6 units of pRBCs, 2 units of FFP, and calcium gluconate. As volume was added, the patient was kept on phenylephrine to keep SBP > 85. The patient was intubated--difficult intubation with grade 3 view. Octreotide and pantoprazole drips started. Ceftriaxone also started. A FAST exam showed fluid in the [**Location (un) **] pouch, which may have been ascites or blood. Patient had atrial fibrillation on EKG. In the Emergnecy Department here, the patient underwent trauma scans, which did not reveal acute problems with head or spine. The patient did have RLL collapse and secretions in the right lower lobe bronchus on CT chest. CT abdomen showed attenuation of liver and edema of gallbladder. . On arrival to the MICU, the patient was intubated and sedated. The Liver service performed endoscopy and saw a substantial ulcer on posterior wall of duodenum, though the ulcer was not actively bleeding. No varices. Past Medical History: Atrial fibrillation Hypertension Alcohol abuse, Hyperlipidemia. Hemochromatosis, hereditary. Polio-induced lower extremity weakness. Frequent falls, last a few weeks ago caused by loss of balance. Chronic venous stasis felt to be secondary to venous insufficiency as opposed to cardiac causes. Social History: He is a current smoker. He has had a problem with alcohol abuse in the past. He is currently drinking [**3-17**] drinks a night and probably more. He is currently smoking a pack-a-day. This is down from 2 packs-per-day in the past. Family History: Father and brother had hemachromatosis. Brother and mother have diabetes. Physical Exam: Admission physical exam: HEENT: Sclerae icteric, pinpint pupils, dried blood in mouth Neck: Supple, JVP cannot be appreciated due to habitus CV: Irregularly irregular rhythm, no murmurs auscultated Lungs: Clear to auscultation to anterior auscultation, no wheezes, rales, rhonchi Abdomen: Distended, dull to percussion, no fluid wave GU: Foley in place Ext: Warm, well perfused, [**3-17**]+ pitting edema bilaterally in lower extremities Neuro: Intubated, sedated, unable to respond to command. Skin: Asymmetric mole on lower left abdomen concerning for melanoma, darkened skin of lower extremities. Discharge PE: VS: T98.6, P: 78, BP: 90/60, RR: 20, O2 100% on 40% face mask GENERAL - chronically ill appearing male in no acute distress, does not open eyes to name, not tracking or following commands. HEENT - NC/AT, PERRL NECK - trach in place, NG tube in place, JVP to 5 cm above clavicle HEART - irregular rate, rhythm, nl S1-S2, no MRG LUNGS - poor inspiratory effort but no rhonchi/ wheezes. no respiratory distress ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 3+ pitting edema over the feet, 1+ pitting edema over lower legs, with blistering of LE, RLE bandaged [**3-16**] weeping edema; right wrist- pain with movement, edematous, minimal swelling of wrist, left wrist- pain with movement NEURO - eyes closed, does not open to voice, not following commands, not answering questions; passive movement of all extremities, grimaces to pain throughout but minimal withdrawal to pain Pertinent Results: Admission labs: [**2124-5-14**] 07:50AM WBC-8.5 RBC-4.26* HGB-14.0 HCT-41.9 MCV-98 MCH-32.8* MCHC-33.3 RDW-20.9* [**2124-5-14**] 07:50AM NEUTS-84.2* LYMPHS-11.5* MONOS-3.6 EOS-0.3 BASOS-0.4 [**2124-5-14**] 07:50AM PT-16.5* PTT-32.1 INR(PT)-1.6* [**2124-5-14**] 07:50AM PLT COUNT-111* [**2124-5-14**] 09:13AM PLT COUNT-118* [**2124-5-14**] 09:13AM PT-14.8* PTT-33.5 INR(PT)-1.4* [**2124-5-14**] 01:19PM HCT-36.4* [**2124-5-14**] 06:32PM HCT-35.1* [**2124-5-14**] 06:32PM GLUCOSE-129* UREA N-29* CREAT-1.2 SODIUM-136 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13 [**2124-5-14**] 09:13AM GLUCOSE-157* UREA N-30* CREAT-1.3* SODIUM-134 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-19* ANION GAP-20 [**2124-5-14**] 09:13AM CALCIUM-8.6 PHOSPHATE-5.1* . [**2124-5-14**] 09:13AM TSH-2.9 [**2124-5-14**] 01:19PM AFP-3.9 [**2124-5-14**] 07:50AM cTropnT-<0.01 . [**2124-5-14**] 09:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [**2124-5-14**] 09:20AM URINE RBC-2 WBC-9* BACTERIA-NONE YEAST-NONE EPI-3 TRANS EPI-1 [**2124-5-14**] 09:20AM URINE HYALINE-46* [**2124-5-14**] 09:20AM URINE MUCOUS-RARE Discharge Labs: [**2124-6-9**] 06:45AM BLOOD WBC-8.8 RBC-3.06* Hgb-11.1* Hct-35.8* MCV-117* MCH-36.3* MCHC-31.0 RDW-22.0* Plt Ct-137* [**2124-6-9**] 06:45AM BLOOD PT-16.2* PTT-39.3* INR(PT)-1.5* [**2124-6-9**] 02:44PM BLOOD Glucose-138* UreaN-44* Creat-0.9 Na-149* K-4.3 Cl-106 HCO3-37* AnGap-10 [**2124-6-9**] 06:45AM BLOOD Glucose-131* UreaN-46* Creat-1.0 Na-148* K-4.4 Cl-105 HCO3-35* AnGap-12 [**2124-6-9**] 06:45AM BLOOD ALT-26 AST-50* AlkPhos-101 TotBili-0.5 [**2124-6-9**] 06:45AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.2 [**2124-6-6**] 03:52AM BLOOD calTIBC-137* Ferritn-1073* TRF-105* [**2124-5-28**] 07:06AM BLOOD VitB12-1619* Folate-GREATER TH [**2124-5-19**] 06:45AM BLOOD Cortsol-21.5* [**2124-6-9**] 12:26PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-60 Monos-40 [**2124-6-11**] 07:30AM BLOOD WBC-7.8 RBC-3.06* Hgb-11.0* Hct-36.1* MCV-118* MCH-36.0* MCHC-30.5* RDW-21.5* Plt Ct-128* [**2124-6-11**] 07:30AM BLOOD Glucose-132* UreaN-48* Creat-1.1 Na-150* K-4.1 Cl-107 HCO3-36* AnGap-11 Endoscopy [**2124-5-11**]: Duodenum: Excavated Lesions A single cratered non-bleeding 30 mm ulcer was found in the posterior bulb. Impression: Granularity and nodularity in the fundus compatible with portal hypertensive gastropathy Ulcer in the posterior bulb Otherwise normal EGD to second part of the duodenum [**2124-5-14**] CXR: IMPRESSION: Endotracheal tube at the level of the clavicles, 9.9 cm above the carina, could be advanced ~ 3-5 cm. Well-positioned nasogastric tube. Right lower lung opacification may represent collapse. Small right pleural effusion. Asymmetry in opacification of bilateral upper lobes, right greater than left, may reflect patient positioning or possibly layering effusion. See immediately subsequent CT. . [**2124-5-14**] CT head: IMPRESSION: No acute intracranial pathology. Left frontal lobe encephalomalacia. . [**2124-5-14**] CT torso: IMPRESSION: 1. Endotracheal tube tip is 6 cm from the carina and needs further advancement. Nasogastric tube in the proximal stomach. 2. Secretions within the bronchus intermedius, with near-complete occlusion of the right lower lobe bronchus and collapse of the right lower lobe and partial collapse of the right middle lobe. 3. Small amount of simple abdominal and pelvic ascites. 4. Cirrhotic liver. Heterogeneous attenuation of the liver, underlying focal liver lesions cannot be excluded. Recommended a non-emergent liver ultrasound or a contrast-enhanced CT for further evaluation. 5. Distended gallbladder with small amount of sludge. Mild gallbladder wall edema is likely due to third spacing. . CT HEAD W/O CONTRAST [**5-16**]: IMPRESSION: Motion-limited study, with no acute intracranial process. If clinical concern for infarct is high, MRI is more sensitive. . MR HEAD W/O CONTRAST [**5-18**] FINDINGS: There is no evidence of acute intracranial hemorrhage or mass effect. In the left frontal lobe, there is an unchanged area of encephalomalacia, previously described by CT. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. The basal ganglia are notable for high signal intensity on T1, which is compatible with hepatic encephalopathy, please correlate clinically. Additionally, the FLAIR sequences, the diffusion-weighted images demonstrate decreased signal in the basal ganglia, subtle areas of magnetic susceptibility in the occipital lobes on the gradient echo sequence (image #15, series #7,image #17, series 302) likely consistent with iron deposits, which correlates with a history of hemochromatosis. The major vascular flow voids are maintained with normal distribution. The paranasal sinuses demonstrate mucosal thickening on the left ethmoidal air cells and minimal mucosal thickening at the left maxillary sinus. Bilateral mucosal thickening is noted at the mastoid air cells. The orbits are unremarkable. IMPRESSION: 1. There is no evidence of diffusion abnormalities to suggest acute or subacute ischemic changes. 2. Chronic area of encephalomalacia identified on the left frontal lobe, previously demonstrated by head CT. 3. Low signal intensity is demonstrated on diffusion and FLAIR sequences in the basal ganglia, with high signal on T1, likely consistent with a combination of iron deposits and possible hepatic encephalopathy and hemochromatosis, please correlate clinically. 4. Bilateral mucosal thickening at the mastoid air cells and also mucosal thickening identified in the left ethmoidal air cells and left maxillary sinus. . MR HEAD [**5-24**] IMPRESSION: 1. Technically limited MRI study because of motion artifact. Signal abnormality in the left frontal region is suggestive of encephalomalacic changes with concern for ongoing edema. No abnormal enhancement is seen. Attention on followup imaging is suggested. 2. No acute intracranial abnormality. 3. Fluid signal in the right mastoid air cells. 4. Abnormal high signal seen adjacent to the atlanto-occipital joint on the left, which may be related to degenerative changes. However, this may be further evaluated by an MRI of the cervical spine with contrast. There is subluxation of the left lateral mass of C1 on C2. MR [**Name13 (STitle) 430**] [**2124-6-8**] FINDINGS: There is a stable focus of encephalomalacia and gliosis in the left frontal lobe which may be related to prior ischemia. No new lesions are seen. There is no hydrocephalus or acute ischemia. No enhancing foci are noted. Intracranial voids are maintained. Right greater than left mastoid opacification is seen. There is volume loss with prominence of ventricles and sulci. IMPRESSION: No acute abnormalities. Stable focus of gliosis in the left frontal lobe. EEG [**2124-5-18**] FINDINGS: CONTINUOUS EEG RECORDING: Began at 18:20 on the evening of [**5-18**]. At the beginning, and through most of the record, there were generalized sharp wave discharges occurring usually with about a 1 Hz frequency. For several periods over the first 2 hours, the discharges occurred with a frequency of up to nearly 2 Hz. Review of the video from this time did not show any clinical seizure or myoclonic activity. For much of the record, the sharp waves were not particularly rhythmic, and from 2 to 4 AM on the morning of the 6th, there was a "calm" period, with primarily background slowing and relatively few sharp waves. Later, the sharp waves recurred, with an average frequency of about 1 Hz, or perhaps slightly slower by the end of the recording. There were no prominent focal findings. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITORING: Showed an irregular rhythm. SPIKE DETECTION PROGRAMS: Showed the same generalized sharp wave discharges. SEIZURE DETECTION PROGRAMS: Showed no definite electrographic seizures PUSH BUTTON ACTIVATIONS: There was one, at 19:38 on the evening of the 5th. It showed sharp wave discharges described above, but there was no clear clinical change on video. IMPRESSION: This telemetry captured a single pushbutton activation. It did not show any change in the record. Throughout most of the recording, there were generalized periodic epileptiform sharp wave discharges. Early in the record there were some episodes with discharges up to 2 Hz, but no clear clinical change was evident on video. There were some other periods with just a slow background. In general, these GPEDs represent a severe encephalopathy with the potential for seizure activity though, at 1 Hz, they're usually not considered active seizures at this time. There were no significant focal findings. The periodic discharges can at times signify ongoing seizures, and management remains a clinical decision. EEG [**2124-6-1**] FINDINGS: CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of the [**6-1**] and continued through 19:33 that evening. At the beginning, it showed a widespread slow background of about [**5-19**] Hz in all areas. There were a few bursts of generalized slowing, very few of which had sharp features. The background did not change appreciably over the course of the recording. SPIKE DETECTION PROGRAMS: Showed almost entirely artifact. There were very few sharp waves. SEIZURE DETECTION PROGRAMS: Also showed artifact. There were no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal waking or sleep patterns were evident. CARDIAC MONITOR: Showed an irregularly irregular tachycardia with a rate of approximately 140, slowing to 105-110 later in the record. IMPRESSION: This telemetry captured no pushbutton activations. It showed an encephalopathy throughout. Generalized sharp wave discharges, however, frequent on earlier recordings had, for the most part, ceased. Brief Hospital Course: 62 yo man with h/o hemochromotosis, etoh abuse, and atrial fibrillation admitted initially with massive GI bleed, admitted to the MICU course complicated by persistent encephalopathy and respiratory failure. # encephalopathy: After the initial GI bleed, this becamae the patient's primary issue and was his main barrier to extubation. Likely multifactorial. Initially suspected that this was related to sedation in addition to poor liver function, however his encephalopathy persisted despite lactulose and rifaximin. Sepsis from his pneumonia for which he completed a course of vanc/cefepime. Given lack of improvement despite the above interventions, CT and MR of the head was obtained. MRI showed mild encephalomaclacia and gliosis. Seizures were considered and he was maintained on continuous EEG. While there was no frank seizure activity, there were frequent GPEDs which neurology felt was likely contributing to his AMS. He was started on an antiepileptic regimen which was uptitrated to Keppra 2g [**Hospital1 **], Lacosamide 200mg [**Hospital1 **], and dilantin 150mg TID. It was ultimately decided to taper the dilantin by 50mg every 3 days as his mental status still waxed and waned despite antiepileptics and we felt that this may have been sedating him further. His AED regimen on discharge was Lacosamide 200 mg IV BID and LeVETiracetam 1000 mg PO/NG [**Hospital1 **]. His mental status improved minimally throughout admission from completely unresponsive to grimacing to pain. A trach was placed by thoracic surgery given inability to completely wean from vent (see below). # Respiratory failure - intubated initially for airway protection for EGD, with course complicated by VAP and encephalopathy as main barrier to extubation. Sputum grew H. Influenza, and he was maintained on vanc/cefepime as above. His pneumonia was treated and his altered mental status was managed as above. He remained [**6-17**] on PSV for several days with the main barrier to extubation being mental status. Trach was placed by thoracic surgery on [**5-31**] (given concern for cervical spine disease on MRI) and he was intermittently trach masked . # Anasarca: Pt with significant total body volume overload and was +28L for LOS. He had [**3-17**]+ total body pitting edema. He was on a lasix drip intermittently throughout the admission which diuresis limited by hypotension. He was then transitioned to lasix 40mg iv TID and his volume status improved. His BUN and HCO3 increased suggesting intravascular volume depletion. His lasix was stopped at discharge. # afib w/ RVR ?????? Pt with difficult to control a.fib throughout admission. Would frequently hit 140 bpm requiring multiple intermittent metoprolol and diltiazem pushes. He was on a dilt ggt at 2 different points over the early part of the admission with occasional control but limited by hypotension. He was eventually transitioned to an oral metoprolol regimen of 25 mg po q6h and was digoxin loaded and maintained on a dose of Digoxin 0.125 mg PO/NG DAILY. By discharge, his rate was moderately controlled in the 90s-100s. He was started on aspirin for anticoagulation as his initial GIB was stable # GI bleed: This was initial reason for admission. Liver performed endoscopy and discovered a significant ulcer on the posterior wall of his duodenum. The patient's hematocrit has stabilized, and no active bleeding was seen on endoscopy. He required no subsequent transfusions, he was weaned from portonix drip. Hpylori was negative. # Hypernatremia: Pt initially came to the MICU with Na of 133. However this climbed over admission, often to the high 140s-150s. He was given free water flushes through his dobhoff to help control this and electrolytes were monitored [**Hospital1 **]. On discharge, Na was 150. He had been getting lasix 40 mg iv TID until [**2124-6-11**]. Given improvement in his volume status, his lasix was stopped on discharge. He was continued on free water flushes 200 mg q4h which can be decreased as hypernatremia improves. # Hpotension: Pt intermittently hypotensive over the admission with MAPs as low as 50s-60s. Likely combination of baseline cirrhosis, complicated by diuresis and beta blockade for a.fib. By discharge SBPs were in 90s-100s # Anemia: Steady Hct drop over admission from 41.9 to the low 30's. Predominantly macrocytic (initially normocytic). Likely combination of nutritional factors and dilantin causing a macrocytic anemia. His dilantin was weaned down as above. Hct was stable at 32 on discharge # GI bleed - due to duodenal ulcer, bleeding appears to have stopped, hct stable, h. pylori negative # Alcohol use/abuse: The patient's family reports significant alcohol use. There was concern for alcohol withdrawl. He was maintained on midazolam boluses for sedation, but given minimal responsiveness, further benzos were avoided. Patient did not demonstrate any signs or symptoms of ETOH withdrwal during his ICU stay. #CODE: In discussion with patient's wife, patient remained full code throughout his hospitalization. ### TRANSITIONAL ISSUES ### - Please check daily BMP and decrease free water flushes as hypernatremia improves. - Patient noticed to have watery bowel movement on discharge. No fever or leukocytosis so low suspicion for c. diff but may consider testing. - L mainstem endobronchial lesion-will defer repeat bronchoscopy and biopsy for now, will need further evaluation in the future - Atlanto-axial changes: Noted on MRI and of unclear significance. - Concerning abdominal mole: Will need follow up with derm regarding atypical mole on abdomen if mental status improves. Medications on Admission: 1. Aspirin 325 daily. 2. Colace as needed 3. Fluticasone spray. 4. Hydrochlorothiazide 25 mg daily. 5. Ibuprofen 800 mg by mouth 4 times a day. 6. Magnesium oxide 400 mg by mouth every day. 7. Multivitamin. 8. Spirolactone 25 mg every day. 9. Lotrisone (Betamethasone/clotrimazole 0.05%/1%) Discharge Medications: 1. Acetaminophen 650 mg PO TID:PRN pain, grimacing do not exceed 2 gm in 24 hrs 2. Aspirin 325 mg PO DAILY 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Digoxin 0.125 mg PO DAILY 6. Fluconazole 200 mg PO Q24H Duration: 7 Days please continue x 7 days after foley removed. LAST DAY = [**2124-6-18**] 7. FoLIC Acid 1 mg PO DAILY 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 9. Heparin 5000 UNIT SC TID 10. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using REG Insulin 11. Lacosamide 200 mg IV BID 12. Lactulose 30 mL PO QID titrate to [**5-18**] BMs 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. LeVETiracetam 1000 mg PO BID 15. Metoprolol Tartrate 25 mg PO Q6H hold for SBP < 95, HR < 60 16. Miconazole Powder 2% 1 Appl TP TID:PRN rash 17. Multivitamins 1 TAB PO DAILY 18. Rifaximin 550 mg PO BID 19. Thiamine 100 mg PO DAILY 20. Outpatient Lab Work Daily BMP (Na, Cl, HCO3, K, BUN, Creatinine) until hypernatremia normalizes 21. voiding trial Please discontinue foley on arrival and give patient voiding trial. Please straight cath if unable to void. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Primary: Upper GI bleed, duodenal ulcer, respiratory failure, encephalopathy Secondary: hemachromatosis Discharge Condition: Mental Status: minimally responsive Level of Consciousness: Lethargic and minimally arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after you began vomiting blood at home. You were found to be bleeding from ulcer in your gut. You were given blood transfusions and medications to help stop the bleed and keep your blood pressure normal. The bleeding stablized. A breathing tube was placed to prevent blood from going into your lungs. Your hospital course was complicated by a pneumonia that was treated with antibiotics. You also became minimally responsive during your hospitalization. We were unable to take you off the ventilator and a tracheostomy was placed. We are not sure of what is causing your altered mental status but it was likely caused by a variety of factors, including low blood pressure from bleeding and your previous history of hemachromatosis and liver disease. Followup Instructions: Please follow-up with in neurology clinic in one month. An appointment should be made for you. If you do not hear from them, please call [**Telephone/Fax (1) 6856**] to make an appointment.

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icd9cm

[ [ [] ] ]

[ "54.91", "45.13", "33.24", "96.72", "96.6", "03.31", "81.91", "31.1" ]

icd9pcs

[ [ [] ] ]

20919, 21002

13706, 19358

294, 342

21151, 21151

3850, 3850

22109, 22302

2217, 2292

19709, 20896

21023, 21130

19384, 19686

21299, 22086

5046, 6794

2332, 2908

2922, 3831

245, 256

370, 1630

6803, 13683

3866, 5030

21166, 21275

1652, 1948

1964, 2201

16,856

193,531

51509

Discharge summary

report

Admission Date: [**2179-8-29**] Discharge Date: [**2179-9-12**] Date of Birth: [**2111-6-10**] Sex: M Service: MEDICINE Allergies: Penicillins / Heparin Agents Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Acute exacerbation of CHF Major Surgical or Invasive Procedure: - cardiac catheterization [**2179-9-1**] - central line placement - [**Month/Day/Year 106792**] placement [**2179-9-10**] History of Present Illness: 68 year old man with CAD s/p CABG [**2154**] (LIMA-LAD, SVG-D1/D3, SVG-OM3), followed by repeat CABG [**2176**] in setting of MVR for severe MR (SVG-RCA, SVG-SVG-OM3), CHF with EF 10%, VT s/p BiV-ICD placement [**2172**], HIT, OSA, HTN, and DM, recently admitted [**Date range (3) 106793**] and again [**Date range (3) 106794**] with acute on chronic CHF exacerbation for aggressive diuresis. He presented with probable acute volume overload, hyperkalemia and azotemia and was admitted to [**Hospital1 1516**] cardiology service. Patient had cardiac catheterization today ([**2179-9-1**]) for assessment of worsening CHF with focal wall motion abnormalities on most recent echocardiogram. He was transferred to the CCU service for management of CHF and worsening renal function, requiring continuous [**Last Name (un) **]-venous dialysis (CVVD), not currently on dialysis. . Mr. [**Known lastname **] [**Last Name (Titles) **] Dr. [**Last Name (STitle) **] yesterday because he has developed dyspnea and has gained 5 lbs. He otherwise is feeling OK. He was advised to take 5 mg metolazone and increase his torsemide to 100 mg [**Hospital1 **]. Labs were checked this morning and returned: Na 131, K 6.2, Cl 95, C02 26, BUN 104, Creatinine 3.4. Dr. [**Last Name (STitle) **] called Mr. [**Known lastname 106795**] wife with these results and asked that he come into the hospital, for direct admission to [**Hospital Ward Name 121**] 3. Since leaving home he has been becoming increasingly breathless. He is happy to be coming back sooner rather than later, because he really would like to avoid dialysis (as with the last admission). . On night of [**2179-8-30**] he had been waking up every twenty minutes or so with a jolt that he think originates from his ICD. He is on monitored telemetry and sent samples last night. He typically does not become breathless while lying flat, however he presently feels that his ditended abdomen is preventing him from breathing well. . Immediate relevant past medical history includes two exacerbations of heart failure with volume overload in [**Month (only) 216**] this year. During his admission (d/c date [**2179-8-2**]) several liters were diuresed but this was limited by advancing azotemia and low blood pressure. Despite diuresis being minimal he claims to have felt less bloated and less dyspneic. . He stated that he was doing well after discharge until 8/17-18/09 when he started gaining weight and suffering increased dyspnea, both on exertion and at rest. His goal intake was 1200 mg or less of sodium and fewer calories per day. He continued to use his BiPAP mask at night. However, he reported gaining 6 pounds over two days with an increase in abdominal girth/firmness. His weight was 224 pounds with a dry weight on discharge [**2179-8-2**] of 216 pounds. He was admitted and he was estimated as [**10-7**] kg above his dry weight. He was admitted to the CCU where he was continued on lasix bolus and gtt, along with milrinone bolus and gtt. He was continued on metolazone 5 mg [**Hospital1 **]. CVVH was started via R femoral line and continued for several days until it clotted off. Through this time, patient was continued on low dose neosynephrine as needed to support blood pressure with goal MAP of 55. When CVVH line clotted off ([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone with good UOP of 100-200 cc/hr. Patient was net -15 L fluid removal on discharge. . During that admission, EP was contact[**Name (NI) **] about the possibility of LV pacing, as patient has severe LV/RV dysynchrony on echo. It was felt that given his NYHA class IV status as well as prior use of LV pacing which was not very successful, the risks outweighed the benefits. However, patient's pacemaker HR was increased to 90 to improve forward flow. Patient approached new dry weight of 110kg (came in at 121 kg). His K+ goal was kept near 5-5.5 with aggressive supplementation. On discharge, patient told to stop his lasix (160 mg [**Hospital1 **]) and carvedilol (25 mg [**Hospital1 **]). Instead, he will take torsemide (80 mg [**Hospital1 **]) and metoprolol succinate (50 mg daily in AM). He was also discharged on potassium supplements 40 meq tid. Patient was informed to check his weights on a daily basis, nutrition care was discussed with patient as well. If the patient were to gain weight (i.e. [**1-26**] lbs), he was to take metolazone 5 mg tablet and call [**Hospital 1902**] clinic. He had f/u planned with [**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic. . Other problems during this last admission included acute renal failure, hypokalemia, OSA, anxiety, diabetes, hypothyroidism, as described below in past medical history. . He was a direct admit from home and thus not seen in the ED. . On review of systems, s/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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: s/p MI in [**2153**] -CABG: CABG in [**2154**] (LIMA-LAD, SVG-D1/D3, SVG-OM3), redo CABG [**2177-4-8**] (SVG-RCA, SVG-SVG-OM3) -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: VT s/p BiV-ICD placement [**2172**] 3. OTHER PAST MEDICAL HISTORY: # CHF -severe systolic dysfunction EF 25% # h/o VT -dx in [**2164**] -> had asx VT on tele while hospitalize for urologic tx -single lead ICD was placed -had 2-3 episodes of appropriate ICD firing -> new lead placed [**2167**] -continued to have shocks -> tried betapace w/o relief -started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks -had BiV ICD placed in [**2172**] -attempted VT ablation in [**2174**] w/ reload of amiodarone -last shocked: -ICD last interrogated: [**2179-8-31**] # S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine valve) [**3-/2177**] # 3+ TR # HTN # CKD - baseline mid 2's # DM -insulin dependent # Hypothyroidism # Hyperparathyroidism # Hypercalcemia # Osteopenia # Hypercholesterolemia # Dyspepsia # Sleep apnea # Obesity # LFT abnormalities attributed to NASH, possibly amio # HIT Social History: Tobacco history: quit 30 yrs ago, 1 ppd x 20 yrs -ETOH: rare use -Illicit drugs: denies He is trained as an attorney but works in purchasing companies, predominantly telecommunications and sports teams. Married. Has 2 adopted boys, aged 18 and 20. Family History: Mother died of SCD in her 40s, though the patient notes that she also suffered from a severe depression at the time and "had lost the will to live". His father died of an MI in his mid 60s. He also has 2 older brothers who have CAD and are post-MIs. + HTN, but no stroke/TIA, no cancer and no DM. Physical Exam: VS: T=35.9 BP=77/59 HR=90 RR=12 O2 sat=95% GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with elevated JVP. CARDIAC: RR (paced), normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Distant heart sounds LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, mild end-expiratory wheezes, no crackles or rhonchi. ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: cool b/l, No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ Pertinent Results: Labs on admission: [**2179-8-29**] 02:50PM BLOOD WBC-9.2 RBC-4.78 Hgb-14.2 Hct-45.6 MCV-95 MCH-29.6 MCHC-31.0 RDW-16.3* Plt Ct-256 [**2179-8-29**] 02:50PM BLOOD PT-13.7* PTT-24.6 INR(PT)-1.2* [**2179-8-29**] 02:50PM BLOOD Glucose-196* UreaN-107* Creat-3.9*# Na-134 K-6.7* Cl-97 HCO3-23 AnGap-21* [**2179-8-29**] 02:50PM BLOOD ALT-49* AST-47* LD(LDH)-340* CK(CPK)-55 AlkPhos-177* TotBili-0.6 [**2179-8-29**] 02:50PM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.8 Mg-2.5 [**2179-9-11**] 04:21AM BLOOD WBC-26.6* RBC-3.39* Hgb-10.2* Hct-30.2* MCV-89 MCH-29.9 MCHC-33.6 RDW-17.1* Plt Ct-184 [**2179-9-11**] 04:21AM BLOOD Neuts-83* Bands-4 Lymphs-2* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-1* [**2179-9-11**] 05:56PM BLOOD PTT-71.6* [**2179-9-11**] 04:21AM BLOOD PT-23.1* PTT-62.3* INR(PT)-2.2* [**2179-9-11**] 04:21AM BLOOD Plt Smr-NORMAL Plt Ct-184 [**2179-9-11**] 04:21AM BLOOD Glucose-148* UreaN-44* Creat-5.2* Na-125* K-5.1 Cl-91* HCO3-21* AnGap-18 [**2179-9-11**] 04:21AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3 [**2179-9-11**] 09:32AM BLOOD Type-MIX pH-7.36 [**2179-9-11**] 09:32AM BLOOD Lactate-1.6 . 2D-ECHOCARDIOGRAM [**2179-8-31**]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Left ventricular systolic function is severely depressed with thinned and akinetic anterior,septal,and apical segments with severe hypokinesis elsewhere. The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Although the tricuspid regurgitation gradient is approximately 18 mmHg there is probably significant pulmonary artery systolic hypertension (since right atrial pressure is likely elevated in the setting of severe tricuspid regurgitaiton). Compared with the prior study (images reviewed) of [**2179-7-30**], findings are similar. The pulmonary artery systolic pressure was probably elevated in the prior study as well. . CARDIAC CATH [**2179-9-1**]: COMMENTS: 1. Coronary angiography in this right dominant system revealed severe multivessel coronary artery disease. The native LAD and LCX were known to be occluded, and therefore the native left coronary artery was not engaged. The RCA had a 50% stenosis in the mid-portion. 2. Selective vein graft angiography of the saphenous vein grafts revealed a patent graft to the RCA. The SVG to D1 graft was patent, with slow flow to the D3 from this graft that was similar in appearance to previous cath from [**2176**]. The SVG to OM3 graft was patent. The new interposition graft from CABG in [**2176**] to SVG-OM3 was not seen. 3. Selective arterial graft angiography of the LIMA to LAD was not performed. 4. Resting hemodynamics revealed markedly elevated right sided filling pressures with mean RA pressure of 30 mmHg. The severely increased RA pressure was associated with a moderate increase in pulmonary pressures, which suggests tricuspid regurgitation. The left sided filling pressures were also increased with mean PCW pressure of 30 mmHg and LVEDP of 33 mmHg. There was no evidence of aortic stenosis. The cardiac output as calculated by Fick equation was moderately depressed at 3.4 L/min. FINAL DIAGNOSIS: 1. Severe coronary artery disease. 2. Elevated left and right sided filling pressures. 3. Likely severe tricuspid regurgitation. 4. Depressed cardiac output. . TTE [**2179-9-10**]: The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= [**10-12**] %). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The gradients are higher than expected for this type of prosthesis. There is no pericardial effusion. The inlet area of the [**Month/Year (2) 106792**] 2.5 device was located 5.o cm away from the aortic valve. The device was then pulled back 1 cm so that the inlet area was properly located at 4.0 cm from the aortic valve. Compared with the findings of the prior study (images reviewed) of [**2179-8-31**], the left ventricular end diastolic dimension is reduced (7.9 cm previously, and 6.5 cm now). The left ventricular total stroke volume (ventricular stroke volume plus [**Year (4 digits) 106792**]-driven flow; as determined by the mitral inflow Doppler velocity time integral) is approximately 50% higher (VTI pre-[**Year (4 digits) 106792**] was 45 cm vs current VTI 65). . CHEST XRAY [**2179-9-11**]: FINDINGS: There has been interval placement of an [**Month/Day/Year 106792**] percutaneous ventricular assist device, the catheter coursing within the abdominal and thoracic aorta with the distal tip located near the expected aortic valve plane. Additionally, a Swan-Ganz catheter has been placed with the distal tip terminating in the left pulmonary artery. However, as discussed by phone with Dr. [**Name (STitle) 26842**], a portion of the catheter overlying the thoracic spine is not well visualized, and a repeat chest radiograph is recommended of this region and to exclude the possibility of catheter fracture. Cardiac silhouette remains grossly enlarged. New poorly defined opacity has developed in the right upper lobe. Linear atelectasis left base. IMPRESSION: New right upper lobe opacity, which could reflect acute aspiration, developing infectious pneumonia, or, in the setting of mitral regurgitation, asymmetric edema. . CHEST XRAY [**2179-9-11**]: The Swan-Ganz catheter is now visualized continuously, and continues to terminate in the region of the left pulmonary artery. The [**Month/Day/Year 106792**] percutaneous ventricular assist device is more fully visualized on the current study, with its distal tip projecting in the region of the left ventricle. Cardiac silhouette remains markedly enlarged. IMPRESSION: Subtle opacity in right upper lobe has nearly resolved. Minimal linear atelectasis persists in the left base. . Brief Hospital Course: 68 yo M with severe end-stage NYHA class IV systolic CHF with EF of 20%, secondary to ischemic cardiomyopathy, admitted [**2179-8-31**] for acute exacerbation of CHF and transferred to CCU from [**Hospital1 1516**] service for aggressive diuresis and acute on chronic renal failure secondary to worsening CHF. . The patient presented in end-stage systolic CHF with an LVEF 20%, severely akinetic left ventricle. The patient was agressively diuresed with lasix gtt and metolazone. Additionally, he underwent CVVH for about 5 days with the goal of removing several liters of fluid. After CVVH, patient was diuresed with Bumex and Metolazone with minimal effect. Since the patient was anuric-oliguric despite aggressive diuresis, ultrafiltration was also performed several times for fluid removal. Additionally, the patient was hypotensive and maintained on several pressor medications including milrinone, dobutamine and vasopressin. Despite several pressors and aggressive fluid removal measures, he continued to have poor end-organ perfusion to kidneys and remained oliguric. The patient's poor prognosis and deteriorating hemodynamic status was discussed with patient and his wife, it was decided to implant [**Name (NI) 106792**] catheter-based ventricular assist device as a final intervention. The goal of this intervention was to improve cardiac output and see if improved perfusion to kidneys would allow for improved renal function. If the [**Name (NI) 106792**] were to show improved renal function, then the patient would be considered a candidate for an LVAD as a destination therapy. The [**Name (NI) 106792**] device was placed on [**2179-9-10**], but failed to improve his cardiac index or renal perfusion significantly. Consequently, it was felt that further interventions would be unsuccessful and the his code status was changed to DNR/DNI and "comfort measures only" after extensive discussion with the patient and his family. A magnet was placed over the patient's pacemaker, pressors were withdrawn and the patient expired on the morning of [**2179-9-12**]. Medications on Admission: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. Disp:*30 Tablet(s)* Refills:*0* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as medication. Disp:*30 Tablet(s)* Refills:*0* 18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 19. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension Sig: 45 units at breakfast, 50 units at dinner units Subcutaneous once a day. 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 25 units at bedtime units Subcutaneous once a day. 21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO three times a day: please take 40 meq potassium supplements three times a day. 22. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day. Disp:*240 Tablet(s)* Refills:*2* Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "38.95", "88.53", "37.23", "88.56", "38.93", "39.95", "37.68" ]

icd9pcs

[ [ [] ] ]

19419, 19428

15061, 17145

323, 447

19479, 19488

8413, 8418

19540, 19546

7263, 7562

19391, 19396

19449, 19458

17171, 19368

12288, 15038

19512, 19517

7577, 8394

5886, 6102

258, 285

475, 5782

8432, 12271

6133, 6980

5804, 5865

6996, 7247

8,231

129,019

49251+59162+59163

Discharge summary

report+addendum+addendum

Admission Date: [**2116-12-30**] Discharge Date: Date of Birth: [**2043-2-2**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 73 year old female with a history of coronary artery disease, status post two vessel coronary artery bypass graft with ischemic cardiomyopathy, hypertension, diabetes type II, hypercholesterolemia; chronic gastrointestinal bleed, secondary to arteriovenous malformation, hypothyroidism and chronic renal insufficiency who presents with several complaints. Her first complaint is abdominal fullness times two days but not abdominal pain. No history of fevers or chills, no nausea or vomiting. She has had some loose stools over the past several days prior to admission but no blood in her stool. She recently returned from [**State 108**] with intermittent chest pain but no shortness of breath, with no radiation to the back. She has also had some dysuria with urination as well. In the Emergency Department, her temperature was noted to be 93 degrees orally. Her blood pressure was 110/50. Her heart rate was 42. Electrocardiogram was showing a slow atrial fibrillation versus a primary arteriovenous block. LABORATORY DATA: Notable for a BUN of 128 and creatinine of 7.5. Her hematocrit was decreased at 28.8. Her urinalysis was positive for an infection. In the Emergency Department, her blood pressure dropped transiently to 85 over 40. She was subsequently transferred to the Medical Intensive Care Unit for his hypotension. Other past medical history, as stated in the history of present illness, plus Helicobacter pylori infections in the past, hypothyroidism, osteoarthritis, iron deficiency anemia and mild pulmonary hypertension. The medications she is on at home are Synthroid, Tricor, Cor-reg, Nexium, iron, Diovan, Tylenol, Isordil, Zaroxolyn, Bumex, Colace, Neurontin and Humulin 70/30. ALLERGIES: Penicillin which causes a rash. Codeine which causes an unknown reaction. PHYSICAL EXAMINATION: On admission, the patient was a pleasant, Spanish-speaking woman, resting comfortably in bed. Her temperature was 96.1 degrees; heart rate was 57; blood pressure was 100/37; respirations were 17. She was saturating 99% on room air. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. She had moist mucous membranes. Her neck was supple. No jugular venous distention was appreciated; however, it was difficult due to her body habitus. Her lungs were clear to auscultation with no rales. Cardiac examination demonstrated bradycardia and a 2/6 systolic murmur at the left sternal border that radiated to the axilla. Her abdomen was obese but soft, nontender and nondistended. Rectal examination demonstrated guaiac positive brown stool which was noted in the Emergency Department. Her skin showed multiple ecchymosis on her upper arms. Extremities had 2+ edema to the knees. Neurologic: Alert and oriented times three. Cranial nerves 2 through 12 were intact. Laboratory values on admission demonstrated a white count of 4.0; hematocrit was 28.8; platelets were 55. Her INR was 1.6. PTT was 28. Chemistry 7 showed a sodium of 138, potassium of 4.6, chloride of 107, bicarbonate of 16, BUN of 128; creatinine of 7.5 and glucose of 81. Urinalysis showed trace protein; greater than 50 white blood cells, many bacteria. CK was 432; MB was 16 and troponin was .03. Electrocardiogram showed bradycardia with possible atrial fibrillation versus primary arteriovenous block. She had an abdominal x-ray that showed no evidence of obstruction. She had a chest x-ray that showed mild congestive heart failure. HOSPITAL COURSE: 73 year old woman with multiple medical problems, now presenting in acute renal failure, possibly acute on chronic renal failure and hypotensive. In the Medical Intensive Care Unit, the patient was started on Dopamine for pressure support, in consideration of her dirty urinalysis and her positive DIC labs. There was a question of urosepsis. A Swan was placed at one point in the Medical Intensive Care Unit which showed a wedge of 28 and a PAP of 61/29 with a mean of 46. This suggested that the patient was in clinical congestive heart failure and volume overload. By hospital day number three, the patient was started on a Lasix drip. She had intermittent episodes of hypotension and, on hospital day number six, required titration of her Dopamine and Dobutamine that she was subsequently started on. The patient began hemodialysis on hospital day number four with an average goal of one to two liters removed each time. With regard to her drop in platelets, the patient was found to be Heparin induced thrombocytopenic, antibody positive and she was subsequently taken off all heparin products. By hospital day number seven, the patient was weaned off Dopamine and started on Hydralazine and Natrecor. Also, on hospital day number seven, the patient was transferred out of the Medical Intensive Care Unit and onto the floor. In terms of the patient's infectious disease issues, she had three out of three blood cultures taken on hospital day number five which grew out Methicillin resistant staph aureus. She was subsequently started on Vancomycin and that was dosed by levels each day. In terms of her cardiovascular status, the patient was initially started on the Lasix drip on the floor with a goal diuresis of negative 500 to a liter cc per day. She was subsequently switched over to 80 intravenous twice a day and ultimately 80 mg p.o. twice a day which is her current dose. On average, she diuresed 500 to 700 cc a day, negative. Her fluid status was also managed via dialysis which was performed several times per week. In terms of her rhythm status and her bradycardia, we were holding all her nodal blockers and monitored her on tele. Her rhythm appeared to be a primary arteriovenous block with a PR interval in upwards of 400 milliseconds. In terms of her coronary artery disease, she was continued on her aspirin, statin and an ace inhibitor was slowly added on hospital day number eight. In terms of her renal status, she received hemodialysis intermittently throughout her hospital course but remained generally azotemic. A 24 hour urine creatinine was being collected at the time of this discharge summary. In terms of her hematologic status, the patient was HIT antibody positive. No heparin products were continued. The patient was transfused to keep her hematocrit above 28. On hospital day number 13, the patient required a transfusion due to a hematocrit of 25. She was also on Epogen and iron for iron deficiency anemia and chronic renal insufficiency anemia respectively. In terms of her pulmonary status, she was continued on her Fluticasone and Ipratropium. In terms of her gastrointestinal status, the patient chronically had guaiac positive stools that were dark; however, she was being treated with iron which somewhat obscured the results. On hospital day number 13, her iron was held to see if the guaiac positivity cleared. The results of holding the iron are unknown at the time of this discharge summary. In terms of her electrolyte status, she was repleted as needed, in terms of her potassium and magnesium. This discharge summary is dictated up to [**2117-1-10**] and the remainder of the patient's course will be dictated by the intern coming on the service, including discharge medications. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 3809**] MEDQUIST36 D: [**2117-1-10**] 05:28 T: [**2117-1-10**] 18:32 JOB#: [**Job Number 103244**] Name: [**Known lastname **], [**Known firstname 2868**] Unit No: [**Numeric Identifier 16705**] Admission Date: [**2116-12-30**] Discharge Date: [**2117-1-19**] Date of Birth: [**2043-2-2**] Sex: F Service: [**Location (un) **] This will cover hospital stay from [**1-10**] through [**2117-1-19**]. An additional discharge summary including further hospital course and discharge medications and diagnosis will be dictated by the next covering intern. Please see previous discharge summary for admission and hospital course up until [**1-10**]. HOSPITAL COURSE: Patient had multiple blood cultures positive for MRSA bacteremia. An echocardiogram was obtained to evaluate for any valvular involvement. Vegetations were seen on the aortic valve and the patient was then diagnosed with MRSA endocarditis. She was continued on IV Vancomycin with plans to treat her for a total of six weeks on IV Vancomycin. Given her renal failure, her levels were followed and her dosing was determined based on her serum Vancomycin concentration. GI bleed: Patient with long history of chronic GI bleeds and has had multiple colonoscopies, scans, and endoscopies without any source isolated. A capsule endoscopy did show previous multiple AVMs in the small bowel, however, these were unable to be accessed. The patient did not consent to surgery. Throughout the initial admission, the patient did have some guaiac positive stools, but no frank melena or bright red blood per rectum. However, later in her admission, she did develop initially melenic stools. These progressed in frequency and then she began passing blood tinged stools and multiple bright red blood clots. GI was consulted to follow the patient. A tagged red blood cell scan was obtained which initially was negative. Patient continued to pass clots and another scan was done which localized her bleeding to her left lower quadrant. She then went to angiography for an attempted embolization, however, this was unsuccessful. In addition, it was complicated by a right groin hematoma and retroperitoneal bleed. Patient did go to the unit for observation following this, and was briefly on pressor support. Surgery was consulted to evaluate her retroperitoneal bleed, and decision was made to simply monitor her. She received multiple blood transfusions and was then weaned off pressors. She then had a colonoscopy. GI was able to localize several AVMs which were cauterized. Following this, patient had no further rectal bleeding and her hematocrit remained stable. 2. End-stage renal disease on hemodialysis: Patient continued to be dialyzed by the Renal service. It was thought that she likely would require lifelong hemodialysis, although her creatinine dose continued to be monitored. Following stabilization, a tunneled hemodialysis catheter would be placed, and dialysis will be arranged for the patient initially while at rehab and while at home. She was initially on Renagel and PhosLo for her elevated phosphate, however, she developed hypophosphatemia and these phosphate binding agents were discontinued. Her electrolytes otherwise remained within acceptable limits. 3. CHF: Patient with history of CHF with EF of approximately 30-35%. She was aggressively diuresed throughout the hospitalization. Her Lasix was briefly held during her hypotension and active GI bleeding. However, she was able to be restarted on her Lasix which she tolerated well. She was also placed back on an ACE inhibitor. She will require a beta blocker, although likely as an outpatient once her acute issues have stabilized. 4. New fevers: On the 23rd, patient had a low grade temperature in the morning. Her central catheter was D/C'd while at dialysis. Approximately one hour after dialysis begun, she did spike a high grade temperature to 101 thought to represent possible line infection. She was continued on Vancomycin and treated symptomatically for her fever. Blood cultures were sent. In addition, patient complained of mild abdominal pain which did seem to localize to the site of her right groin hematoma. This pain did improve with control of her fevers. Decision was made to closely monitor the patient with serial abdominal examinations. Should she spike another fever, additional antibiotic coverage would be added to broaden her gram-negative rod coverage. In addition, she should have any further abdominal pain, a CT of the abdomen with contrast will be obtained to rule out any progression of her bleeds or for any acute GI infectious process. Please see next discharge summary addendum for completion of hospital course. [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**] Dictated By:[**Last Name (NamePattern1) 9097**] MEDQUIST36 D: [**2117-1-19**] 22:07 T: [**2117-1-20**] 05:08 JOB#: [**Job Number 16706**] Name: [**Known lastname **], [**Known firstname 2868**] Unit No: [**Numeric Identifier 16705**] Admission Date: [**2117-1-19**] Discharge Date: [**2117-1-26**] Date of Birth: Sex: F Service: PLEASE SEE PREVIOUS DISCHARGE SUMMARIES COVERING HOSPITAL COURSE [**2116-12-30**] THROUGH [**2117-1-19**]. CURRENT DISCHARGE SUMMARY ADDENDUM COVERS HOSPITAL COURSE [**1-19**] THROUGH [**2117-1-26**], WHICH IS HER DATE OF DISCHARGE. HOSPITAL COURSE: 1. Methicillin resistant Staphylococcus aureus endocarditis: Patient was maintained on intravenous vancomycin for her Methicillin resistant Staphylococcus aureus endocarditis. She is to complete a six week course which will be through [**2117-2-19**]. Her vancomycin was renally dosed and levels were checked each morning, and she was given vancomycin for levels less than 15, given her fluctuating creatinine clearance. A dosing schedule was not able to be established. Patient did spike low grade temperatures on [**1-19**] and her Dialysis catheter was removed and sent for culture and did not grow out any organisms. She had a full body CT scan which was negative for any acute processes. She did not have any further febrile spikes and was continued only on vancomycin. 2. Gastrointestinal bleed: Serial hematocrits were continued to be monitored and were stable. She had no further episodes of melena or bright red blood per rectum. 3. Congestive heart failure: Patient was started back on Lasix twice a day with excellent diuresis on this level. She was continued on an ACE inhibitor and was also started on a low dose beta-blocker. Patient tolerated this regimen well. A repeat echocardiogram showed improvement in her cardiac function with an ejection fraction now improved to 55-60%. Her previous congestive heart failure exacerbation was thought to be volume related given her acute renal failure. 4. Endocrine: The patient continued on levothyroxine for her hypothyroidism and had no symptoms on this regimen. She was started on 70/30 insulin for her diabetes and covered with sliding scale insulin for elevated blood sugar at meals and her sugars were excellently controlled on this regimen. DISCHARGE DIAGNOSES: 1. Cardiogenic shock. 2. Bradycardia. 3. Acute on chronic renal failure. 4. End stage renal disease with severe uremia. 5. Methicillin resistant Staphylococcus aureus bacteremia. 6. Methicillin resistant Staphylococcus aureus endocarditis. 7. HIT. 8. DIC. 9. Chronic gastrointestinal bleed with multiple colonic AVMs. 10. Congestive heart failure. 11. Coronary artery disease. 12. Chronic anemia. 13. Hypothyroidism. 14. Diabetes. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To rehabilitation. RECOMMENDED FOLLOW-UP: Follow-up with primary care physician in one to two weeks. Follow-up with Renal for schedule on hemodialysis. DISCHARGE MEDICATIONS: 1. Levothyroxine 175 mcg q.d. 2. Colace 100 b.i.d. 3. Gabapentin 300 q. 48 hours. 4. Tylenol prn. 5. Dulcolax prn. 6. Atorvastatin 10 q.d. 7. Albuterol inhalers 1-2 puffs q. 4 hours. 8. Atrovent inhaler 2 puffs q.i.d. 9. Fluticasone 8 puffs b.i.d. 10. Fexofenadine 60 mg b.i.d. 11. Toprol XL 12.5 mg q.d. 12. Lasix 80 mg b.i.d. 13. Lisinopril 5 mg q.d. 14. Pantoprazole 40 mg q.d. 15. 70/30 insulin, 23 units q.a.m., sliding scale insulin. 16. Combivent inhaler 1-2 puffs q. 6 hours prn. 17. Vancomycin 1 gram q. 24 hours for vancomycin levels less than 15. Please note, patient may receive vancomycin at Dialysis. DR.[**Last Name (STitle) 117**],[**First Name3 (LF) 116**] 12-988 Dictated By:[**Last Name (NamePattern1) 9097**] MEDQUIST36 D: [**2117-1-26**] 10:15 T: [**2117-1-26**] 10:33 JOB#: [**Job Number 16707**]

[ "286.6", "403.91", "599.0", "996.62", "427.31", "428.40", "584.9", "428.0", "038.11" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "45.43", "88.72", "38.93", "99.10", "00.13", "99.04", "89.64" ]

icd9pcs

[ [ [] ] ]

15323, 15507

14860, 15301

15530, 16390

13115, 14839

1987, 3684

143, 1964

82,810

109,759

31153

Discharge summary

report

Admission Date: [**2110-8-5**] Discharge Date: [**2110-8-23**] Date of Birth: [**2055-6-23**] Sex: M Service: SURGERY Allergies: Bee Pollens Attending:[**First Name3 (LF) 695**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: colonoscopy colostomy and mucous fistula History of Present Illness: 55 year old man with a history of rectal cancer s/p resection ([**7-13**]) and ileostomy takedown [**1-14**], as well as cirrhosis [**2-5**] hepC + EtOH abx, who was recently admitted with SBO ([**5-14**], to surgery/[**Doctor Last Name 1120**]) now presents with abdominal discomfort x 1day with nausea and fever at home to 100.0. He denies emesis, reports flatus, with recent BM last PM, no brbpr or melena. He typically moves his bowels 5-6 times per day - had normal BM's yesterday (non bloody, brown), none today- but states he has not eaten today due to pain. Pain is located around his scar from prior ileostomy. States that he has been feeling better since arriving at the ED, and currently is hungry and pain free. No chest pain, dyspnea or palpatations. ROS otherwise negative in full. In the ED: 98.2 70 131/77 18 98% RA; repeat temp at 2110 was 101.9. Exam notable for soft abd with mild tenderness @ RLQ, no rebound or guarding; prior ostomy site clean and intact w/o erythema or induration. A CT abdomen with contrast demonstrated no signs of obstruction. A chest CXR did not demonstrate focal consolidation. Though his pain had improved, he was admitted for fever workup. Past Medical History: Hep C/EtOH Cirrhosis, T2N0 Rectosigmoid CA sp LAR w/ diverting loop ileostomy ([**7-13**]) and Ileostomy takedown ([**1-14**]), HTN, Aortic Stenosis, GERD, EtOH abuse Past Surgical History: Open LAR w/ diverting loop ileostomy c/b ureteral injury s/p reimplantation, anastomotic stricture s/p balloon dilitations & stent placement, Ileostomoy takedown [**1-24**] c/b wound infection. Social History: He lives alone. He smokes 1.5 ppd since age 15. He has largely quit EtOH for the last 3 yrs but reports drinking occasionally. He used to drink 0.5l hard alcohol. He uses marijuana but denies IVDU. He is currently unemployed. Family History: No history of liver disease or malignancies Physical Exam: Obese man, NAD VS: T 100, 124/69, 71, 18, 97% RA HEENT: MMM PULM: lungs are clear in all fields CV: RRR no MRG ABD: obese, many healed surgical scars, mildly tender over site of prior ileostomy, no rebound or guarding, hypoactive bowel sounds ext: no c/c/e neuro: fluent speech, moves all 4 psych: appropriate affect Pertinent Results: [**2110-8-5**] 12:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM [**2110-8-5**] 12:26PM URINE RBC-<1 WBC-8* BACTERIA-FEW YEAST-NONE EPI-<1 [**2110-8-5**] 12:26PM PLT COUNT-106*# [**2110-8-5**] 12:26PM NEUTS-85.5* LYMPHS-9.6* MONOS-3.6 EOS-1.1 BASOS-0.2 [**2110-8-5**] 12:26PM WBC-5.0# RBC-3.61* HGB-12.0* HCT-34.3* MCV-95 MCH-33.2* MCHC-35.0 RDW-15.0 [**2110-8-5**] 12:26PM ALBUMIN-4.0 [**2110-8-5**] 12:26PM LIPASE-27 [**2110-8-5**] 12:26PM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-70 TOT BILI-0.8 [**2110-8-5**] 12:26PM GLUCOSE-164* UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13 [**2110-8-5**] 09:58PM LACTATE-1.0 . CXR: prelim negative CT ABD: prelim: Relative transition with dilated fecal loaded sigmoid colon proximal to the point of the sigmoid-rectal reanastomosis most compatible with a component of anastomatic narrowing. No evidence of small bowel obstruction though the ileoileo reanastomosis has a tethered appearance to the anterior abdominal wall. No evidence of abcess. Cirrhosis. Sequelae of portal hypertension. [**8-8**] TTE: Conclusions The left atrium is dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.8 cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No definite vegetations seen Compared with the findings of the prior study (images reviewed) of [**2107-9-28**], the findings are similar. If clinically indicated, a transesophageal echocardiographic examination is recommended. IMPRESSION: no definite vegetations seen but best excluded by transesophageal echocardiography [**8-14**] KUB: FINDINGS: There is no evidence of free air. The previously seen dilated loops of bowel are much less prominent on today's study. There is a [**Last Name (un) **]-rectal stent seen within the pelvis. The visualized osseous structures are unremarkable. [**2110-8-16**] Doppler Liver IMPRESSION: 1. Echogenic cirrhotic liver without discrete lesions. 2. Doppler assessment of the hepatic vasculature including the portal and superior mesenteric veins and main hepatic artery are widely patent with appropriate waveforms. 3. Splenomegaly. 4. Cholelithiasis. Brief Hospital Course: - Abdominal Pain: Mr. [**Known lastname 32126**] was initially admitted to the medical service for work-up of abdominal pain and fevers. He had an admission CT that revealed fecal loading with an associated dilated proximal colon. There was no evidence of obstruction, ascites, or colitis per report. He was placed on an aggressive bowel regimen and had 2 BMs within 24 hours of admission. U/A and CXR were negative. His diet was slowly advanced, which he tolerated well. He was started on Oxycodone, which was titrated up to 10mg Q4H PR. Pt underwent colonoscopy with dilation of anastamotic stricture on [**2110-8-11**] which he tolerated well, however, afterwards became apneic requiring transfer to ICU. A metal stent was placed on [**8-13**] which he tolerated and f/u KUB showed decreased bowel distension. On [**8-14**], his stent was dislodged and the following day it was removed and he was transferred to the transplant service for evaluation. He had an abdominal [**Month/Year (2) 950**] performed to assess his liver vasculature, which showed patent vessels. He went to the OR on [**8-19**] for end colostomy and mucous fistula. He returned to the floor in stable condition and on POD 1 his diet was advanced to clears and he was restarted on his pre-operation medications. He ambulated to chair and his pain was controlled on oral pain medication. On POD 2 he was advanced to a regular diet and his foley was discontinued. He complained of abdominal pain around his ostomy site but that was controlled on narcotics and he ambulated within his room. He was evaluated by physical therapy on [**2110-8-22**] and was cleared to go home. He was in stable condition and ready for discharge to home with visiting nurse services on [**2110-8-23**]. - GPC bacteremia: Admission blood cultures grew GPC in pairs and chains. He was started empirically on Vancomycin and Cefazolin, which was narrowed to Vancomycin monotherapy. He continued to have daily evening fevers. Speciation revealed Strep viridans so abx coverage was narrowed to ceftriaxone. Flagyl was also on for GI coverage. TTE was neg for vegetations and f/u cultures were neg. Because of the concern for over sedation, it was decided to treat the patient empirically for endocarditis with 4 weeks of ceftriaxone. A PICC line was placed and the patient was sent home with IV ceftriaxone and flagyl until [**9-5**]. He is to follow up with ID on [**9-4**]. - Apnea: After the colonoscopy with dilation of anastatamotic stricture, pt became apneic on the floor and a code was called. Pt required high doses of sedatives/narcotics to be comfortable. He received Fentanyl 300mg IV and Versed 8mg IV during the procedure. Given high doses of fentanyl/versed in the setting of liver disease, patient was monitored after the procedure for an hour. During this time, he was awake and well. When he was brought up to the medicine floor he became unresponsive and apneic. His O2 saturation was 100% at this time, and he was hemodynamically stable with BP ~140/80 and HR 71. After receving narcan, patient became responsive and respiratory rate normalized. He was transfered to [**Hospital Unit Name 153**] for observation. Overnight, pt remained alert and comfortable. Pt was breathing well on room air. Sedating meds were slowly reintroduced. - Pancytopenia: Patient had a pancytopenia on admission, which is his baseline. There were no signs of overt GI bleeding and no hemodynamic instability that would suggest a hematologic catastrophe. He was given neupogen, to which he responded with an increase in his WBC. Most likely, pancytopenia is secondary to history of chronic alcohol abuse. - Hypertension: BP was stable on his home meds. - Cirrhosis: There was no evidence of an acute decompensation, although varices and splenomegaly were noted on CT abdomen. He should follow w/ Dr. [**Last Name (STitle) 497**] as outpt per routine. - Insomnia: His home Seroquel, Neurontin, Ambien were continued initially however held in ICU given apnea [**2-5**] oversedation. He was restarted on these medications while on the transplant service. Medications on Admission: 1. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 2. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. nadalol Sig: Twenty (20) mg qAM, 60 mg qPM 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 5. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Wellbutrin 100 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Neurontin 1500 mg HS Discharge Medications: 1. nadolol 20 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO QAM (once a day (in the morning)). 4. nadolol 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for pain. 8. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 9. gabapentin 300 mg Capsule Sig: Five (5) Capsule PO HS (at bedtime). 10. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). 15. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). 16. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: strep viridans bactremia Colonic stricture Colon cancer s/p resection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted initially to the medicine service with several days of fever and abdominal pain and found to have bacteria in your blood. You underwent a colonoscopy which showed a stricture at the anastomosis. Please call Dr.[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] if you experience any fevers, chills, high output blood in your ostomy bag, difficulty tolerating solids or liquids, increasing pain, or redness around the wound site. Do not do any heavy lifting >10 lbs for six weeks. Do not drive while taking narcotic medications. Please resume a regular diet and your home medications as well those prescribed from the hospital. You can shower but do not take baths or showers for at least a week after surgery or until follow-up in clinic. You were started on antibiotics for the bacteria in your blood, which will continue until [**9-5**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2110-8-27**] 10:40 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 32437**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-9-4**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2110-9-4**] 3:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]., MD [**2110-9-30**] 10:15a at [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Colon/Rectal CC3 (NHB) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2110-8-23**]

[ "564.00", "571.2", "790.7", "284.1", "996.59", "E878.2", "E849.9", "572.3", "303.90", "305.1", "401.9", "997.4", "786.03", "305.20", "V10.05", "571.5", "E878.1", "424.90", "E849.7", "276.3" ]

icd9cm

[ [ [] ] ]

[ "38.97", "45.23", "46.86", "98.05", "46.85", "46.10" ]

icd9pcs

[ [ [] ] ]

11528, 11586

5318, 9433

284, 327

11700, 11700

2615, 5295

12742, 13560

2217, 2263

10001, 11505

11607, 11679

9459, 9978

11851, 12719

1762, 1957

2278, 2596

230, 246

355, 1549

11715, 11827

1571, 1739

1973, 2201

16,369

163,889

27503

Discharge summary

report

Admission Date: [**2131-7-23**] Discharge Date: [**2131-8-7**] Date of Birth: [**2073-11-23**] Sex: F Service: HISTORY: The patient is a very pleasant 57 year-old woman who comes to us from [**Hospital 3278**] Medical Center. She underwent a gastric bypass which resulted in substantial weight loss but she did develop a near critical condition with open abdomen and hernia. A hernia repair was done in [**2127**] but still there was a significant area of herniation and she is here for hernia repair. Complicating factors is that she has an aortic valve and is on Coumadin. PAST SURGICAL HISTORY: As above plus hand surgery in [**2122**]. MEDICATIONS: Coumadin and Levoxyl, lisinopril and propranolol. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: She is a well developed female in no acute distress. There is a large central midline hernia. HOSPITAL COURSE: The patient was first brought into the hospital and anticoagulated. Ultimately she was then taken to the operating room where a hernia repair with component separation including the use of mesh was used. The repair itself was uneventful and the wound was closed over large drains. The patient was taken back to the recovery room. The difficult decision as always when to restart anticoagulation on aortic valve and we initiated the anticoagulation approximately 8 hours or so after surgery. Unfortunately that led to the development of a very large hematoma in the abdomen which required transfer to the Intensive Care Unit. She ultimately had to go back to the operating room for evaluation of the hematoma. She received multiple units of blood transfusion but actually tolerated all these procedures well. Ultimately by the end of her stay she had no hematoma. She was able to tolerate POs. She had a closed wound with no hernia and was ready for discharge. DISCHARGE MEDICATIONS: Same as her admission medications and she will follow up with Dr. [**Last Name (STitle) **] and the associated physicians such as her cardiologist and her primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10418**], [**MD Number(1) 18192**] Dictated By:[**Last Name (NamePattern4) 27436**] MEDQUIST36 D: [**2131-9-27**] 10:15:51 T: [**2131-9-27**] 12:49:06 Job#: [**Job Number 67281**]

[ "V45.3", "401.9", "V43.3", "244.9", "998.0", "552.21", "458.29", "V58.83", "E878.8", "998.12", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "53.61", "99.04", "54.12" ]

icd9pcs

[ [ [] ] ]

1888, 2342

903, 1864

621, 767

790, 885

23

124,321

4311

Discharge summary

report

Admission Date: [**2157-10-18**] Discharge Date: [**2157-10-25**] Date of Birth: [**2082-7-17**] Sex: M Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 3227**] Chief Complaint: seizures Major Surgical or Invasive Procedure: [**2157-10-21**]: Left craniotomy for mass resection History of Present Illness: Mr. [**Known lastname 18661**] is a 75yo RHM with CAD s/p CABG, AS, HTN, Hyperlipidemia, now here for resection of parasagittal meningioma. Pt first noted symptoms three years ago with dizziness, was evaluated in [**State 108**] where a head CT revealed L frontal extraxial mass (~2cm per pt). Seen by a neurosurgeon in [**State 108**] and told watchful waiting was best. However 6 weeks ago the patient had an episode where his right lower extremity "gave way." Occasionally "feels like wood." He underwent MRI scan which revealed enlargement of the mass, with descriptions from records documenting 2.5x3.4x2cm L frontal lobe extraaxial mass, and also a much smaller 12mmx8mmx4mm mass in the R temporal lobe (per [**Hospital3 417**] report). He was started on decadron 1mg [**Hospital1 **]. Pt was scheduled for resection with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2157-10-22**]. However last night he was moving furniture, and upon moving a bureau back into his home he developed a sensation of numbness at his foot that travelled to his upper thigh over the course of only a few seconds. He then noted rhythmic low amplitude shaking of the limb that was not suppressable. His right arm then extended outwards beyond his volitional control. His wife took him to [**Hospital3 417**] where he was given ativan IV, loaded with Fosphenytoin 1,000mg IV. The movements subsided in about 15 minutes. No loss of consciousness. No speech/language deficits. No visual loss. He reports no further episodes since. Currently feeling well. Denies any headaches. He does still feel a loss of sensation in a stocking distribution of his right foot to his ankle. When he walks he feels like he does not have command over his right leg. No bowel or bladder dysfunction. Past Medical History: PMHx: CAD- CABG x 4 ([**2153**]) here at [**Hospital1 18**] HTN AS- no syncopal symptoms. Hypercholesterolemia Past Surgical Hx: Appendectomy Bilateral Inguinal hernia repair Anal fissure repair Cholecystectomy tonsillectomy and adenoidectomy Social History: Social Hx: married, retired electrical equipment designer with three years of engineering training, Korean War Veteran, Currently smokes pipe tobacco x last 55yrs, smoked cigarettes during the war but none since, rare social ETOH use. No illicits. Family History: Family Hx: Mother- d. 93, CAD Father- d. 73, Parkinson's Disease, CAD Brother- d. 73, had hemo Physical Exam: On Admission: PHYSICAL EXAM: O: T: 97.3 BP: 118/70 HR: 71 R: 20 O2Sats: 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. crescendo-decrescendo murmur best at RUSB radiates throughout precordium and abdomen. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-29**] 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, 5 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with sustained nystagmus at lateral end-gaze. 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 [**5-31**] throughout. No pronator drift Sensation: Reduced to LT only on right foot in stocking distribution to the ankle. Otherwise intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2------> - Left 2------> - Toes mute bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Gait: good initiation, wide based, discoordinated stride with right lower extremity, leans to the right. Absent Romberg. Pertinent Results: Labs on Admission: [**2157-10-19**] 04:55AM BLOOD WBC-10.9 RBC-4.29* Hgb-13.4* Hct-38.9* MCV-91 MCH-31.3 MCHC-34.6 RDW-14.4 Plt Ct-216 [**2157-10-19**] 04:55AM BLOOD Neuts-88.7* Lymphs-7.0* Monos-3.6 Eos-0.3 Baso-0.3 [**2157-10-19**] 04:55AM BLOOD PT-11.9 PTT-26.6 INR(PT)-1.0 [**2157-10-19**] 04:55AM BLOOD Glucose-141* UreaN-16 Creat-0.7 Na-140 K-4.2 Cl-104 HCO3-27 AnGap-13 [**2157-10-19**] 04:55AM BLOOD ALT-26 AST-21 AlkPhos-68 TotBili-0.8 [**2157-10-19**] 04:55AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.0 Mg-2.1 ------------------- IMAGING: ------------------- MRI Head [**10-20**]: FINDINGS: Limited post-contrast MRI of the brain demonstrates an enhancing left parafalcine lesion measuring approximately 2.1 x 3.3 x 3.5 cm. This lesion is in close proximity to the adjacent sagittal sinus although it does not appear to be involving the sinus. No other abnormal enhancing lesions are identified. There is minimal surrounding edema and no significant mass effect. IMPRESSION: Dural-based enhancing lesion arising from the left parafalcine region with minimal mass effect and small amount of surrounding edema. This likely represents a meningioma. MRI Head [**10-22**](post-op): FINDINGS: Since the previous study, the patient has undergone resection of left parietal parafalcine extra-axial mass. Blood products are seen in the region with edema. Air is seen intracranially. Bilateral small subdural collections are seen. These findings are indicative of post-operative change.No acute infarct seen. No midline shift or hydrocephalus identified. No residual nodular enhancement is identified. IMPRESSION: 1. Status post resection of left parietal parafalcine mass with expected post-surgical changes of blood products and air in the region and intracranial air and bilateral small subdural collections. No acute infarct, mass effect, or hydrocephalus. No residual nodular enhancement seen. EEG [**10-20**]: BACKGROUND: A 9 Hz posterior predominant rhythm was seen in the brief waking state. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Produced no activation of the record. SLEEP: The patient progressed from wakefulness to drowsiness but did not attain stage II sleep. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60 bpm. IMPRESSION: This is a normal predominantly drowsy routine EEG in the waking and drowsy states. There were no focal lateralize or epileptiform features. Brief Hospital Course: Patient was admitted to the Neurosurgical service on [**10-18**] following an episode of seizure. The patient underwent resection of the left para-sagittal mass on [**10-21**]. He tolerated this procedure well and remained neurologically unchanged post-resection. He was taken to the ICU post-operatively for close monitoring on POD0. On POD#1, he was transferred to the neurosurgical floor. He was subsequently seen and evaluated by PT and OT and was cleared for discharge home. Medications on Admission: Aspirin 81mg daily (currently held) Tylenol PRN Decadron 1mg [**Hospital1 **] Amlodipine 5mg daily Lisinopril 40mg daily Simvastatin 40mg daily Synthroid 50mcg daily Decadron 2mg q6hrs Dilantin 100mg PO TID Nexium 40mg daily Metoprolol 25mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: left parasagital brain mass Discharge Condition: Neurologically stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry, you may shower from the neck down. You will not need to have sutures removed, as Dr. [**First Name (STitle) **] has used dissolvable sutures. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You were on Aspirin, prior to your surgery. You may restart this one week after your surgery. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication taper, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office in [**8-5**] days (from your date of surgery) a wound check(your sutures are dissolvable). This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-28**] at 10:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will / will not need an MRI of the brain with/ or without gadolinium contrast. If you are required to have a MRI, you may also require a blood test to measure your BUN and Cr within 30 days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **] please make sure to have these results with you, when you come in for your appointment. Completed by:[**2157-10-25**]

[ "348.5", "401.9", "780.39", "225.2", "272.0", "V15.82", "424.1", "272.4", "V45.81", "V45.79" ]

icd9cm

[ [ [] ] ]

[ "01.51" ]

icd9pcs

[ [ [] ] ]

8727, 8782

7019, 7504

284, 339

8854, 8878

4552, 4557

14121, 15312

2707, 2803

7813, 8704

8803, 8833

7530, 7790

8902, 8923

2847, 3154

12290, 14098

236, 246

8935, 12263

367, 2157

3447, 4533

4571, 6996

3169, 3431

2179, 2425

2441, 2691

73,971

182,744

41711+58468

Discharge summary

report+addendum

Admission Date: [**2133-12-1**] Discharge Date: [**2133-12-14**] Date of Birth: [**2063-7-12**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1406**] Chief Complaint: SOB, Palpitations, Chest pain Major Surgical or Invasive Procedure: [**2133-12-3**] Coronary artery bypass grafting x4 (LIMA-LAD,SVG-PLVB,SVG-D2,SVG-RI) History of Present Illness: This 70 year old male was admitted to another institution on [**11-26**] with shortness of breath, chest discomfort and confusion. He was seen the day prior to admission by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] and had a Holter monitor placed. He was found to be in rapid atrial fibrillation with a rate in the 150's when he presented to the ED. He was brought to the cath lab [**11-26**] which showed EF 10-15% as well as a 100% LAD and RCA and Cx lesions. He was ruled out for MI and started on Lovenox for the atrial fibrillation. He was transferred to [**Hospital1 18**] for evaluation for revascularization. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass [**2133-12-3**] Atrial Fibrillation Cerebrovascular Accident Hypertension Social History: Lives with: Wife, dtr, son in law Contact: Phone # Occupation: Retired - goes back and forth between USA and [**Country 13622**] Republic every few months Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [x] [**3-9**] drinks/week [] >8 drinks/week [] Illicit drug use - none Family History: Premature coronary artery disease - none Physical Exam: Pulse:82 Resp:18 O2 sat: 99% RA B/P Right:129/84 Left: Height:68" Weight:153# General: AAO x 3 in NAD, Spanish speaking, pleasant Skin: Dry [x] intact [x] Vitaligo left hand HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace LE edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:groin hematoma, + TTP Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2133-12-9**] 06:05AM BLOOD WBC-7.9 RBC-3.50* Hgb-10.2* Hct-31.9* MCV-91 MCH-29.1 MCHC-31.9 RDW-15.2 Plt Ct-213 [**2133-12-9**] 06:05AM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-137 K-4.7 Cl-97 HCO3-31 AnGap-14 [**2133-12-3**] Intra-op TEE Conclusions Pre-CPB: Mild spontaneous echo contrast is present in the left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Overall left ventricular systolic function is severely depressed (LVEF= 10 - 15 %), with septal, lateral and anterior hypokinesis, and inferior akinesis. There is mild echo contrast in all [**Doctor Last Name 1754**]. There is mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**2-1**]+) mitral regurgitation is seen. There is no pericardial effusion. There is a small left pleural effusion. The tip of the SGC is at the PA bifurcation. Post-CPB: The patient is AV-Paced, on infusions of epinephrine and nitroglycerine. RV systolic fxn is unchanged. The LV is slightly improved, with all walls moving slightly better than pre-bypass. EF is now 15 - 20%. The PFO is unchanged. MR is trace - 1+. No AI. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2133-12-4**] 11:07 Brief Hospital Course: The patient was brought to the Operating Room on [**2133-12-3**] where he underwent Coronary Artery Bypass x 4 with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He developed rapid atrial fibrillation and was bolused with Amiodarone. He did require epicardial pacing and NeoSynephrine for blood pressure support. He converted to Sinus Rhythm. The patient was neurologically intact. Hemodynamics improved and he was weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Lisinopril was started for further blood pressure control in the setting of systolic heart failure with an EF 10-15%. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. As he had no benefits for rehabilitation admission he was kept in house for further recovery prior to returning home with his wife. By the time of discharge on POD 13 the patient was ambulating with his walker, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions. PT WILL TAPER HIS AMIO, NO COUMADIN Medications on Admission: Toprol 50 daily, ASA 81 daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): PLEASE TAPER 200 MG BO [**Hospital1 **] X 7 DAYS, THEN 200 QD UNTIL YOU FOLLOW UP WITH YOUR PCP. 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass [**2133-12-3**] Atrial Fibrillation Cerebrovascular Accident Hypertension Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2134-1-14**] at 1pm Wound check on [**2133-12-17**] at 10:30pm at [**Last Name (NamePattern1) **], [**Hospital Unit Name **] Cardiologist Dr. [**Last Name (STitle) 42394**] on [**2133-12-21**] at 1:30pm Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**Last Name (un) **] [**Doctor Last Name **] [**Telephone/Fax (1) 80120**] in [**5-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2133-12-13**] Name: [**Known lastname 4408**],[**Known firstname 2490**] Unit No: [**Numeric Identifier 14309**] Admission Date: [**2133-12-1**] Discharge Date: [**2133-12-14**] Date of Birth: [**2063-7-12**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 135**] Addendum: Patient was discharged home on [**2133-12-14**] Medication adjustments included Lasix and Potassium Chloride extended to 2 week duration. Discharge Disposition: Home [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2133-12-14**]

[ "348.31", "401.9", "427.31", "410.71", "428.0", "438.89", "V63.8", "783.21", "458.29", "285.1", "426.3", "414.01", "998.11", "V85.1", "428.23", "433.10", "V14.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.13", "36.15", "39.61", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9673, 9837

4093, 5652

310, 396

7436, 7593

2411, 4070

8381, 9650

1605, 1648

5733, 7225

7288, 7415

5678, 5710

7617, 8358

1663, 2392

240, 272

424, 1076

1098, 1225

1241, 1589

3,998

164,827

19664

Discharge summary

report

Admission Date: [**2135-3-26**] Discharge Date: [**2135-4-12**] Date of Birth: [**2091-8-29**] Sex: M Service: NOTE: Discharge date is pending. A Discharge Summary Addendum will be upon discharge. CHIEF COMPLAINT: Status post motor vehicle accident. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gentleman status post motor vehicle crash, unrestrained driver ejected partially. The patient complaining of severe back pain and inability to move bilateral lower extremities on presentation. The patient was hemodynamically stable with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15 on transfer by medical flight. PAST MEDICAL HISTORY: 1. Left lower extremity fracture. 2. Significant tobacco history. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: No medications at home. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: On presentation, the patient's temperature was 98 degrees Fahrenheit, his heart rate was 120, his blood pressure was 110/60, his respiratory rate was 24, and his oxygen saturation was 92% on face mask. On examination, the pupils were equal, round, and reactive to light. The extraocular movements were intact. There was ecchymosis inferior to the left eye. The trachea was midline. Cardiovascular examination revealed a regular rate and rhythm. There were bilateral coarse breath sounds. Tenderness to the thoracolumbosacral. The abdomen was soft, nontender, and nondistended. The pelvis was stable. There were no deformities or costovertebral angle tenderness to the bilateral flanks. The back and neck examination was positive for a gross deformity at T12-L1. The cervical spine had no deformities or stepoff tenderness. Rectal examination revealed a decreased tone and was guaiac-negative. Extremity examination was within normal limits with palpable pulses throughout, but inability to move bilateral lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count was within normal limits. Chemistries and coagulations were within normal limits. His lactate was 1.6. Urine was negative. Toxicology screen was negative. Urine toxicology screen was positive for cocaine. PERTINENT RADIOLOGY/IMAGING: Radiologic films with a chest x-ray which showed bilateral pulmonary contusions and rib fractures of six, seven, and nine on the right and nine on the left. This also revealed a left pneumothorax for which a chest tube was placed. A computed tomography of the abdomen also showed a large retroperitoneal hematoma and a L1 burst fracture with bone in the spinal canal. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was intubated with a orogastric tube inserted. A Foley catheter was placed. The patient was put on a Solu-Medrol drip and was kept sedated while intubated in the Intensive Care Unit. Neurosurgery was consulted. Lower extremity examination showed bilateral lower extremity placidity. No reflexes. No withdrawal to painful stimulation, and no clonus. Also on admission to the Intensive Care Unit, the patient had a Swan-Ganz catheter placed which showed depressed cardiac output and index. Cardiology was consulted, and an echocardiogram was performed. This echocardiogram showed no effusion or evidence of tamponade with normal-appearing right ventricular function and possibly somewhat depressed left ventricular function. In addition, and Ophthalmology consultation was called regarding fractures of the zygomatic arch and macular sinus. Their conclusion was that the bilateral globes were intact, and subconjunctival hemorrhage of the left eye required no treatment and recommended conservative treatment. A magnetic resonance imaging of the lumbar spine was obtained on [**3-28**], when the patient was hemodynamically stable enough to have this study. The findings were abnormal signals in L1 anteriorly and posteriorly; consistent with fractures. It also showed abnormal cord signal with high-grade cord compression in T10, T11, L1, and L2. Neurosurgery reviewed these films and decided to take the patient to the operating room. The patient is status post L1 laminectomy and T7 through L3 posterior fixation on [**2135-4-1**]. At this time, the patient had spiking temperatures with possible leukocytosis. Cultures were obtained, and methicillin-resistant Staphylococcus aureus from the sputum culture from [**4-1**], and Escherichia coli from his sputum culture from [**3-30**], and Klebsiella from a blood culture from [**3-30**]. Levaquin and vancomycin were started on [**4-1**] and [**4-2**]; respectively. On [**4-3**], the patient was extubated and the chest tube was discontinued. The patient tolerated these events well. The rest of the patient's course was unremarkable. The patient was transfused packed red blood cells on an as needed basis. Psychiatry was consulted for supportive care and two events of hallucinations at night. The Speech and Swallow Service was also consulted. The patient passed the swallow study and was able to tolerate a regular diet upon discharge without problems. The patient had a persistent leukocytosis but remained afebrile with negative cultures throughout the hospital course. This was thought to be a leukemoid reaction secondary to the neurosurgical operation. The patient had no signs of infection. The patient was aggressively with Physical Therapy and Occupational Therapy and had a TLSO brace in place throughout his hospital stay. Upon discharge, the patient was afebrile with stable vital signs. The patient was tolerating a regular diet. The chest tube site was clean, dry, and intact. The patient had a regular rate and rhythm, and the lungs were clear to auscultation bilaterally. The patient's abdomen was soft, nontender, and nondistended. The patient was educated on self catheterization. The patient was on an aggressive bowel regimen and was having regular bowel movements upon discharge. The patient completed a course of vancomycin and was switched to by mouth levofloxacin for a 14-day course upon discharge. DISCHARGE DIAGNOSES: 1. Status post motor vehicle collision; partial ejection and bilateral lower extremity paralysis. 2. Bilateral pulmonary contusions. 3. Respiratory distress. 4. Left pneumothorax; status post chest tube placement. 5. Rib fractures of the left sixth, seventh, and ninth ribs and right ninth. 6. L1 burst fracture with retropulsion. 7. Retroperitoneal hematoma. 8. Bacteremia. 9. Methicillin-resistant Staphylococcus aureus pneumonia. 10. Status post chest tube placement. 11. Status post Swan-Ganz catheter placement. 12. Status post L1 laminectomy. 13. Posterior fixation of T7 through L3 secondary to L1 fracture/dislocation and chronic burst fracture. DISCHARGE DISPOSITION: The patient was to be discharged to a rehabilitation center with aggressive Physical Therapy and Occupational Therapy. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient should be followed by Social Work, Psychiatric Service for supportive care and possible outpatient followup and recommendations. 2. The patient's treatments are as per Physical Therapy and Occupational Therapy. 3. The patient should have vital signs per routine with self catheterization education. 4. The patient was to have TLSO brace in place. 5. The patient was to follow up with Neurosurgery in two weeks; the patient to call the office for an appointment. 6. The patient was also instructed to follow up with the Trauma Clinic in two to three weeks; the patient to call the office for an appointment. CONDITION AT DISCHARGE: Condition on discharge was stable. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Albuterol inhaler 1 to 2 puffs q.4-6h. as needed. 2. Polyvidone alcohol drops 1 to 2 drops both eyes as needed. 3. Nicotine patch transdermally once per day. 4. Heparin 5000 units subcutaneously q.12h. (until ambulating three times per day without problems). 5. [**Name2 (NI) 6196**] 40 mg by mouth once per day. 6. Bisacodyl 10 mg by mouth/per rectum once per day as needed. 7. Lactulose 30 mg per rectum as needed. 8. Levofloxacin 500 mg by mouth q.24h. (until [**4-16**]). 9. Ativan 0.5 mg to 2 mg by mouth q.4-6h. as needed (for agitation). NOTE: An Addendum to this Discharge Summary will be made upon acceptance to rehabilitation center. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**] Dictated By:[**Last Name (NamePattern1) 27744**] MEDQUIST36 D: [**2135-4-12**] 16:15 T: [**2135-4-12**] 17:01 JOB#: [**Job Number 53245**]

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icd9cm

[ [ [] ] ]

[ "96.6", "81.08", "96.04", "96.72", "38.93", "99.04", "34.04", "03.53", "81.63", "89.64", "81.05", "38.91" ]

icd9pcs

[ [ [] ] ]

6841, 6961

6141, 6817

7711, 8683

837, 2661

6994, 7633

803, 810

2691, 6119

7648, 7684

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45289

Discharge summary

report

Admission Date: [**2129-12-23**] Discharge Date: [**2129-12-29**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year-old female with [**Age over 90 1291**], A fib and sinus tach with HR in 120s, dCHF, CABG, HTN, and right leg cellulitis x1 month who was admitted for cellulitis, diarrhea (bloody), and was found to have c diff. Yesterday in afternoon she had an episode of chest pain that resolved with no intervention and ekg was unremarkable. At 3 am she became tachypnic to the 30s with SBP in the 170s. An EKG was done showing sinus tach with PACs. The pt had crackles on exam R>l. A CXR was done which concerned the overnight team for pulmonary edema. She got lasix 40 IVx 1 at 3:45 am and put out 1100cc of urine. ABG was done (we think on room air) and showed 7.41/37/67/24. Lytes were checked and showed a bicard of 24 with a gap of 24. She also had a new 2L oxygen requirement this Am with sats in the 80s. Her HR was 105 this AM and she received 5IV lopresor. CBC this AM was concentrated with increased WBC (19.5 ->28.6) and HCt also elevated. She had several episodes of cp this AM and got 3 SL nitro approx every hour. She was started on ASA. Given concern for possible PE she was started on a heparin gtt. . Of note pt reports weakness and feeling poor for 1 wk prior to admission and with new onset lose stools in the setting of being on abx x1 month for. . On the floor, prior to transfer to ICU vital signs were BP156/93 RR38 HR 102 97% on 2L. Pt reported she was feeling fine. Past Medical History: - [**7-8**]: CAD s/p 3V CABG with saphenous vein grafts to the LAD, OM and posterior descending coronary arteries using cardiopulmonary bypass. - [**7-8**]: Aortic valve replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] bovine prosthesis. Normal function on echo of [**3-13**] - CHF EF 60%, grade I diastolic dysfunction, mild MR - Hypercholesterolemia - h/o PAF - Depression - HTN - s/p TAH - left Total hip replacement Social History: walks with walker at baseline, lives at [**Hospital3 **] in [**Location (un) **], [**Hospital3 **], gets help with ADLS, distant h/o tobacco (quit 50yrs ago), no illicit drugs or ETOH. Does not wear a lifeline, has one in bldg. Reports occasional mechanical falls at home. Family History: Mother died at 84 from stomach cancer, had hypertension. Father died at [**Age over 90 **]y/o from "old age" Physical Exam: Vitals: T: 100.4 BP: 127/65 P: 96 O2: 93% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackes at b/l bases, 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: right anterior shin with 4cm-long crusted atrophic lesion along length of anterior shin with flaking of skin surrounding the lesion. no erythema, warmth, or exudate. On Admission to MICU: Vitals: T:95.8 BP:152/72 P:94 RR30 97% on 2L General: drowsy, alert and oriented x3, eyes closed throughout unless I ask her to open them HEENT: Sclera anicteric, very dry mm Neck: supple, JVP not elevated. Lungs: + crackles at right lung base. CV: mild tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: + bs, soft, non-tender, no rebound tenderness or guarding, no organomegaly Ext: right leg with scabbed over ulcer on RLE, + pockets of edema at right shin/ankle and under right knee, no edema in the foot, no palpable cords. Skin with chronic venous stasis changes both sides no LLE edema. DP pulses +1 bilaterally. Pertinent Results: EKG ([**2129-12-23**]): Sinus rhythm. Diffuse T wave flattening that is non-specific. Compared to the previous tracing of [**2129-11-10**] there is no significant diagnostic change. EKG ([**2129-12-24**]): Resting sinus tachycardia. P-R interval 200 milliseconds. Left atrial abnormality. Relative low lateral precordial voltage. Non-specific ST-T wave change. Compared to the previous tracing of [**2129-12-23**] heart rate is faster and voltage criteria for left ventricular hypertrophy are not seen. LENI ([**2129-12-25**]): No evidence of DVT in the bilateral lower extremities. CTA chest ([**2129-12-26**]): 1. No evidence of pulmonary embolism or aortic dissection. 2. Increased in size of right pulmonary artery. Please clinically correlate for signs of pulmonary artery hypertension. 3. Probable mild pulmonary edema. 4. Multiple stable vertebral compression deformities. 5. Stable bilateral adrenal thickening most compatible with hyperplasia. On admission ([**2129-12-23**]): WBC-23.6*# RBC-4.90 Hgb-13.1 Hct-39.7 MCV-81* MCH-26.7* MCHC-33.0 RDW-14.2 Plt Ct-197 Neuts-92.0* Lymphs-4.0* Monos-3.1 Eos-0.7 Baso-0.1 Glucose-101 UreaN-30* Creat-1.6* Na-129* K-4.0 Cl-89* HCO3-27 Calcium-9.0 Phos-3.2 Mg-1.7 ALT-8 AST-17 LD(LDH)-239 AlkPhos-149* TotBili-0.4 Lactate-2.2* On discharge ([**2129-12-29**]): WBC-10.2 RBC-4.80 Hgb-13.4 Hct-40.5 MCV-84 MCH-27.9 MCHC-33.1 RDW-14.4 Plt Ct-204 BLOOD PT-13.2 PTT-27.5 INR(PT)-1.1 Glucose-107* UreaN-20 Creat-0.9 Na-139 K-4.3 Cl-103 HCO3-30 Brief Hospital Course: [**Age over 90 **] year-old female with mild diastolic heart failure, PAF, CAD, and hypertension admitted with C. difficile colitis. Hospital course was as follows: 1. C. difficile colitis: In context of antibiotic use for treatment of RLE cellulitis. On discharge, diarrhea improved. No abdominal pain, nausea, vomiting, fever. Leukocytosis resolved. Good PO intake. Although patient qualified for severe C. difficile infection given age and initial leukocytosis, given good response to metronidazole did not transition to oral vancomycin. Metronidazole should be continued for total 14 day course (stop date [**2130-1-6**]). 2. Decompensated diastolic heart failure: Grade I noted by TTE in [**2128**]. Previous severe aortic stenosis, now s/p bioprosthetic [**Year (4 digits) 1291**]. Transferred to MICU on [**2129-12-25**] for new oxygen requirement in context of HR 120-130s, SBP to 170s. Heart failure was thought to be leading cause after patient was ruled out for PE (negative CTA chest and lower extremity doppler studies) and ACS. She received modest amount of IVF prior to onset of symptoms. On transfer back to medical floor, patient began to autodiurese with improvement in oxygen saturation on room air. Furosemide restarted per home regimen on discharge. 3. Paroxysmal atrial fibrillation: Continued amiodarone 100mg PO daily and aspirin 81mg PO daily per home regimen. CHADS2 score is 3. Patient with long-standing PAF per review of OMR. On review of OMR, was anticoagulation in [**2123**], but not during several recent hospitalizations. Decision to withhold anticoagulation with coumadin not stated in records, although may be related to age/fall risk. 4. Hypertension: On review of OMR, previously treated with lisinopril and metoprolol. No mention is made in OMR of why/when medications were stopped, but per recent discharge summaries, blood pressure well-controlled off of antihypertensives. During this hospitalization, sBP 170s prior to transfer to MICU. On transfer back to medical floor, sBP elevated on occasion despite overall clinical improvement. No evidence of hypertensive emergency/end-organ damage on medical floor. Was briefly on labetalol 100mg PO BID, although this drastically decreased blood pressure. On discharge, furosemide restarted at home dose. Blood pressure should be monitored in rehab. If systolic BP persistently elevated >150, would recommend starting low-dose ACE inhibitor (was previously on lisinopril). 5. CAD: s/p 3V CABG ([**2123**]). Continued simvastatin 20mg PO daily, ASA 81mg PO daily (briefly 325mg PO daily with concern for ACS, as above) per home regimen. 6. Depression: Continued venlafaxine XR 75mg PO daily per home regimen. 7. Right lower extremity wound: Previously with surrounding cellulitis. Patient was on antibiotic therapy at time of admission. Antibiotic therapy for cellulitis stopped on admission given that wound appeared to be healing appropriately and with no evidence of infection. Patient will need continued wound care in rehabilitation facility. 8. Prophylaxis: Continued calcium/vitamin D supplementation per home regimen. Code status: DNR/DNI, confirmed with patient Medications on Admission: Docusate Sodium 100 mg twice daily as needed Acetaminophen 500 mg every 6 hours as needed pain Aspirin 81 mg daily Calcium Carbonate 500 mg Twice daily Amiodarone 100mg daily Cholecalciferol (Vitamin D3) 800units daily Simvastatin 20mg daily Venlafaxine 75 mg daily Trazodone 50 mg nightly prn insomnia Senna 8.6 mg twice daily as needed Bisacodyl 5 mg as needed Furosemide 20 mg daily Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): For total 2 weeks. Started [**2129-12-23**]. Continue through [**2130-1-6**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: - C. difficile colitis - Acute renal failure, now resolved Secondary: - Decompensated diastolic heart failure Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to [**Hospital1 69**] on [**2129-12-23**] for diarrhea due to a bacteria called Clostridium difficle. You were treated with Flagyl, an antibiotic, and did well. You will need to continue taking this antibiotic as directed. You required a short stay in the ICU likely due to fluid in your lungs; on your day of discharge, your oxygen levels are normal on room air. Given that you are deconditioned from the infection and the hospital stay, we recommend that you go to a rehabilitation center for a short stay. Medication changes during this hospitalization include: - Starting Flagyl, an antibiotic - Stopped antibotics for treatment of cellulitis - Stopped medications for constipation Followup Instructions: Dr.[**Name (NI) 3744**] office will call you for an appointment. You should see her in 2 weeks. If you do not hear about an appointment time by the [**1-6**], please call ([**Telephone/Fax (1) 8427**]. Completed by:[**2129-12-29**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9891, 9957

5438, 8614

272, 278

10120, 10120

3920, 5415

11025, 11258

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1,656

162,975

27702

Discharge summary

report

Admission Date: [**2192-7-4**] Discharge Date: [**2192-7-21**] Date of Birth: [**2130-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right upper lobe carcinoma Major Surgical or Invasive Procedure: Bronchoscopy. Cervical mediastinoscopy. Right thoracotomy with upper lobectomy and radical mediastinal lymphadenectomy. History of Present Illness: Mr. [**Known lastname 23215**] is a 62-year-old gentleman with a substantial smoking history who presented with solitary brain metastasis was found to have a spiculated lesion in the right upper lobe consistent with a lung primary. He has done well with resection of the metastasis and is being evaluated now for oligometastatic disease. Past Medical History: -COPD, currently smokes -high cholesterol -h/o vertigo -h/o pericarditis -prior ETOH abuse, sober x17 years -chronic LBP s/p laminectomy Social History: -lives with wife and son -currently smokes 1ppd x 50 yrs -worked as a cook Family History: -mother with TB -father with TB and cancer (does not know what kind) Physical Exam: General: Slim size, short, mature gentleman, no teeth or dentures, looks tired and diaphoretic. Neck: Supple, no carotid bruits Lungs: Decreased bibasilar sounds. CV: Regular rate and rhythm. Abdomen: Non-tender, non-distended, bowel sounds present. Ext: Warm, no edema. Pertinent Results: Pathology Examination SPECIMEN SUBMITTED: R 4 F/S., RT UPPER LOBE F/S, RT LN # 10, 11, LEVEL 3 NODE, RT NODE, 4,2, LEVEL 7 LN. Procedure date Tissue received Report Date Diagnosed by [**2192-7-4**] [**2192-7-4**] [**2192-7-15**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/tk?????? Previous biopsies: [**-6/2076**] RIGHT BRAIN MASS RESECTION DIAGNOSIS: 1. Lymph node, R4 (A): One lymph node, with no evidence of malignancy (0/1). 2. Lung, right upper lobe, lobectomy (B-I): a. Adenocarcinoma, see synoptic report. b. The malignancy has a similar histologic appearance to the brain metastasis ([**-6/2069**]). 3. Lymph nodes, 11R, (J): One lymph node, positive for adenocarcinoma, 0.6 cm deposit. 4. Lymph node, 10R, (K): One lymph node, no evidence of malignancy (0/1). 5. Lymph nodes, level 3, (L-N): Adenocarcinoma present in one out of nine lymph node lymph node fragments. 6. Lymph node, 4R, (O): One lymph node with no evidence of malignancy (0/1). 7. Lymph node, 2R, (P): Seven lymph node fragments, all with no evidence of malignancy. 8. Lymph node, level 7, (Q-S): Nineteen lymph node fragments, all with no evidence of malignancy. Lung Cancer Synopsis MACROSCOPIC Specimen Type: Lobectomy. Laterality: Right. Tumor Site: Upper lobe. Tumor Size Greatest dimension: 4 cm. Additional dimensions: 4 cm x 3.5 cm. MICROSCOPIC Histologic Type: Adenocarcinoma, not otherwise characterized. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT2 [**2192-7-4**] 01:47PM GLUCOSE-108* UREA N-20 CREAT-0.8 SODIUM-137 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2192-7-4**] 01:47PM CALCIUM-8.0* PHOSPHATE-6.1*# MAGNESIUM-2.1 [**2192-7-4**] 01:47PM HCT-36.8* [**2192-7-4**] 11:10AM TYPE-ART PO2-262* PCO2-36 PH-7.45 TOTAL CO2-26 BASE XS-2 [**2192-7-4**] 01:47PM HCT-36.8* [**2192-7-4**] 11:10AM HGB-12.5* calcHCT-38 [**Month/Day/Year 706**] Final Report CHEST (PA & LAT) [**2192-7-18**] 7:40 AM Reason: assess interval change [**Hospital 93**] MEDICAL CONDITION: 61 year old man with RUL mass s/p rul lobectomy via right thorocotomy REASON FOR THIS EXAMINATION: assess interval change INDICATION: Right upper lobe mass, status post right upper lobectomy via right thoracotomy, follow up. COMPARISON: [**2192-7-17**]. TECHNIQUE: PA and lateral chest. FINDINGS: Heart size and mediastinal contours are unchanged. Left-sided PICC with tip in SVC in unchanged position. Right-sided hydropneumothorax is increased in the interval. There is continued loculation of pleural fluid along the right lateral chest wall. Right basilar atelectasis appears unchanged. Dobbhoff feeding tube terminates in the proximal small bowel. IMPRESSION: 1. Slight increase in right-sided pneumothorax. 2. Stable right lower lobe atelectasis. Brief Hospital Course: Patient admitted on [**7-4**]. On [**7-4**] patient underwent Bronchoscopy, Cervical mediastinoscopy, Right thoracotomy with upper lobectomy and radical mediastinal lymphadenectomy. Post operatively, the patient was transferred to the ICU, where he was stabilized. Patien was transferred to a regular bed on [**7-19**] from which he was discharged on [**7-21**]. Medications on Admission: lipitor 20, klonopin 0.5", dexamethasone 4", dilantin 100"', protonix, seroquel [**7-16**]-passed S&S Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*1* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day for 10 days: then Two (2) Tablets PO each Morning and One (1) Tablet PO each Evening for 10 days, then One (1) Tablet PO each Morning and One (1) Tablet PO each Evening for 10 days, then One (1) Tablet PO each Morning for 10 days, then discontinue medication. Disp:*100 Tablet(s)* Refills:*0* 4. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 cannister* Refills:*7* 5. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day for while taking Codeine days. Disp:*40 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*2* 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 1 days. Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Non-small cell lung cancer brain metastasis SIADH adjustment disorder atrial fibrillation aspiration pneumonia Discharge Condition: fair Discharge Instructions: Please call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you experience fever, chills, chest pain, shortness of breath, redness or drainage from your incision site. You may shower. After showering, remove your chest tube site dressing and cover the site with a clean bandaid daily until healed. Do not drive while you are taking narcotic pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 2389**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4741**] Appointment should be in [**7-30**] days Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-7-23**] 1:00 Completed by:[**2192-7-24**]

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icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "32.4", "38.93", "40.3", "34.22", "33.24" ]

icd9pcs

[ [ [] ] ]

6435, 6510

4350, 4714

347, 469

6665, 6671

1487, 3535

7086, 7385

1105, 1175

4867, 6412

3572, 3642

6531, 6644

4740, 4844

6695, 7063

1190, 1468

281, 309

3671, 4327

497, 836

858, 996

1012, 1089

16,249

164,809

27303

Discharge summary

report

Admission Date: [**2151-4-4**] Discharge Date: [**2151-4-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: STEMI, shortness of breath Major Surgical or Invasive Procedure: intubation central venous line placement History of Present Illness: 81yo F with hyperlipidemia, PVD, CKD who initially presented to OSH with dyspnea on [**4-4**]. She woke up in the middle of the night with acute SOB, without associated chest pain or diaphoresis, possibly with nausea. The week PTA, she had been experiencing flu-like symptoms (cough, rhinorrhea, myalgias). At the OSH, she had a CXR with pulmonary edema, elevated cardiac enzymes (troponin T 0.2--> 3.33), proBNP 35,000, and she developed inferior ST elevations that reportedly resolved on heparin and integrilin. She also received beta blocker and Lasix, and was transiently on nitro gtt. . She was transferred to [**Hospital1 18**] ([**Hospital Unit Name 196**]) yesterday for consideration of catheterization and for further workup and management. She was initially continued on heparin and integrilin, and received 1U PRBC for a Hct of 23.9. This morning, she developed acutely worsening shortness of breath. She also had hemoptysis x 2, for total of ~100cc dark red blood. Her integrilin was stopped. Her SBP transiently dropped to the 70s, but improved without intervention. She was also on a nitro gtt transiently, and received Lasix 120mg IV x 1 and Diuril 250mg IV x 1. She had increasing O2 requirement and was put on 100% NRB. Given her tenuous respiratory status and labile BP, she was transferred to the CCU for closer monitoring. . Currently, she denies chest pain, palpitations, fever/chills, abdominal pain. She is still feeling short of breath. Past Medical History: - Hyperlipidemia: on Lipitor - h/o TOB (40 pack years, quit decades ago) - hearing impairment - anxiety - depression - Carotid artery stenosis R 50-79% lesion; L totally occluded, dx [**2148**] - macular degeneration - CKD (baseline Cr. 2.3 per PCP) - s/p R clavicular fracture s/p fall 2-3 months ago - PMR Social History: Lives with daughter in split level apt, widowed, h/o of TOB, quit many years ago, no ETOH Family History: NC Physical Exam: vitals- T 99.0, HR 70, BP 118/42 (79/32 this am), RR 25, O2sat 98-99% NRB, I/O [**Telephone/Fax (1) 66941**] since MN General- lying in bed with HOB at 30deg, tachypneic, no use of accessory muscles HEENT- sclerae anicteric, NRB Neck- JVP ~10cm at 30deg Lungs- + rhonchi diffusely L>R Heart- RRR, difficult to hear over breath sounds but no murmur auscultated Abd- soft, NT, ND, NABS Ext- venous stasis changes, trace LE edema b/l, DP pulses faint b/l, feet warm Neuro- asleep but easily arousable, strength grossly intact and symmetric, CNs grossly intact Pertinent Results: [**2151-4-4**] 06:25PM WBC-12.3* RBC-2.71* HGB-8.3* HCT-23.9* MCV-88 MCH-30.7 MCHC-34.9 RDW-14.4 [**2151-4-4**] 06:25PM PLT COUNT-168 [**2151-4-4**] 06:25PM PT-13.9* PTT-118.3* INR(PT)-1.2* [**2151-4-4**] 06:25PM TSH-0.94 [**2151-4-4**] 06:25PM LD(LDH)-468* CK(CPK)-1082* TOT BILI-0.3 [**2151-4-4**] 06:25PM cTropnT-4.08* [**2151-4-4**] 06:25PM GLUCOSE-121* UREA N-71* CREAT-3.8* SODIUM-135 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-18* ANION GAP-22* . ECG: NSR @ 70bpm, nl axis, QTc 456, Q wave in III, STE in III, <0.5mm STE in aVF, TWI I/L/V3-6, LVH. . CXR: Moderate cardiomegaly is stable. Mild interstitial edema has improved, but peripheral consolidative opacities in the left upper lung as well as left perihilar consolidation that is new, raise possibility of pneumonia particularly aspiration. No pneumothorax. Pleural effusion, if any, is small, on the right. . TTE ([**4-5**]): The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the inferolateral wall, hypokinesis of the mid-inferior wall, and mild dyskinesis of the basal inferior and distal inferior walls. The remaining left ventricular segments contract normally. EF 35-40%. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with prominent mitral annular calcifictation. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Briefly, this is an 81yo F with smoking history, hyperlipidemia, [**Hospital 66942**] transferred from OSH after having 1 week of flu like symptoms, dyspnea, and was found to have STEMI with pulmonary edema and BNP [**Numeric Identifier 14123**]. The pt was diuresed and treated with integrillin, heparin, asa, plavix at OSH, and transferred to [**Hospital1 **] for cath/evaluation. She also had had a single fever at OSH to 102. The pt was admitted on [**4-4**] to [**Hospital Unit Name 196**] with for possible cath, but was then transferred to CCU for hypoxic respiratory distress and hypotension. The pt was found to have multifocal pneumonia vs. pulmonary hemorrhage on CT, as well as severe emphysematous disease. Integrillin and heparin were ultimately discontinued. The pt was started on levo/flagyl for empiric treatment of aspiration PNA. Pulmonary consult felt her sxs were likely due to PNA/bronchitis and her hemoptysis/bleeding was likely [**2-4**] anticoagulants. In regards to her STEMI, the pt was felt to have likely RCA disease given STE in inferior leads. Cath was deferred given the pts ARF. Renal also was consulted for the pts [**Doctor First Name 48**] (baseline Cr 2, Cr here up to) felt to be due to ATN. She also had diarrhea on the floor and her stool culture came back positive for C. difficile. . CCU course [**Date range (1) 52620**]/06: On [**4-11**], she had acute respiratory distress with acute onset shortness of breath and desaturation to 88% on room air, in the setting of SBP to 150s-170s. She had diffuse rales on exam. EKG showed persistent ST elevations inferiorly, and more prominent ST changes and T-wave inversions V1-2, concerning for ischemia. The most likely cause for her respiratory distress was thought to be acute pulmonary edema possibly secondary to ischemia, however her differential did include aspiration pneumonia, pulmonary embolism, and pulmonary hemorrhage. She was placed on a nonrebreather mask, but did not improve with nitroglycerin drip, IV furosemide, and morphine. She was intubated for continued respiratory distress and paradoxical breathing. After long discussion with the family and Cardiology staff, the decision was made not to pursue cardiac catheterization given the likelihood that it may lead to the need for hemodialysis, which the family felt would be against the patient's wishes. She was brought to the CCU for further care. The patient's family also decided to make the patient DNR. In the CCU, her temperature was found to be 104.9. She had worsening bilateral alveolar opacities on chest x-ray, thought to indicate pulmonary hemorrhage vs. aspiration. She was on maximal ventilatory support but had persistent progressive hypoxia. She also developed hypotension requiring pressors. Her clinical picture was thought to be consistent with sepsis, likely secondary to aspiration pneumonia. In continuing extensive family discussion, her children felt the patient would not have wanted such aggressive intervention. The decision was made to withdraw pressors but to keep her intubated. On the morning of [**4-12**], she became asystolic and was pronounced dead. Medications on Admission: Outpatient meds: Atorvastatin Clarinex Prozac Trazadone Clonazepam . Meds on transfer: Levofloxacin 250mg IV q48h (1 dose) Flagyl 500mg IV q12h Heparin gtt Atorvastatin 80mg qd Plavix 75mg pd Metoprolol 12.5 [**Hospital1 **] Acetylcysteine (x 2 doses) Fluoxetine 20mg qd Colace 100mg [**Hospital1 **] Senna 1 tab [**Hospital1 **] prn Clonazepam 0.5mg tid prn Ipratropium neb q6h Albuterol neb q2h prn Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: Multifocal pneumonia Acute renal failure ST elevation myocardial infarction Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired Completed by:[**2151-5-13**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8278, 8287

4624, 7787

288, 330

8406, 8423

2883, 4600

8487, 8533

2287, 2291

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358, 1833

1855, 2164

2180, 2271

7900, 8215

70,368

146,326

16237

Discharge summary

report

Admission Date: [**2112-9-22**] Discharge Date: [**2112-9-26**] Date of Birth: [**2066-1-17**] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 2698**] Chief Complaint: Pericardial effusion on Echo Major Surgical or Invasive Procedure: Pericardiocentesis with serosanguinous fluid History of Present Illness: Mrs. [**Known lastname **] is a 46 yo woman with a h/o DCD renal transplant [**1-16**] IgA nephropathy in [**11-18**], dyslipidemia and bipolar disorder who presents from clinic due to a large pericardial effusion noticed on routine echo. Echo was first ordered one month prior to evaluate palpitations which have since resolved. The patient reports dyspnea on exertion over the past month that has actually improved with exercise. She denies chest pain, weight loss, fevers, night sweats. She is at her baseline level of energy/fatigue. Her leg edema has improved over the past month. Per the patient's daughter, the patient has a history of a positive PPD with 9 months of INH therapy pre-transplant with a Dr. [**First Name (STitle) 116**] in [**Location (un) **], Ma. The patient has also recently travelled to upstate [**State 531**], although she denies any outside time. She reports no joint pain or rashes. She has also been present in a [**Age over 90 **]-year-old home that is being renovated. ROS: Otherwise negative for lightheadedness, changes in urine or stool, sick contacts or other exposures. Past Medical History: ESRD [**1-16**] IgA nephropathy s/p DCD renal transplant [**11-18**] (Baseline Cr 1.4) Dyslipidemia Bipolar disorder PTSD Hypertension s/p fibroid surgery -[**2085**] history of AV fistulas x2 s/p Cesarean section Social History: The patient is of Cambodian origin. She lives with her husband and daughter in [**Name (NI) **], [**Name (NI) **]. She denies tobacco, alcohol or drug use. Her only recent travel to upstate [**State 531**]. Family History: Patient's daughter explains that the patient lost nearly her whole family in a war in [**Country **] as a child and has no details regarding family history of illnesses/cancers. Physical Exam: VS: T 97.3F BP 134/63mmHg HR 60 bpm RR 18 98%@RA Gen: Obese female in no acute distress HEENT: CN II-XII. No thyromegaly. No JVD CV: S1 + S2 obscured by a murmur vs. rub throughout the cardiac cycle. Pulm: B CTA Abd: Soft, NTND. No HSM or tenderness. No hepatojugular reflux appreciated. Ext: 1+ edema in LE, 2+ DP. Pulsus~8-9mmHg Pertinent Results: [**2112-9-22**] ADMISSION EKG: rate 60, NSR, normal axis, with biphasic T-waves in V2, no other ST changes [**2112-9-22**] CXR PA and Lateral: marked enlargement of the cardiac silhouette in the absence of significant congestion or pneumonic infiltrate. The finding is compatible with chronic pericardial effusion. [**2112-9-22**] 2D-ECHOCARDIOGRAM / Pre-cath prior to drainage demonstrated the following: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). 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. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a moderate to large sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. [**2112-9-23**] 2D-ECHOCARDIOGRAM in cath lab after drainage of 400cc fluid: left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). There is a moderate to large sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements.Compared with the findings of the prior study (images reviewed) of [**2112-9-22**], the size of the pericardial effusion is similar. No echocardiographic evidence of cardiac tamponade is present. [**6-/2109**] STRESS MIBI: Normal myocardial perfusion study at the level of stress achieved, ejection fraction is 69% Discharge Labs: [**2112-9-26**] 05:25AM BLOOD WBC-4.7 RBC-3.99* Hgb-10.3* Hct-31.5* MCV-79* MCH-25.7* MCHC-32.6 RDW-12.9 Plt Ct-172 [**2112-9-26**] 05:25AM BLOOD Glucose-108* UreaN-23* Creat-1.6* Na-140 K-4.0 Cl-108 HCO3-24 AnGap-12 [**2112-9-22**] 05:45PM BLOOD C3-143 C4-37 [**2112-9-22**] 05:45PM BLOOD TSH-5.0* [**2112-9-24**] 05:26AM BLOOD Anti-Tg-PND [**2112-9-23**] 11:47AM BLOOD dsDNA-PND [**2112-9-25**] 06:12AM BLOOD Triglyc-60 HDL-64 CHOL/HD-2.3 LDLcalc-72 [**2112-9-23**] 01:15PM OTHER BODY FLUID WBC-[**2103**]* RBC-[**Numeric Identifier 46304**]* Polys-56* Bands-4* Lymphs-38* Monos-2* [**2112-9-23**] 01:15PM OTHER BODY FLUID TotProt-5.6 Glucose-107 LD(LDH)-187 Amylase-108 Albumin-3.7 [**2112-9-23**] 01:15PM OTHER BODY FLUID ADENOSINE DEAMINASE, FLUID-PND Brief Hospital Course: In summary, the patient is a 46-year-old cambodian speaking female who presented to her nephrologist complaining of 1 month of intermittent palpitation episodes and worsening shortness of breath with exertion. On further workup she was found to have a moderate to large size pericardial effusion noted on echocardiogram without tamponade. She was admitted for an elective pericardial drainage on [**2112-9-23**]. She was monitored in the CCU s/p procedure and recovered smoothly without any serious complications. 1) Pericardial Effusion: The etiology of the effusion remains unclear. The patient had CT, CXR, and pericardiocentesis with fluid analysis which did not reveal the etiology of the disease. The differential includes TB, malignancy or idiopathic. She was briefly transferred to the CCU post procedure where she experienced an episode of bradycardia and hypotension which resolved and did not return. In addition, she briefly developed atrial tachycardia which was controlled on metoprolol. The patient was comfortable without signs or symptoms of effusion or tamponade on discharge. Her [**Doctor First Name **], dsdna and fluid cultures were pending on discharge. A CT showed continued effusion confirmed as stable on follow up echocardiogram. She will continue amlodipine and metoprolol and have a follow up echocardiogram in 1 week, followed by an appointment with Dr. [**Last Name (STitle) **] in 2 weeks. 2. Renal Transplant: The patient is status post renal transplant for IgA Nephropathy in [**2108**]. She was continued on Mycophenolate Mofetil and Sirolimus while admitted, with Sirolimus levels followed. She was also continued on Vitamin D & calcium. Her creatinine remained at baseline while admitted. 3. Hypertension: The patient was continued on her home dose of Amlodipine 5mg and Toprol 100mg. 4. Bipolar disorder: The patient was continued on her home dose Benztropine & Risperidal. Medications on Admission: Mycophenolate Mofetil 500mg PO BID Sirolimus 2mg PO Qday Amlodipine 5mg PO Qday Metoprolol Succinate 100mg PO Daily Calcium/Vitamin D 500 Risperdal 3mg PO Qday Benztropine 1mg PO Qday Trimethroprim-Sulfamethoxazole 400/80 PO Qday Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 9. Outpatient Lab Work Please have a CH50 drawn with results sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 62**] 10. Outpatient Lab Work Please schedule an outpatient echocardiogram in 1 week, instructions attached. Discharge Disposition: Home Discharge Diagnosis: Primary Diagosis: 1) Pericardial effusion Secondary Diagnoses: 1) Renal Transplant 2) Hypertension 3) Bipolar Disorder Discharge Condition: Vital signs stable on room air, no discomfort. Discharge Instructions: You have been admitted to the hospital because of a fluid collection that was found around your heart. While you were here we extracted the fluid and found that it was a mix of blood and fluid. We are still unsure why you have an effusion but we think you are safe to go home. Please take all of your medicines as described. Please schedule an echocardiogram in 1 week and make all doctors [**Name5 (PTitle) 4314**]. If you should feel short of breath or have chest pain (or any other concerning medical symptom), please call your doctor or 911 to return to the emergency room. Followup Instructions: Test for consideration post-discharge: Complement CH50 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-9-29**] 9:40 Please make an appointment with Dr. [**Last Name (STitle) **] within 2 weeks. [**Telephone/Fax (1) 46305**]. Please schedule an Echocardiogram in 1 week. The order & instructions are attached to these instructions. Please Call [**Telephone/Fax (1) 62**] to make an appointment to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks.

[ "780.2", "423.9", "401.9", "E879.0", "309.81", "997.2", "795.5", "458.29", "427.89", "V42.0", "272.4", "296.80" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21", "89.59" ]

icd9pcs

[ [ [] ] ]

8362, 8368

5209, 7133

301, 347

8532, 8581

2513, 4412

9212, 9785

1967, 2146

7413, 8339

8389, 8432

7159, 7390

8605, 9189

4428, 5186

2161, 2494

8453, 8511

233, 263

375, 1490

1512, 1727

1743, 1951

49,971

199,393

47292

Discharge summary

report

Admission Date: [**2119-2-20**] Discharge Date: [**2119-3-12**] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4748**] Chief Complaint: non-healing ulcers Major Surgical or Invasive Procedure: right lower extremity angiogram without intervention and right lower extremity femoral to popliteal bypass with right saphenous graft History of Present Illness: The patient is an 89 year-old female who presents with non-healing ulcers on the right lateral three toes. The ulcers have been present for the past 6 weeks. She also complains of leg pain at night. She presents for diagnostic right lower extremity angiogram with possible intervention. Past Medical History: PMH: CAD s/p MI [**2117**] s/p stent, CVA [**2112**], HTN, incontinence . PSH: bladder suspension, hysterectomy Social History: Son is HCP. [**Name (NI) **] home health aid/bathing, adult daycare 4d/wk Family History: non-contributory Physical Exam: On admission following angio afebrile, VSS NAD, alert, interactive, aphasic RRR CTAB Breathing easily Abd st, nt, scar noted from previous surgery Ext warm, right lateral toes with ulcers, TTP Pulses: R&L dp/pt + doppler left groin w/ dressing c/d/i, no bleeding or hematoma Pertinent Results: [**2119-2-20**] 09:23PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2119-2-20**] 09:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [**2119-3-2**] 04:17AM BLOOD WBC-32.3* RBC-3.18* Hgb-9.5* Hct-31.1* MCV-98 MCH-30.0 MCHC-30.6* RDW-14.9 Plt Ct-161 [**2119-3-1**] 03:36AM BLOOD WBC-33.7* RBC-3.70* Hgb-11.1* Hct-35.3* MCV-95 MCH-30.1 MCHC-31.5 RDW-15.4 Plt Ct-168 [**2119-2-28**] 10:00PM BLOOD WBC-34.6* RBC-3.78* Hgb-11.2* Hct-35.7* MCV-95 MCH-29.6 MCHC-31.3 RDW-15.2 Plt Ct-176 [**2119-2-28**] 02:53AM BLOOD WBC-23.5* RBC-3.90* Hgb-11.4* Hct-37.3 MCV-96 MCH-29.2 MCHC-30.6* RDW-14.7 Plt Ct-233 [**2119-2-27**] 02:35PM BLOOD WBC-22.7* RBC-4.02*# Hgb-11.8*# Hct-38.9 MCV-97 MCH-29.2 MCHC-30.2* RDW-14.3 Plt Ct-209 [**2119-2-27**] 05:42AM BLOOD WBC-26.4* RBC-3.07*# Hgb-9.0*# Hct-31.2* MCV-102* MCH-29.4 MCHC-29.0* RDW-13.8 Plt Ct-230 [**2119-2-26**] 10:05PM BLOOD WBC-29.2* RBC-4.11* Hgb-12.4 Hct-40.6 MCV-99* MCH-30.1 MCHC-30.5* RDW-14.0 Plt Ct-300 [**2119-2-26**] 08:00PM BLOOD WBC-26.8*# RBC-4.17* Hgb-12.7 Hct-41.8# MCV-100* MCH-30.5 MCHC-30.4* RDW-13.7 Plt Ct-321# [**2119-2-25**] 03:00AM BLOOD WBC-13.7* RBC-3.36* Hgb-10.2* Hct-31.7* MCV-94 MCH-30.4 MCHC-32.3 RDW-14.4 Plt Ct-158 [**2119-3-2**] 04:17AM BLOOD Glucose-182* UreaN-64* Creat-2.5* Na-137 K-4.4 Cl-107 HCO3-22 AnGap-12 [**2119-3-1**] 04:33PM BLOOD Glucose-203* UreaN-57* Creat-2.4* Na-136 K-4.2 Cl-105 HCO3-21* AnGap-14 [**2119-3-1**] 03:36AM BLOOD Glucose-158* UreaN-52* Creat-2.3* Na-137 K-4.3 Cl-105 HCO3-20* AnGap-16 [**2119-2-28**] 10:00PM BLOOD Glucose-145* UreaN-49* Creat-2.2* Na-137 K-4.3 Cl-104 HCO3-19* AnGap-18 [**2119-2-28**] 05:56PM BLOOD Glucose-153* UreaN-49* Creat-2.3* Na-135 K-4.1 Cl-102 HCO3-21* AnGap-16 [**2119-2-28**] 10:20AM BLOOD Glucose-161* UreaN-48* Creat-2.2* Na-137 K-4.4 Cl-103 HCO3-20* AnGap-18 [**2119-2-28**] 02:53AM BLOOD Glucose-63* UreaN-42* Creat-2.0* Na-136 K-4.5 Cl-103 HCO3-19* AnGap-19 [**2119-2-27**] 02:35PM BLOOD UreaN-42* Creat-1.7* Na-136 K-3.8 Cl-102 HCO3-19* AnGap-19 [**2119-2-27**] 11:34AM BLOOD ALT-1056* AST-2534* LD(LDH)-4045* CK(CPK)-1874* AlkPhos-80 Amylase-156* TotBili-0.6 [**2119-2-28**] 02:53AM BLOOD ALT-946* AST-1788* CK(CPK)-1830* AlkPhos-82 Amylase-158* TotBili-1.9* [**2119-2-28**] 10:20AM BLOOD ALT-863* AST-1318* LD(LDH)-611* CK(CPK)-1438* AlkPhos-88 Amylase-142* TotBili-1.2 [**2119-2-28**] 05:56PM BLOOD ALT-534* AST-785* LD(LDH)-488* CK(CPK)-1010* AlkPhos-74 Amylase-109* TotBili-1.6* [**2119-2-28**] 10:00PM BLOOD ALT-553* AST-777* CK(CPK)-856* AlkPhos-85 Amylase-100 TotBili-2.1* [**2119-3-2**] 04:17AM BLOOD ALT-333* AST-219* LD(LDH)-383* AlkPhos-86 Amylase-67 TotBili-1.8* [**2119-3-1**] 04:33PM BLOOD CK-MB-8 cTropnT-0.08* [**2119-3-1**] 06:06AM BLOOD CK-MB-12* MB Indx-2.6 cTropnT-0.07* [**2119-2-28**] 10:00PM BLOOD CK-MB-18* MB Indx-2.1 cTropnT-0.09* [**2119-2-28**] 02:53AM BLOOD CK-MB-34* MB Indx-1.9 cTropnT-0.15* [**2119-2-27**] 10:00PM BLOOD CK-MB-60* MB Indx-2.1 cTropnT-0.10* [**2119-2-27**] 02:35PM BLOOD CK-MB-69* MB Indx-2.5 cTropnT-0.05* [**2119-2-27**] 05:42AM BLOOD CK-MB-17* MB Indx-3.3 cTropnT-0.06* [**2119-2-28**] 10:00PM BLOOD TSH-2.0 [**2-28**] RUQ US: 1. Limited examination by portable technique and poor acoustic window. 2. Cholelithiasis without evidence of acute cholecystitis. Mildly prominent common bile duct measuring 10 mm., possibvly age-related. No intrahepatic ductal dilatation. 3. Please see CT report for liver/spleen findings given poor visualization. [**2-27**]: Echo Suboptimal image quality. Within these limitations, LV and RV systolic function appears preserved. Normal end-diastolic and end-systolic LV chamber size. Moderate mitral annular calcification makes determining the severity of mitral regurgitation difficult due to shadowing. LVOT flow shows high variabliity with respiration (35%), though in the context of a ventilated patient making respiratory efforts, this value can be misleading. [**2-27**] KUB: Nonspecific colonic dilatation. [**2-27**] CT head: Right putamen hypodensity is likely a chronic infarct, although subacute infarct cannot be excluded. No evidence of acute intracranial hemorrhage or mass effect. [**2-27**]: CT/CTA Abdomen/Pelvis 1. The SMA is difficult to follow beyond the proximal portion, but no definite thrombus identified. There is no bowel wall thickening, free fluid or pneumatosis to suggest mesenteric ischemia. 2. Fluid filled nondilated small and large bowel is compatible with diarrhea and likely post operative ileus. No evidence of megacolon. Appendix not seen. Per discussion with general surgery, pt may be status post appendectomy. 3. Small right groin hematoma is likely post-surgical. 4. Cystic lesion in the pancreatic head is probably an IPMN. Given size and patient's age, no specific follow up is needed. Brief Hospital Course: The patient was admitted on [**2-20**] for elective right lower extremity angiography with possible stent placement. The patient was prepped and brought down to the endo suite room for the procedure. Intra-operatively, the patient was closely monitored and remained hemodynamically stable. The stenosis in the right superficial femoral artery was visualized. Please see the angiography report for further details. Based on these results the patient was determined to be a candidate for a right femoral-popliteal bypass the following day, on [**2-21**]. During bypass procedure, operation was complicated by low urine output. JP drain was placed. A central line was placed emergently in the OR for hypotension, and she received phenylephrine. Please see operative note for further details. Post-operatively, the patient was transferred to the PACU for further stabilization and monitoring. Her SBP was low to the 60s, and her urine output continued to be low. She was bolused 500cc of NS, and subsequently put out 10cc of concentrated urine, and her BP improved. She underwent bladder scan which showed no urine, and received one unit of PRBC for a hematocrit of 27.4. She received several more boluses with improvement in urine output. The patient received appropriate peri-operative antibiotics. On [**2-21**] she had an elevated WBC count and was found to have a UTI on urine culture. She was treated with bactrim for this UTI. She was continued on fluids to improve her urine output. She received 1u pRBCs. On [**2-23**] the patient was transfused 2u pRBCs for low Hct. On [**2-22**] the patient developed increased difficulty breathing, likely due to this fluid increase which was supporting her urine output. A chest X-ray did not show clear signs of fluid overload, but the lung exam had crackles at the lung bases. She was given lasix for diuresis and her oxygen requirement decreased and she was breathing much easier. She was given additional doses of lasix for diuresis as needed. On [**2-25**] a CXR showed improved pulmonary edema, her EKG was stable, and she reported improved shortness of breath. Her right leg drain was removed. On [**2-26**] the patient had several episodes of diarrhea. Her bowel regimen was discontinued, however the bowel movements continued and a C. diff test was negative. On early [**2-27**] the patient developed abdominal pain, and had a rising WBC in the 20s'. She had a systolic BP in the 60's. She was given fluid but did not respond appropriately. She was tachypneic and tachycardic and so was intubated and transferred to the ICU. [**2-27**]: A KUB obtained in the ICU showed colonic dilation, and a CT/CTA was obtained which ruled out toxic megacolon and perforation. There were no signs of ischemic bowel on the scan. C. diff tests were negative, however the patient was treated for presumed C. diff with IV vancomycin, as well as vancomycin enemas and vancomycin through an NG tube. She was also started on ciprofloxacin and flagyl. A non-contrast head CT was negative for bleed, but did show a chronic vs. subacute right putamen hypodensity. The patient remained intubated and General Surgery was consulted. They recommended no operative intervention at that time, and the family also did not want further surgery at that time. She was started on pressors to support her blood pressure, and her urine output decreased to less than 10ml per hour. She was given additional fluids but did not initially respond. Nephrology was consulted and recommended decreasing her fluids. Overnight her UOP increased and her SBP was >100s. She was transfused 2u pRBCs for low HCT. [**2-28**]: The patient went into atrial fibrillation with HR 150s and was given metoprolol and diltiazem, as well as a diltiazem drip which were unsuccessful in converting her or controlling her heart rate. Her blood pressure was stable during this time. She was continued on the dilt drip. [**3-1**]: The patient continued to have paroxysmal afib with rapid rate. She was cardioverted x2 which successful conversion to sinus rhythm with rates in the 50s. Her blood pressure was stable and she was weaned off pressors as tolerated. A family meeting was held and it was decided that a repeat CT scan would be performed the following day to decide if improvement had occurred. Infectious disease was consulted for her persistently elevated WBC, and she was switched from cipro to cefepime, and rifimaxin was added to her C. diff regimen. Overnight her urine output decreased and she was unresponsive to fluids. [**3-2**]: Her atrial fibrillation continued and she was bolused with amiodarone and a drip was started which converted her back into sinus rhythm. Her BP were stable, and she was given several doses of lasix which improved her urine output. She remained on the ventilator. She underwent a CT scan of her abdomen which showed anasarca, jejunal wall thickening and heterogeneous renal enhancement. Her urine output came up after being administered lasix. [**3-3**] - [**3-4**]: She remained stable, continued to produce urine, and remained intubated. [**3-5**]: Her amio drop was stopped and she was started on metoprolol and amiodarone PO, she continued to be diuresed with lasix, and miconazole was started for a likely yeast infection in the L groin. [**3-6**]: Her lasix was weaned as was her sedation, and she was extubated. She tolerated this well. Her abdomen remained tender, but appeared to be improving. Her antibiotics were altered with the cefepime and PO vancomycin being stopped and starting tigecycline. [**3-7**]: Her oxygen was weaned and she became more alert. Her white count began to rise, however, rising from 30 to 34. [**3-8**]: Her oxygen continued to be weaned, she became more alert, and her white count rose to 46. After discussing her antibiotics with ID, the tigecycline was stopped and she was restarted on PO vancomycin as well as meropenem. Her anti-fungal was changed to nystatin cream as the fungal infection was not responding well. [**3-9**]: She was intermittently off of oxygen and began to have short coherent conversations though remained somewhat confused still. Her white count came down to 36. Her abdomen was also significantly less tender. [**3-10**]: Her white count continued to decrease, but her mental status worsened, likely due to a combination of benzodiazepines and hypernatremia. She was started on free water bolus through her dobhoff tube, but became agitated and pulled out the tube. Her tube was replaced and a psych consult was called, which recommended using haldol instead of ativan for anxiety. [**3-11**]: Her mental status continued to deteriorate and she was tachypneic in the morning. ABG showed respiratory alkalosis and a chest xray was wet. She was started on aggressive diuresis with lasix and metolazone, and given morphine and haldol for anxiety. Her respiratory status initially improved somewhat, but then she became hypotensive. Her pressure improved with some free water boluses. After consulting with the family the decision was made to proceed with a CT scan of the torso, which was negative for PE and intraabdominal abscess. Unfortunately, upon returning from the CT scan her respiratory status acutely worsened. She was nasotracheally suctioned, but gradually became more obtunded and her breathing became agonal and hypotensive. She passed away at 1:22 AM. The family was notified and came in to see the patient. Autopsy was declined. Medications on Admission: amlodipine 5, plavix 75, vitamin D, HCTZ 12.5, imipramine 50, lisinopril 20, pravastatin 40, trazodone 50, atenolol 100, omeprazole 20 Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: right superficial femoral artery stenosis Discharge Condition: Expired Discharge Instructions: None Completed by:[**2119-3-12**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "88.48", "39.29", "88.42", "38.93", "99.15", "38.91", "99.61" ]

icd9pcs

[ [ [] ] ]

13865, 13880

6160, 13651

269, 405

13966, 13975

1292, 5329

964, 982

13836, 13842

13901, 13945

13677, 13813

13999, 14034

997, 1273

211, 231

433, 721

5338, 6137

743, 857

873, 948

21,900

192,614

50103

Discharge summary

report

Admission Date: [**2201-10-26**] Discharge Date: [**2201-10-30**] Date of Birth: [**2142-12-26**] Sex: F Service: MEDICINE Allergies: Norvasc Attending:[**First Name3 (LF) 7055**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Non-invastive positive pressure ventilation. History of Present Illness: 58 yo female w/ hx of CAD status post LAD and RCA stents, LHCath w/ multivessel disease, CHF, HTN, Hyperlipidemia, PVD (s/p fem-fem bypass on L, R iliac stent, iliac stenosis prox to popl artery), end-stage renal disease, status post allograft transplant [**2197**] complicated by graft rejection treated with ATG, scleroderma, and GI bleed who presented to the ED progressively worsening SOB. . Over the past 2 weeks, she has had progressively worsening DOE and intermittent chest tightness. She repots that this has progressively gotten worse since she began to take the new medications since d/c from hospital (see below). She can only walk ~ 5ft w/o DOE and does not recall how far she could walk prior to this exacerbation. She has no CP or SOB at rest. There have been URI sx, she has had nonproductive cough. She denies dietary indiscretions. Did not notice weight gain. . She had a recent hospitalization ([**10-11**] - [**10-13**]) at which time cardiac cath showed proximal LAD had 40% in-stent restenosis with patent proximal RCA stent though there were serial 60% to 80% stenosis throughout the mid to distal LAD, the circumflex had proximal 40% stenosis, and the distal left circumflex was occluded with collateralization. There were also 40% stenoses in the mid and distal RCA. She was deemed to have two-vessel coronary artery disease that was not intervenable by angiography and would not be a good CABG candidate. Her blood pressure was very high during her hospitalization and peri-procedure, thus it was felt that the most useful thing to do would be to aggressively control her blood pressure and improve the flow to her transplanted kidney. . During this hospitalization, her lisinopril was increased to 30 mg and Imdur was added though not continued as an outpatient her PCP notes in [**Name9 (PRE) **]. . Per OMR, PCP was called by VNA on [**10-21**] for hypertension (180/80); at this point, she had started the increased lisinopril and imdur and was started on Norvasc 2.5mg QD (which she did not take). . On review of systems, s/he denies any prior history of stroke, TIA, but endorses hx of DVT (timing unclear and unsure if its venous or arterial), no pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. She reports leg pain w/ ambulation. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain, dyspnea on exertion. She denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, initial vitals were 98.1F, 191/90, 68, 92% on RA. She c/o of CP, had rales b/l. She was given SL nitro, lasix 60mg IV, started on NTG gtt, given ASA 325mg and was placed on BiPAP 10/5. She also received CaGluconate, 10U of insulin and D50 amp for K of 6.8. . In the ICU, vitals were 98F, 175/53, 97, 20 100% 50%O2 on Bipap [**3-30**]. pt. was resting comfortably. Denied CP, SOB or any discomfort. Past Medical History: 1. CARDIAC RISK FACTORS:: Diabetes (-) Dyslipidemia (+) Hypertension (+) . 2. CARDIAC HISTORY: -CABG: None known. -PERCUTANEOUS CORONARY INTERVENTIONS: status post anterior MI in [**2190**] with MID LAD BMS in [**2190**], PCIs to the RCA in the past and brachytherapy in [**2192**] to LAD. See cath from [**10-3**] below. -PACING/ICD: None known. 3. OTHER PAST MEDICAL HISTORY: . -Peripheral arterial disease status post left fem-fem bypass and right external iliac stent in [**2198**]. -Renal failure status post renal transplant x2, most recently in [**2197**] with subacute rejection, Cr. 1.9. - History of GI bleed in [**2195**]. - Scleroderma. - History of zoster. Social History: [**11-26**] pack per day of tobacco, has been a smoker most of her life. She denies alcohol or illicits. She is married, lives with her husband and is unemployed, has two grown children. She is able to perform her ADLs, but limited over past 3mo [**12-27**] DOE. Family History: No family history of premature coronary artery disease, unexplained heart failure, or sudden death. Mother - DM, Father - brain ca. Physical Exam: VS: [**Age over 90 **]F, 175/53, 97, 20 100% 50%O2 on Bipap 5/5 GENERAL: NAD, w/ BiPAP. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, no cyanosis of the oral mucosa. No bruits. NECK: Supple, unable to assess JVP 2/2 bipap. CARDIAC: PMI could not be located. RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Pt. supine, unable to ausc. post. Unlabored resp on Bipap, no accessory muscle use. Diffuse rhonchi laterally. ABDOMEN: Obese, soft, NTND. Multiple scars,well healed. Could not palpate abd aorta. No abdominial bruits appreciated. EXTREMITIES: warm, dry, no edema. calcinosis and loss of skin texture, no sclerodactyly. Contractures in RUE, LE b/l. RUE fistula, no erythema, thrill present. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ could not appreciate DP or PT. extremity warm. Left: Carotid 2+ could not appreciate DP or PT. extremity warm. Pertinent Results: [**2201-10-26**] 05:42PM BLOOD WBC-6.5# RBC-3.27* Hgb-9.7* Hct-29.4* MCV-90 MCH-29.8 MCHC-33.1 RDW-14.2 Plt Ct-142* [**2201-10-26**] 05:42PM BLOOD Neuts-90.1* Lymphs-5.5* Monos-3.5 Eos-0.7 Baso-0.3 [**2201-10-26**] 05:42PM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.2* [**2201-10-26**] 05:42PM BLOOD Glucose-144* UreaN-36* Creat-2.1* Na-141 K-6.1* Cl-114* HCO3-18* AnGap-15 [**2201-10-26**] 05:42PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]* [**2201-10-26**] 05:42PM BLOOD cTropnT-0.03* [**2201-10-27**] 01:47AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2201-10-27**] 01:47AM BLOOD CK(CPK)-77 [**2201-10-29**] 05:30AM BLOOD calTIBC-237* Ferritn-588* TRF-182* [**2201-10-28**] 05:30AM BLOOD tacroFK-8.0 [**2201-10-26**] 06:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.047* [**2201-10-26**] 06:30PM URINE Blood-SM Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2201-10-26**] 06:30PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2201-10-27**] 05:56PM URINE Eos-NEGATIVE [**2201-10-28**] 03:14PM URINE Hours-RANDOM Creat-134 TotProt-113 Prot/Cr-0.8* [**2201-10-27**] 05:56PM URINE Hours-RANDOM UreaN-297 Creat-91 Na-90 K-27 Cl-84 . EKG [**2201-10-26**]: NSR, No peaked Tw or Twi. Anteroseptal ST elev < 1mm, unchanged from prior [**2201-10-13**] . CXR [**2201-10-26**]: These findings favor cardiogenic edema with slightly more confluent collection in the right mid lung zone. Conversely this particular area may represent a focus of infection and repeat radiography following appropriate diuresis recommended. . CXR [**2201-10-27**]: Resolution of cardiogenic edema. Stable-appearing right upper lobe nodule, consistent with old granulomatous disease . Renal U/S [**2201-10-28**]: No significant abnormality or change in appearance of the transplanted kidney which has patent vasculature. Brief Hospital Course: 1. DYSPNEA The patient was admitted with signs and symptoms of left sided heart failure, likely from poor hypertension control and flash pulmonary edema. Her chest x-ray was consistent with pulmonary edema. She initially required bipap but was given 40mg IV Lasix in the ED and 40mg IV Lasix on admission and responded. She was placed on a nitroglycerin drip on admission and this was able to be titrated down and stopped on [**2201-10-27**]. Her oxygen was able to be weaned to minimal settings after diuresis. She was then put on her home dose of Lasix 20mg PO qday. She was ordered for Amlodipine 5mg PO qday but refused to take this due to a history of leg swelling as a side effect. Her Lisinopril was restarted but stopped on [**2201-10-27**] due to rising creatinine. On discharge, she was able to maintain sats on room air and hypertension was well controled on Carvedilol, Lasix 20mg PO qday and Imdur 30mg PO qday. Her blood pressure returned to the 100s-120s systolic prior to transfer with minimal adjustments to her home medications and discontinuing her Lisinopril. On discharge, her Lasix was discontinued and Imdur was increased to 60mg PO qday for blood pressure control. . 2. CORONARY ARTERY DISEASE The patient presented with signs and symptoms of unstable angina with chest pain. ECG was unchaged from prior. She has known 3 vessel disease and is not a good candidate for CABG or stenting. Medical management was optimized and she was kept on Aspirin, Carvedilol and Imdur. Cardiac enzymes were flat. She was initially put on Lisinopril but this was stopped as her creatinine rose. . 3. CHRONIC RENAL FAILURE The patient has chronic renal failure with an allograft renal transplant. Her creatinine was elevated to 2.1 on admission from a baseline of 1.9. The renal trasplant service was consulted. She had a renal ultrasound which showed patent vasculature. She was continued on Cellcept, Tacrolimus and Prednisone for her transplant. Her creatinine increased to 2.7 by the time of discharge. She has follow-up with her transplant nephrologist after discharge. . 4. ANEMIA The patient's hematocrit was 29 on admission and trended down to 26. This was likely from anemia of chronic disease as well as renal failure and decreased erythropoetin. Iron studies were checked and the patient was not iron deficient. Retic count was 2.4. She had no signs of active bleeding and HCT was stable during the admission. She should follow-up as an outpatient for her anemia. . 5. HYPERLIPIDEMIA She was continued on Atorvastatin 40mg PO qday. . The patient was managed in the CCU initially and transferred to the floor on [**2201-10-27**]. She was discharged home on [**2201-10-30**] with instructions to follow-up with her transplant nephrologist, her cardiologist and her primary care doctor. Medications on Admission: ALENDRONATE [FOSAMAX] - 35 mg Tablet Qwk ATORVASTATIN [LIPITOR] - 40 mg Tablet QD CARVEDILOL - 25 mg Tablet - [**Hospital1 **] ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule Qmo FUROSEMIDE [LASIX] - 20 mg Tablet - QD ISOSORBIDE MONONITRATE - 30 mg SR QD LISINOPRIL - 30 mg Tablet -QD MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg [**Hospital1 **] NITROGLYCERIN - 0.4 mg PRN PREDNISONE -3mg QD TACROLIMUS [PROGRAF] - 1.5 mg [**Hospital1 **] BACTRIM DS QD ASPIRIN - 81 mg QD SODIUM BICARBONATE - 650 mg [**Hospital1 **] Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 8. Imdur 60 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* 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO 1X/WEEK ([**Doctor First Name **]). 11. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Prograf 1 mg Capsule Sig: 2.5 Capsules PO twice a day. 15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q 5 minutes x3. 16. Outpatient Lab Work Please check Chem-7 and CBC on Monday [**11-2**] before Dr. [**Doctor Last Name **] appt. Please call results to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Primary: 1. Congestive heart failure, acute on chronic, diastolic and systolic 2. Hypertension 3. Acute on Chronic Renal Failure Secondary: 1. Dyslipidemia 2. Hypertension 3. Peripheral vascular disease 4. Renal failure status post renal transplant x2 5. Scleroderma Discharge Condition: Hemodynamically stable and saturating well on room air. Discharge Instructions: You were admitted with congestive heart failure, likely from elevated blood pressures. Your kidney function worsened but is now improving. Please take all of your medicines every day, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. The following changes were made to your medication regimen: . 1. Do not take your Furosemide or Lisinopril. Dr. [**Last Name (STitle) 171**] will decide when to restart thses medications. 2. Your norvasc was held because of leg swelling. 3. Your Imdur was increased to 60 mg daily Please continue to take your transplant medicines as before. . Please stop smoking. Information was given to you on admission regarding smoking cessation. . Please weigh yourself every day and call Dr. [**Last Name (STitle) 171**] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Please follow a low sodium diet. Information regarding this was given to you at discharge. Followup Instructions: You have the following appointments scheduled: Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2201-11-9**] 1:00 Renal: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:Monday [**11-2**] at 1:20pm. Primary Care: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/time: Monday [**11-29**] at 10:30am

[ "996.81", "414.01", "585.9", "403.90", "518.81", "V45.82", "272.4", "E878.0", "443.9", "710.1", "411.1", "428.43", "428.0", "285.21", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12340, 12426

7398, 10227

279, 326

12738, 12796

5515, 7375

13782, 14276

4385, 4519

10806, 12317

12447, 12717

10253, 10783

12820, 13759

4534, 5496

3510, 3763

232, 241

354, 3393

3794, 4087

3415, 3490

4103, 4369

28,323

102,274

31463

Discharge summary

report

Admission Date: [**2114-9-14**] Discharge Date: [**2114-9-21**] Date of Birth: [**2063-4-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: transfer from [**Hospital1 18**] [**Location (un) 620**] for thrombocytopenia and lymphadenopathy of unclear origen Major Surgical or Invasive Procedure: none History of Present Illness: This is 51 y/o M with history of hyperlipidemia who presented to OSH on [**2114-9-13**] complaining of shortness of breath and palpitations. He refers that in [**Month (only) **] he started having increase urinary frequency. No clear burnin on urination or decrease in the caliber of the stream. After the [**9-1**], he started having dry cough, night sweats, fevers and general malaise. No pariticular pattern of his fevers. Low appetite as well. No abdominal sympotms. He felt that it was a viral infection. After 3 weeks of this sympotms he developed more urinary sympotms, burning on urination, bilateral frank pain. He felt that his urinary symptoms had came back. . He went to see his PCP on [**9-1**]. he was started on ciprofloxacine 500 daily for 10 days. He continue to have persistent urinary symptoms, malaise and fatigue. he felt that he coudl not doo as much work as he wanted. he was then refered to the Urologist. He was seen on [**9-3**], (Dr [**Last Name (STitle) 24934**] who felt that his prostate was enlarged and tender. His dose of ciprofloxacine was increase to 500 [**Hospital1 **]. He also ordered a CT Abdomen and checked labs. His CT revealed cystic strucuture in the lower portion of left kidney and also numerous periaortic, celiac and pelvic lymph node. Also enlarged prostate. Platelets were noted to be [**Numeric Identifier 38500**] . Over the next week, he developed Right upper quadrant abdominal pain, constant, and also over his right chest wall. He started taking some Ibuprofen as per his report aroudn 600mg ~ q3h. A week prior to admission he developed increasing shortness of breath specially on exertion, extreme fatigue, palpitations, nausea and vomit. Also increase in night sweats. . After talking to PCP coverage he was refered to the ED. . In OSH ED, VS T 98.6, Hr 113, Bp 94/75, RR 16 Sats 98% 2L. + petechial lesion over extremities and abdomen. U/a had WBC 2 to 5. EKG with sinus tachycardia. CT Abdomen was done that showed new pockets of ascitis, pelvic lymphadenopathy worse thatn prior, cirrhotic liver, enlarged portoahepatis and portocaval notes and heterogeneus prostate. A CTA was done that was negative for PE - altough states that a suboptima IV bolus was given-. Subpleural node 2.9 mm RML noted, 3mm focal opacity along RM fisure. His labs were notable for WBC 5.6, HCT 41.6 Platelets of [**Numeric Identifier 961**], INR 1.0, PTT 25.8, elevated bili 2.63 Direct 1.66, and elevated transaminases ALT 225, AST 184, alk phosphatase 165LDH 2163.normal Creatinine 1.0 Peripheral smear was reviewed with no evidence of schistocytes. . Upon transfer to [**Hospital1 18**], the patient was evaluated by Hem/Onc who reviewed smear - negative schistocytes. Platelet transfusion was recomended with increase to 12. Bone marrow biopsy performed on Friday showed findings consistent with neuroendocrine tumor. Surgery was consulted for possible biopsy of lymph nodes but felt it was unsafe to do it with thrombocytopenia. . On the evening of [**2114-9-17**], he developed acute respiratory distress. He became more tachycardic, hypoxic, and tachypnic. He was given Lasix 20 mg IV x 1 with good response. STAT CXR revealed worsening B/L pleural effusions. CT chest concerning for new opacities. He was started on Zosyn. ABG revealed hypoxia and he was switched to a NRB and transferred to the MICU for closer respiratory monitoring. In MICU he was treated with morphine for SOB and continued on zosyn. Heme/onc recommended initiating chemotherapy and due to his worsening respiratory status with increased oxygen requirement he was transferred to the [**Hospital Unit Name 153**] for close monitoring. He was placed on BiPAP for increased SOB prior to transfer on [**9-19**]. . On arrival to the [**Hospital Unit Name 153**] the patient was complaining of some mild SOB, however reported that his breathing was better on BIPAP. He denied CP, N/V, abdominal pain. He expressed that he was anxious about his new diagnosis and the upcoming chemotherapy. Past Medical History: [**2114-9-14**] Bone Marrow biopsy Social History: Lives with wife and two dauthers. He is IT manager in a Bank. Denied iv drug use. No smoking, Alcohol 3 glass of wine a week. beer every three weeks. No ocuppational exposures. Family History: Mother and Father with [**Name2 (NI) **] Cancer ~ age 50's. Brother Melanoma. Brother [**Name (NI) **]. Physical Exam: Vitals: T: 100.1 P:114 R: BP:113/83 SaO2:94%on RA General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, mild icteric sclera Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Decrease breath soudns in the bases. No crackles. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No edema 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: + petechia in lower extremitis and abdomen. Neurologic: AxO times three. CN II-xII normal. DT reflexes 2+/4+. Normal gait. Pertinent Results: CT Abdomen [**2114-9-13**] PELVIS: There is minimal interval enlargement of prominent retroperitoneaL lymph nodes; a representative left parailiac node measures 1.6 cm (image 59 series 2), previously measuring 11 mm. There is a 3.3 x 2.3 cm lymph node noted along the right external iliac vessels. In addition, there is a stable 1.8 cm lymph node along the left pelvic side wall. An additional represenatative enlarged measures 2.9 x 2.9 cm left common iliac lymph node. A 1.2 cm node is seen within the perirectal fat. The prostate gland is slightly heterogeneous. Rectal fat right of midline. The bony structures are grossly unremarkable. IMPRESSION: 1. NEW POCKETS OF ASCITES OF UNCERTAIN ETIOLOGY. 2. PELVIC LYMPHADENOPATHY CONCERNING FOR AN UNDERLYING MALIGNANCY, SPECIFICALLY [**Month (only) **] REFLECT UNDERLYING LYMPHOMA. 3. LIKELY CIRRHOTIC LIVER. 4. ENLARGED PORTAHEPATIS AND PORTOCAVAL NODES [**Month (only) **] BE INFLAMMATORY IN NATURE. 5. HETEROGENEOUS PROSTATE GLAND [**Month (only) **] REFLECT A HISTORY OF PROSTATITIS. . CT PE [**2114-7-14**]: negative for PE . TTE [**2114-9-17**] Small left ventricular cavity with hyperdynamic function, tachycardia, moderate outflow tract gradient and systolic anterior motion of the mitral valve leaflet in the absence of left ventricular hypertrophy (suggestive of intravascular volume depletion with high catecholamine state). No intracardiac shunt identified. . CT Chest [**2114-9-17**] No pulmonary embolism. Diffuse tree-in-[**Male First Name (un) 239**] opacities predominating within the lower lobes bilaterally representing an acute infectious process. Multiple hypoattenuating lesions diffusely throughout the liver of varying sizes. While most of the opacities in the lung are tree-in-[**Male First Name (un) 239**], some are morenodular and repeat chest CT may be indicated if further abdominal workup reveals underlying malignancy to rule out lung metastases. . CXR [**2114-9-19**]: No new focal consolidations are identified with increased obscuration of the right hemidiaphragm likely related to underlying atelectasis. There is persistent left lower lobe linear atelectasis and low lung volumes. The cardiomediastinal silhouette, contours and pleural surfaces are unchanged. . Single organ US (liver) [**2114-9-20**]: CONCLUSION: Small amount of ascites. Brief Hospital Course: Assessment and Plan: The patient is a 51 y/o M who was transferred from OSH with thrombocytopenia, newly dx cirrotic liver, and worsening lymphadenopathy. Preliminary BM biopsy showed evidence of neuroendocrine tumor, complicated by respiratory distress. The patient was transferred to the [**Hospital Unit Name 153**] for initiation of chemotherapy, s/p intubation on [**9-20**] for worsening respiratory distress. ICU course by problem is as follows: . # Neuroendocrine tumor: Preliminary BM biopsy was consistent with neuroendocrine tumor, not lymphoma. The patient had diffuse LAD and hepatic nodules concerning for metastatic disease. Chemotherapy was initiated on [**2114-9-20**]; however, due to the patient's rapid clinical decline chemotherapy was felt to be unlikely to produce an effect. These findings were discussed with the family during a family meeting. . # New onset liver failure/ lactic acidosis: felt to be secondary to metastatic disease. There was no plan for biopsy given low platelets; however MR of the abdomen showed several diffuse nodules in liver with necrosis - infectious vs lymphoma, less likely HCC. Transaminitis continued to rise during the hospital course. On [**2114-9-20**] there was a dramatic rise in lactate secondary to liver failure with a steady increase throughout the day from 7 to >18. . # Thrombocytopenia/ Anemia: Most likely [**3-2**] cancer. Preliminary BM biopsy showed infiltrating carcinoma of bone marrow consistent with neuroendocrine tumor. Hct progressively declined, as below, but there was no clinical evidence of active bleeding. An autoimmune process was also considered given that platelets did not bump appropriately to transfusion. . # Anemia: The patient was at risk of bleeding given thrombocytopenia, but did not show any active signs of bleeding. Hct steadily declined from baseline 43 at OSH with values slowly trending down into the mid-20s. B12 and folate were normal. Hemolysis labs negative. Anemia was also thought to be related to malignancy and BM process. . # SOB/tachypnea/hypoxia: Etiology was not entirely clear, but most likely related to worsening acidemia and/or lymphangitic spread of his tumor. CTA was negative for PE. CT chest with opacities and concern for possible infectious process, and the patient was broadly covered with vancomycin and zosyn for possible PNA. Echo with bubble study negative for shunt. No clinical evidence of volume overload currently with flat JVP. Anemia may have also been contributing. During the ICU course the patient was intubated on AC for increased work of breathing and increasing O2 requirement. The patients O2 requirement dramatically increased as lactate levels increased and pH decreased. . # Hypotension: The patient became increasingly hypotensive as acidosis worsened and ventilation and sedation were increased. An arterial line was placed without complication and the patient was started on levophed, which was uptitrated to maximal settings, and vasopressin which produced temporary increases in SBP. Pressors failed to maintain BPs as the patient became more acidemic, and despite receiving multiple crystalloid boluses with LR, the patient's MAPs began to steadily decline. . # PEA/ arrest: On the morning of [**9-21**] in the above setting, the patient had an episode of PEA arrest for which he temporarily responded to epinephrine. His wife, [**Name (NI) **], was contact[**Name (NI) **] with this information, and chose not to rescusitate any further. Later that morning the patient had steadily declining BPs and entered a period of asystole. The patient was pronounced at 7:10am on [**2114-9-21**]. The attending was notified. The family was at the bedside, and chose to pursue a limited autopsy. . # Communication was with [**Name (NI) **] (wife) home [**Telephone/Fax (1) 74072**] cell [**Telephone/Fax (1) 74073**] . Medications on Admission: Lipitor Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: neuroendocrine tumor, metastatic liver failure lactic acidosis Discharge Condition: Expired.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

11851, 11860

7894, 11764

430, 436

11967, 11978

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4060

Discharge summary

report

Admission Date: [**2118-2-4**] Discharge Date: [**2118-2-5**] Date of Birth: [**2061-6-25**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 56-year-old female with known coronary artery disease, status post right coronary artery stent four days ago, transferred from outside hospital for catheterization to rule out acute stent thrombosis. She was urgently admitted to [**Hospital 1474**] Hospital on [**1-31**], after presenting to primary care provider's office for routine physical exam with complaints of left scapular pain. She had reported to her primary care provider that she had been having this dull steady pain behind her left scapula radiating to her left shoulder and arm x two days. The pain was not associated with shortness of breath, nausea, diaphoresis. It was not related to position or activity except for some improvement at times with movement of neck or rubbing the arm. When she told her primary care provider of these symptoms during her routine annual physical exam, an electrocardiogram was done which revealed changes consistent with an inferior myocardial infarction (Q waves in the inferior leads and T wave inversions that were different from prior electrocardiogram in [**2116**] by report). He gave the patient sublingual nitroglycerin x 4 with some relief of pain and the patient was admitted to [**Hospital 1474**] Hospital and later transferred to [**Hospital6 256**] where she underwent cardiac catheterization that revealed total occlusion of the mid right coronary artery that was stented x two with good results. The patient had CKs, MBs and troponins all negative during this previous hospitalization. She had an uncomplicated hospital course and was discharged home on the 31. She was doing well until the evening of [**2-3**] when she again began experiencing left subscapular pain following dinner. This pain continued overnight and into the morning so the patient called her primary care provider on [**2-4**] and was told to take sublingual nitroglycerin. When she took two sublingual nitroglycerin, within five minutes she experienced some relief, but upon taking the second sublingual nitroglycerin became lightheaded and passed out while seated in chair. The patient regained consciousness and was pain-free, but because of prior symptoms and now syncope, her husband called ambulance. The patient was taken to [**Hospital1 1474**] Emergency Department and was admitted to rule out myocardial infarction. Electrocardiogram showed inferior Q waves, reportedly unchanged from prior, and cardiac enzymes were initially negative. A myocardial viability scan was done at [**Hospital 1474**] Hospital and reportedly revealed no viability in the inferior wall. The patient was pain-free for some time at [**Hospital 1474**] Hospital, but then at 7:00 pm on [**2-4**] again began experiencing left shoulder pain. She was given some intravenous fluid boluses of normal saline and sublingual nitroglycerin with resultant drop in her blood pressure from a systolic of 90 to 80, but no significant improvement in left shoulder pain. Because of concern over possible acute right coronary artery stent thrombosis, the patient was anticoagulated with heparin and started on intravenous Integrelin and then transferred to [**Hospital6 649**] for cardiac catheterization. Cardiac catheterization was performed at [**Hospital6 1760**] upon arrival and revealed patent right coronary artery stents and on preliminary review of catheterization films, no significant change in coronary anatomy from study four days prior. Femoral artery sheath was pulled in the catheterization laboratory and the patient was Angio-Sealed and was then sent to coronary care unit for monitoring. Angio-Seal was discontinued soon after arrival to coronary care unit. The patient complained of mild back pain mostly in the lower back for which she was given Tylenol #3. Otherwise, she currently was without complaints. Denied shortness of breath, chest pain, shoulder pain, arm pain, nausea, vomiting, diaphoresis, lightheadedness. PAST MEDICAL HISTORY: 1) Coronary artery disease, status post inferior myocardial infarction in the past (exact date unknown), status post percutaneous transluminal coronary angioplasty and stenting of totally occluded right coronary artery, 2) Status post right knee surgery, 3) Hypercholesterolemia, 4) Peripheral vascular disease, status post right lower extremity bypass operation with ongoing bilateral lower extremity claudication, 5) Chronic obstructive pulmonary disease. MEDICATIONS: 1) Lopressor 50 mg po bid, 2) Lipitor 10 mg po qd, 3) Lisinopril 10 mg po qd, 4) Plavix 75 mg po qd, 5) Aspirin 325 mg po qd, 6) Sublingual nitroglycerin prn chest pain. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Significant for bilateral lower extremity claudication, worse over the past couple of years. No orthopnea, dyspnea on exertion, fever, chills, cough, nausea, lightheadedness, palpitations. The patient denies having episodes of left shoulder pain prior to [**2118-1-29**]. She does report an episode of shortness of breath on [**2117-12-16**] for which she was seen at [**Hospital 4415**] Emergency Department, reportedly had an unremarkable electrocardiogram, was thought to have anxiety-related shortness of breath. Discharged home. Reported feeling ill for the next seven to eight days. The patient suspects that this is when she had her myocardial infarction. FAMILY HISTORY: Significant for myocardial infarction in father who died at age 41, aunt died at age 36, and sudden death in uncle at age 21 of unclear etiology. SOCIAL HISTORY: Married, four children. Works part-time in customer service. Smoker - 1.5 packs per day x four years. Social alcohol. Denies illicit drugs. PHYSICAL EXAM: This is a pleasant female, in no acute distress, laying flat in bed. Her heart rate has been in the 60s outside the hospital, respiratory rate 16, blood pressure anywhere from 92-109/60-70. CO2 99% on room air. Head, eyes, ears, nose and throat exam reveals moist mucous membranes. No evidence of jugulovenous distention. Chest is clear to auscultation anteriorly. Heart regular rate and rhythm with II/VI systolic murmur best heard at left upper and lower sternal borders without radiation. Abdomen soft, nontender, nondistended, no palpable masses. Extremities - no clubbing, cyanosis or edema, 2+ dorsalis pedis and posterior tibial and radial pulses bilaterally. LABS: At outside hospital the only white count is 7.7, hematocrit 35.5, platelets 254, MCV 85, sodium 142, potassium 4.1, chloride 106, bicarb 24, BUN 15, creatinine 0.8, glucose 103, calcium 9.6. Electrocardiogram shows Q waves in III and AVF, question of less than 1 mm ST segment elevation in lead III and T wave inversions in II, III, AVF, V4 through V6. No old electrocardiograms available for comparison. Cardiac catheterization preliminary results reveal right coronary artery 40% proximal, normal mid with patent stents and diffuse distal occlusion, acute marginal shows discrete 70%, right posterior descending artery shows diffuse disease, right posterolateral shows diffuse disease, proximal circumflex shows discrete 40%, normal left main with diffuse disease in the proximal and mid left anterior descending and D1 and D2 in the mid to distal circumflex, and in OM1, OM2 and OM3. She has a right dominant system. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the coronary care unit and monitored overnight. Because of recent hypotension was placed on a lower than usual dose of Lopressor at 25 mg po bid. She was continued all of her other previous medications and given intravenous fluids at 75 cc/h overnight. Given dye load of 70 cc in catheterization. She had no major events overnight and in the morning was without complaints. Had not had any further left shoulder pain since receiving Tylenol #3 the night before. Exam was largely unchanged. Groin site exam was benign. Morning CPK was 29. The patient was felt to be stable for discharge home. The patient will be discharged home with follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient's cardiologist in [**Hospital1 1474**], in four days. The patient will continue previous medical regimen for coronary artery disease. DISCHARGE MEDICATIONS: 1) Lipitor 10 mg po qd, 2) Lopressor 50 mg po bid, 3) Lisinopril 10 mg po qd, 4) Plavix 75 mg po qd x 1 month, 5) Aspirin 325 mg po qd, 6) Sublingual nitroglycerin prn chest pain as directed. The patient was advised to lay down before taking sublingual nitroglycerin in the future. The patient was also given a prescription for Tylenol #3 1 tablet po q 4-6 h prn musculoskeletal shoulder pain, dispensed 15, with no refill. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1) Left shoulder pain, ruled out acute stent thrombosis by catheterization, 2) Known coronary artery disease with no significant change in coronary anatomy and patent right coronary artery stent, status post cardiac catheterization [**2118-2-1**], 3) Hypercholesterolemia, 4) Peripheral vascular disease, 5) Questionable history of chronic obstructive pulmonary disease, 6) History of right knee surgery. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 6614**] MEDQUIST36 D: [**2118-2-5**] 14:23 T: [**2118-2-7**] 05:17 JOB#: [**Job Number 17877**] cc:[**Hospital1 17878**]

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icd9cm

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icd9pcs

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3181

Discharge summary

report

Admission Date: [**2152-6-4**] Discharge Date: [**2152-6-13**] Date of Birth: [**2086-10-5**] Sex: F Service: MEDICINE Allergies: Imdur Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: DKA, Sepsis Major Surgical or Invasive Procedure: Central line placement Arterial line placement History of Present Illness: HPI: 65 yo F with h/o CAD s/p CABG, diastolic CHF, hyperlipidemia, DMII with h/o DKA, HTN and metastatic breast cancer to brain/lung s/p WBXRT [**5-4**] on steroid taper p/w FS 567 at home, poor appetite. Patient reports feeling generally weak for some time, FS running high in 300-500 range at home. Also with no taste therefore not eating or drinking much. She also had a fever to 102.3 last night with chills and sweats. No cough, sore throat, sputum production, no SOB, no orthopnea. No HA. No N/V/D. No abd pain. No BRBPR/melena. No dysuria. Right arm pain has been severe, not on pain meds, not in sling, just using ice and rest. Has difficulty getting out of bed, needs assistance, denies any falls. Other ROS negative in detail. . In the ED, VS: 98.4 HR 80-140s BP initially 197/104 then 64-121/30-40s RR 15 100% RA. Given 3L NS, 4 gm Mg, Insulin gtt started. AG 19-->13. ECG showing RBBB, LAFB, LVH with strain and sinus tachy to 140s which improved to 120s with IVF. CXR showing large left sided lung mass now 50% larger than prior, unable to r/out infectin, rec CT when stable. ECG showing likely sinus tachy improving with IVF. Also 4 grams of Mg sulfate, ASA, insulin gtt started at 7 U/hr. Also with SBP in 80-90 range, no obvious source of infection, not treated for sepsis. Currently receiving fluids, very volume down on exam. Hct down to 23 with IVF, guaiac trace positive in ED. . Interval Hx: Patient was admitted [**5-27**] to [**5-29**] with RUE swelling and pain found to have either a mass with bicepts tendon rupture and surrounding edema with plans for repeat MRI and ortho eval as outpatient. CTA at that time negative for PE but showing LLL mass c/w metastatses. During her hositalization she had high FS in the 600s, small AG, and was treated with insulin. She was sent home on a higher sliding scale dose of insulin compared to her prior. This was all thought to be [**1-29**] to her dexamethasone taper. The patients blood pressure was found to be slightly low as well in the range of 90-110/40-60. She was assymptomatic. Amlodipine 5mg was stopped. She was instructed to discontinue this medication. Past Medical History: # Metastatic Breast CA: Infiltrating ductal breast cancer (Stage II) diagnosed in [**11-3**] -- s.p Right mastectomy for a 3.7cm breast tumor which was grade III, pT2, zero of five lymph nodes and ER negative, PR negative, and Her2/neu negative. Has finished four cycles of Taxotere and Cytoxan ending [**3-4**]. --Admitted [**4-4**] with HA found to have brain metastases, XRT started completed [**2152-5-9**] on dexamethasone taper --[**5-4**] CTA showing large mass within the left lower lobe abutting the pleura with central cavitation, most consistent with metastases # CAD s/p CABG and remote history of angioplasty. --CABG in [**2143-1-28**]((LIMA-LAD, SVG-RCA, jump SVG-RI-OM occluded) --cardiac cath on [**2149-8-18**] for her increasing angina and positive stress test. They were unable to put a stent in her SVG graft, LIMA patent # Hypertension # Hypercholesterolemia # Congestive heart failure --Admission [**4-3**] with acute pulmonary edema requiring intubation. She was found to have an EF in the 30% range on echo; echo [**5-3**] EF 50%, Grade II (moderate) LV diastolic dysfunction, PCWP >18 # DM Type II (last Hgb A1c 6.2 in [**12-3**]); h/o DKA in the past # H.pylori # Esophageal webbing # Ovarian cyst--- rising CA125 -> plan for lap BSO, held [**1-29**] brain mets # Hypothyroidism, Surgery for a thyroid nodule # Gout Social History: Patient is married and lives with her husband who has diabetes and is disabled in [**Location (un) 669**]. She has four children in their 50's. One of her daughter's has been helping her at home since she has not been able to cook or take care of herself. She owns a travel agency. Patient quit smoking cigarettes 11 years ago, but smoked a half pack a day for 20 years. She denies alcohol use or illegal drug use. She feels safe at home. Her health care proxy is her daughter [**Name (NI) 6177**] [**Name (NI) 5903**]. Her home number is [**Telephone/Fax (1) 14958**]. Family History: The patient denies family history of malignancies in her uterus, breast, colon, ovary, or cervix. Grandmother and Grandfather both had diabetes, otherwise everyone is healthy. Physical Exam: VS: 97.5 107 90/41 90-95% RA Gen: ill appearing but NAD, alopecia Heent: OP dry, anicteric, edentulous Neck: supple, JVP flat CV: nl S1 S2, RRR, distant Lungs: coarse crackles left base, milder on right, good air movement otherwise Abd: obese, echymoses b/l lower quadrants, soft, NT, BS+ Ext: warm, trace edema b/l Neuro: A&O x 3, CN intact, appropriate, full strength, limited on right by pain, sensations intact. Pertinent Results: CT HEAD [**2152-6-10**] Multiple hyperdense foci of the left hemisphere including parasagittal, anterior left frontal and the left parietal have decreased in size; for example, the left anterior frontal lesion measured 10 mm on the prior study and now measures 5 mm. No evidence of edema is noted within the brain. Previously mentioned shift of midline structure has completely resolved. The hyperdense lesion of the right hemisphere are not well visualized on today's study. One of the residual sequelae of the prior disease is noted within the right subinsular white matter. The bone windows demonstrate mild mucosal thickening of the right sphenoid sinus. The mastoid air cells also contain fluid. The remainder of the paranasal sinuses appear unremarkable. IMPRESSION: 1. Interval resolution of multiple hemorrhagic foci with small residual lesions in the left hemisphere. There has also been resolution of the mass effect of the metastasis and surrounding edema ECHO [**2152-6-5**] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CXR 06/13/008 1. Interval resolution of pulmonary edema. 2. No significant change to small bilateral effusions and fluid-filled rounded opacity corresponding to known left lower lobe cavity. 3. Unchanged widespread pulmonary nodules, likely infectious. CT CHEST [**2152-6-4**] 1. Interval development of multiple pulmonary nodules. Given the short interval, infection and/or septic emboli should be considered. 2. Minimal increase in left lower lobe lung mass with what appears to be a necrotic center. No evidence of active hemorrhage within this lesion. 3. Interval increase of multiple mediastinal lymph nodes, which at baseline were pathological and now also increased in size due to likely reactive. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. Brief Hospital Course: 65 F with metastatic breast CA to brain and lung, on steroid taper, DM II, CAD s/p CABG,admitted with DKA and sepsis. . # Sepsis. Pt on vanc/zosyn/flagyl for presumed pulmonary source given LLL mass with necrotic area on CT scan. Team felt that although it would be helpful to have some data to guide antibiotic coverage, the risks associated with obtaining sample via BAL or CT guided biopsy outweighed the benefits of obtaining culture data. Therefore patient was treated with empiric antibiotics. She was transiently hypotensive requiring pressors. Therefore she was started on stress dose steroids. Blood, urine, stool samples were negative for source of infection. Glucan and Galactomannan also negative. Leukocytosis worsenend after receiving high dose steroids but patient remained afebrile and hypotension improved. . # Hypoxia: Known diastolic dysfunction. Required volume resuscitation in setting of DKA and hypotension and patient developed severe pulmonary edema. Underwent diuresis as patient tolerated but was still net positive approximately 12L at the time of transfer from the ICU. However patient was breathing comfortably on 6L nasal cannula. Given her poor prognosis, patient decided to change her code status to DNR/DNI. . # Diabetic ketoacidosis: Glucose elevated to 400s with anion gap of 19 on admission. + ketones in urine consistent with DKA. Patient has a history of DKA in the past while not on steroids. Treated with aggressive IV hydration, insulin drip and close monitoring of electrolytes with appropriate repletion. FS improved, Gap closed and patient was able to be transitioned to basal glargine and insulin sliding scale. Her glargine was restarted at a lower dose given the patient's poor PO intake. # Acidosis: Initially due to DKA. Then later developed lactic acidosis with elevated lactate to 3.9. Likely secondary to sepsis and hypotension. Treated as above with resolution of acidosis. . # Renal Failure: Likely related to hypotension and sepsis. Urine lytes consistent with pre renal etiology. Creatinine elevated to 1.2 with improvement in blood pressure. Meds were renally dosed according to creatinine clearance. . # Metastatic Breast CA to lung and brain. CXR showing evidence of rapid growth of likely metastatic mass in lung. CT with evidence of necrotic mass in left lower lobe, nonhemorrhagic, and multiple nodules consistent with infection. Known mets to r shoulder and bicepts tendon with rupture. Received steroids for brain mets with resolution on most recent CT head. Due to rapid growth of tumor with invasion of bone, musle, lung, brain and altered menta. status, plan to rediscuss goals of care with family with a focus on comfort. Patient continued to be treated for symptoms with fentanyl and lidocaine patches for pain control and IV morphine for breakthrough pain. . # Anemia: no obvious source of bleeding. Anemia felt to be multifactorial, secondary to bone marrow suppresion from sepsis and malignancy as well as phlebotomy and dilutional component with volume resuscitation. Stable. Did require transfusion with apporptriate bump in hematocrit. # Thrombocytopenia: Initially concerned for consumptive process such as DIC given sepsis or HIT. DIC labs not consistent. PF4 antibody was negative. Platelets trended. Also likely multifactorial with bone marrow suppression or medication related. Did not trend low enough to require platelet transfusion. . # CAD. s/p CABG with progressive angina, now medically managed. Currently w/out CP. - Continued Statin - held BB/ACEI given hypotension . # FEN. diabetic diet though patient taking minimal POs and time of transfer from ICU; Net positive approximately 12L for length of stay. . # Access: LIJ [**6-5**], R rad art line [**6-5**] . # Code: DNR / DNI; Plan to discuss goals of care with focus on comfort . Medications on Admission: 1. Allopurinol 200 mg po daily 2. Atorvastatin 80 mg po daily 3. Colchicine 0.6 mg po daily 4. Furosemide 20 mg Tablet po daily 5. Metoprolol Tartrate 100 mg q AM 6. Metoprolol Tartrate 50 mg Tablet po qPM 7. Levothyroxine 100 mcg po daily 8. Lisinopril 40 mg daily 9. Dexamethasone 1 mg taper until [**2152-6-1**]; [**6-2**] - no decadron; [**6-3**] decadron 2mg; [**6-4**] -no decadron; [**6-5**] decadron 2mg; [**6-6**] no decadron; [**6-7**]; decadron 2mg then STOP 11. Pantoprazole 40 mg po daily 12. Cholecalciferol (Vitamin D3) 800 U po daily 13. Calcium Carbonate 500 mg po QID 14. Ibuprofen 400 mg po TID 15. Bisacodyl 5 mg prn 16. Oxycodone 5 mg PO Q4H 17. Senna 8.6 mg PO BID 18. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous qPM. 19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed per sliding scale SC three times a day. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

[ "V10.3", "287.5", "285.9", "401.9", "274.9", "198.3", "414.00", "427.32", "428.0", "V45.81", "197.0", "995.92", "785.52", "584.9", "244.9", "038.9", "250.12", "428.20" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12395, 12404

7610, 11435

284, 332

12463, 12480

5093, 7587

12544, 12562

4463, 4641

12355, 12372

12425, 12442

11461, 12332

12504, 12521

4656, 5074

233, 246

360, 2494

2516, 3860

3876, 4447

21,688

177,415

6482+6483

Discharge summary

report+report

Admission Date: [**2164-10-8**] Discharge Date: [**2137-3-18**] Date of Birth: Sex: M Service: CHIEF COMPLAINT: Fevers. HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with a past medical history significant for end-stage renal disease, hypertension, type 2 diabetes, status post right pontine CVA, retinopathy, left brachiocephalic DVT, and several admissions in the past for CVA, rule out myocardial infarction, and change in mental status. The patient was recently discharged on [**9-25**] for a chief complaint of change in mental status and for repair of a left upper extremity fistula thrombus. The patient presented during this admission with a chief complaint of temperatures of 102 on [**10-4**] and fevers and chills. He was seen in the Emergency Department, where his potassium level was measured to be 7.9. The patient received calcium gluconate, glucose, Kayexalate. He had no EKG changes. The patient also had a period of hypotension with systolic blood pressure in the 80s. At that point, Dopamine was started. Many attempts were made at placing an intrajugular central line, but were unsuccessful. The patient was then transferred to the Medical Intensive Care Unit. On admission to the Medical Intensive Care Unit, the patient would open his eyes to voice. He was moaning occasionally. He did not follow any commands. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Type 2 diabetes. 3. Status post right pontine CVA in [**2164-1-18**]. 4. Hypertension. 5. Retinopathy. 6. Hypertriglyceridemia. 7. Tinnitus. 8. Past alcohol abuse. PAST SURGICAL HISTORY: 1. Right common femoral-dorsalis pedis bypass. 2. Left brachiocephalic thrombectomy with angioplasty in early of [**2164-9-17**]. 3. Status post right femoral fracture repair. MEDICATIONS: 1. Plavix 75 mg q.d. 2. Lipitor 10 mg q.d. 3. Renagel. 4. Zoloft 25 mg q.d. 5. Colace 100 mg b.i.d. 6. Folate 1 mg q.d. 7. B12 25 mg q.d. 8. Lopressor 12.5 mg b.i.d. 9. Captopril 12.5 mg t.i.d. 10. Aspirin 325 mg q.d. 11. NPH insulin, regular insulin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient resides in a nursing home. PHYSICAL EXAM: On admission to the Medical Intensive Care Unit, the patient was afebrile with a temperature of 98.0, blood pressure 141/78, respiratory rate 21, heart rate 109, and 100% on nonrebreather mask. He was an elderly-appearing man lying in bed, tachypneic, and responsive to voice, but unable to follow commands. His pupils were small and minimally reactive to light. His mucous membranes were dry. His conjunctivae were injected. His neck had bilateral hematomas secondary to central line placement attempts. His heart had a normal S1, S2 with distant heart sounds, but no murmurs, rubs, or gallops appreciated. His lungs were difficult to assess secondary to patient's cooperation, but were diffusely rhonchorous. His abdomen was soft with mild voluntary guarding. He had no hepatosplenomegaly. His left and right upper extremities were edematous. He had an area of a hematoma over the left fistula site. The hematoma was warm to touch. Bruit could be auscultated over the hematoma. He had faint dorsalis pedis pulses bilaterally. LABORATORIES: In the Emergency Department, the patient's CBC was as follows: White blood cell count 11.3, hematocrit 33.5, platelets 324. His INR was 1.2. His electrolytes were as follows: Sodium 134, potassium 7.9, chloride 94, bicarb 31, BUN 71, creatinine 8.3, glucose 343. His calcium was 10.4, albumin 2.6, magnesium 2.3. His AST was 69, ALT 40, CK 50, alkaline phosphatase 160. His amylase was 66. T bilirubin 0.4, lipase 60. His urinalysis was positive for trace blood, 50 of protein, 1,000 of glucose, no ketones, no leukocyte esterase, no white blood cells, and no bacteria. HOSPITAL COURSE BY PROBLEMS: Fevers: In the Medical Intensive Care Unit, the patient was temporarily placed on dopamine to restore his blood pressures. He immediately became hemodynamically stable. The source of his fevers even after transfer to the floor on hospital day three was unclear. His blood cultures had been obtained several times during his hospital course. Out of his many sets of blood cultures, only one set grew gram-negative Staphylococcus. His urinalysis done on the day of admission was negative. His chest x-rays continuously showed bibasilar atelectasis. He was started empirically on Zosyn, Flagyl, and Vancomycin was dosed randomly for a level less than 15. Since it was unclear exactly what the source of his fevers was, and because the patient was complaining of left hip pain, there was a question of whether he might have a retroperitoneal abscess. At that point, it was decided to do a CT of his chest, abdomen, and pelvis to rule out any abscesses. the CT was negative except for right lung atelectasis. Also during his hospital stay, his central line, which had been placed in his right subclavian, was changed after one week since the patient continued to spike temperatures with the highest temperature of 100.5 on hospital day seven. A new line was placed in the right internal jugular vein. It is also unclear whether the hematoma over his left arm fistula could potentially be infected leading to his continued temperatures. Transplant Surgery was consulted regarding whether the hematoma needed to be evacuated. They did not find that this was necessary at the time. After the central line had been changed, it was decided that the antibiotics should be discontinued since it was unclear what we were treating. The antibiotics were stopped. The patient did not spike a temperature for 24 hours. It was determined at this point, that it would best for the patient to be transferred back to his nursing home from an infectious disease standpoint. The patient symptomatically, towards the end of his hospital stay had significantly improved. He was able to have a conversation with the physicians as well as the nursing staff. Arteriovenous fistula: On [**10-9**], the patient underwent an ultrasound of his left arm due to the left hematoma over his A-V fistula site. The ultrasound showed a patent deep venous system, patent left arteriovenous graft, and a large hematoma. Transplant Surgery was consulted, who recommended a fistulogram to rule out a pseudoaneurysm. The fistulogram showed a small pseudoaneurysm with no communication with the hematoma. The Surgery team suggested that a repair be done for the pseudoaneurysm, but that it was not emergent, and the patient's fever should be cleared prior to surgery. At that point, his Plavix was restarted. After the patient's temperatures had resolved towards the end of his hospital stay, Transplant Surgery was reconsulted. They determined that it was not necessary to operate at this time, and could be done at a future date. They stated that the hematoma over the fistula site was an unlikely source of his temperatures. Type 2 diabetes mellitus: The patient was placed on a regular insulin-sliding scale throughout his hospital stay. His blood glucose levels were monitored daily through fingersticks. His blood glucose levels were well controlled during his hospital course. End-stage renal disease on hemodialysis: The patient received hemodialysis on the same schedule as prior to admission. He was sent down to hemodialysis on Mondays, Wednesdays, and Fridays. He was closely monitored by the Renal team, and his electrolytes were closely monitored. Fluids, electrolytes, and nutrition: Patient's diet was slowly advanced during his hospital stay. Towards the end of his admission, he was tolerating thicken liquids and puree solids. Orthopedics: During his hospital stay, the patient had complaint of left hip pain, and there was continued tenderness on palpation of his left hip. Plain x-rays were done, which did not reveal any signs of fracture, but did show degenerative joint disease. A CT of the pelvis was also done to rule out any abscess. The CT was negative for any signs of abscess. The patient steadily improved during his hospital stay. His mental status had improved. The source of his temperatures was still unclear. However, the patient was afebrile for a period greater than 24 hours prior to discharge. His white blood cell count was well within normal range. His blood cultures continue to show no growth to date. Thus, it was decided that all antibiotics could be stopped and the patient would be discharged back to his nursing facility. DISCHARGE STATUS: Discharged to nursing facility. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Fevers of unknown origin. 2. Chronic renal failure. 3. Hyperkalemia. 4. Left arm hematoma. 5. Left arm arteriovenous fistula pseudoaneurysm. 6. Confusion. DISCHARGE INSTRUCTIONS: The patient was told to call his doctor if he experienced any further fevers, increased pain, or other worrisome symptoms. He was told to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. 2. Atorvastatin calcium 10 mg p.o. q.d. 3. Renagel 800 mg p.o. t.i.d. 4. Zoloft 25 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. Folic acid 1 mg p.o. q.d. 7. Vitamin B12 250 mcg p.o. q.d. 8. Metoprolol 12.5 mg b.i.d. 9. Aspirin 81 mg p.o. q.d. 10. Regular insulin regimen prior to admission. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**] Dictated By:[**Name8 (MD) 4955**] MEDQUIST36 D: [**2164-10-17**] 13:54 T: [**2164-10-17**] 13:56 JOB#: [**Job Number 24882**] Admission Date: [**2164-10-8**] Discharge Date: [**2164-10-18**] Date of Birth: [**2099-4-21**] Sex: M Service: GENERAL MEDICINE ADDENDUM TO DISCHARGE SUMMARY OF [**2164-10-17**]: There were no events with the patient over the past 24 hours. The patient has continued to be afebrile. He is asymptomatic. He does not complain of any pain or tenderness over the hematoma site. He also does not complain of any chills, or malaise. The patient was seen by transplant surgery regarding the pseudoaneurysm of his AV fistula site, as well as the hematoma over the AV fistula site. Transplant surgery did not think it was necessary to operate on the fistula, or evacuation of the hematoma at this time. They recommend that the patient follow-up with Dr. [**First Name (STitle) **] from transplant surgery in the next two weeks. From their standpoint, the patient may be discharged to his rehab facility today. DISCHARGE CONDITION: Stable. DISCHARGE TO: Nursing facility. DISCHARGE DIAGNOSES: 1. Fevers of unknown origin. 2. Chronic renal failure. 3. Hyperkalemia. 4. Left arm hematoma. 5. Left arm arteriovenous fistula pseudoaneurysm. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po qd. 2. Renagel 800 mg po tid. 3. Atorvastatin and calcium 10 mg po qd. 4. Sertraline 25 mg po qd. 5. Colace 100 mg po bid. 6. Folic acid 1 mg po qd. 7. Metoprolol 12.5 mg po bid. 8. Aspirin 81 mg po qd. 9. Cyanocobalamin 250 mcg po qd. 10.Insulin regimen, same as prior to admission. DISCHARGE INSTRUCTIONS: 1. The nursing facility is to call the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], if the patient experiences any fevers, changes in mental status, or other worrisome symptoms. 2. The patient is to make a follow-up appointment with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], within the next 2 weeks. His primary care physician's number is ([**Telephone/Fax (1) 24883**]. 3. The patient is also to schedule a follow-up appointment with Dr. [**First Name (STitle) **] from transplant surgery within the next 2 weeks regarding repair of his fistula site for the pseudoaneurysm. Dr.[**Name (NI) 670**] phone number is ([**Telephone/Fax (1) 24884**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2164-10-18**] 09:52 T: [**2164-10-18**] 09:53 JOB#: [**Job Number 24885**]

[ "584.9", "403.91", "362.01", "997.2", "780.6", "388.30", "250.50", "E878.2", "518.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

10682, 10725

10746, 10891

10914, 11218

11242, 12338

1645, 2126

2199, 8596

144, 153

182, 1388

1410, 1622

2143, 2183

77,251

166,652

35089

Discharge summary

report

Admission Date: [**2200-12-22**] Discharge Date: [**2200-12-29**] Date of Birth: [**2138-5-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: Epidural catheter placement History of Present Illness: 62 yo F restrained driver in rollover auto crash. Reportedly +LOC; GCS15 upon EMS arrival. She was taken to an area hospital where found to have multiple left rib fractures and left clavicle fracture; she was then transferred to [**Hospital1 18**] for further care. Past Medical History: HTN Hypothyroid PSH: s/p Hysterectomy Social History: Lives with husband Family History: Noncontributory Pertinent Results: [**2200-12-22**] 04:20PM GLUCOSE-101 UREA N-12 CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-29 ANION GAP-9 [**2200-12-22**] 04:20PM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.9 [**2200-12-22**] 04:20PM WBC-11.0 RBC-3.78* HGB-12.4 HCT-34.0* MCV-90 MCH-32.8* MCHC-36.5* RDW-13.0 [**2200-12-22**] 04:20PM PLT COUNT-163 [**2200-12-22**] 04:20PM PT-13.7* PTT-23.4 INR(PT)-1.2* [**2200-12-22**] 12:48AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT Abdomen/Pelvis [**2200-12-22**] IMPRESSION: 1. No solid organ injury is detected in the abdomen and pelvis. 2. Nondisplaced fracture of posterior element of left 10th, 9th and 8th ribs. 3. Small bibasilar effusion and bibasilar atelectasis, left greater than right. Chest AP [**2200-12-25**] IMPRESSION: 1. Multiple rib fractures. 2. Left lower lobe collapse and/or consolidation, unchanged. 3. Left apical capping (pleural fluid) adjacent to the left 2nd rib fracture and indistinctness of the left aortic knob, unchanged compared with [**2200-12-23**]. Further assessment with chest CT would be recommended to exclude a mediastinal hematoma. Left clavicle [**2200-12-22**] Fracture involving the middle third of the left clavicle is associated with inferior displacement of the lateral fracture fragment. Fractures involving the posterior parts of left second and third ribs are noted. The left humeral head is in the glenoid fossa with no fracture. Brief Hospital Course: She was admitted to the Trauma Service and transferred to the Trauma SICU for close monitoring given her multiple rib fractures. Acute pain service was consulted given her injuries and difficulty with adequate pain control with PCA. An epidural catheter was placed; her PCA dose was increased; prn IV narcotics for breakthrough pain were also added to her regimen. A long acting narcotic was later added; the epidural was removed. Instruction regarding coughing, deep breathing and use of incentive spirometer were provided; she does require ongoing encouragement with this. She continued to have pain but to a much lesser degree than she did initially. MSIR was added for breakthrough and this was changed to oral Dilaudid with the addition of Toradol. She was started on a bowel regimen early on. Her clavicle fracture was managed non operatively; she was placed in a sling for comfort. She will follow up in 2 weeks in [**Hospital 5498**] clinic for follow up films. She did develop a UTI and is being treated with a 5 day course of Cipro which was started on [**2200-12-26**]. Physical and Occupational therapy were consulted and have recommended short term rehab after her acute hospitalization. Medications on Admission: levothyroxine 245 mcg, minoxipril, spironolactone, tylenol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 3. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day: to be taken with the 200mcg tablet to total dose of 225mcg daily. 5. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 13. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q12H (every 12 hours). 14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: s/p Motor vehicle crash Left clavicle fracture Multiple left rib fractures Urinary tract infection Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Continue to wear the sling for comfort. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call [**Telephone/Fax (1) 600**] for an appointment. Inform the office that you will need an AP chest xray on the day of your appointment just prior to seeing Dr. [**Last Name (STitle) **]. Follow up in 2 weeks in [**Hospital 5498**] clinic with Dr. [**Last Name (STitle) **] for your clavicle fracture; call [**Telephone/Fax (1) 1228**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2200-12-31**]

[ "599.0", "850.11", "511.9", "244.9", "E816.0", "401.9", "338.11", "810.01", "807.07" ]

icd9cm

[ [ [] ] ]

[ "03.90" ]

icd9pcs

[ [ [] ] ]

5006, 5092

2293, 3498

339, 368

5234, 5314

813, 2270

5402, 5993

777, 794

3609, 4983

5113, 5213

3524, 3586

5338, 5379

276, 301

396, 664

686, 725

741, 761

31,136

115,148

9060

Discharge summary

report

Admission Date: [**2133-5-30**] Discharge Date: [**2133-6-5**] Date of Birth: [**2065-10-16**] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 3913**] Chief Complaint: Febrile neutropenia, relative hypotension Major Surgical or Invasive Procedure: paracentesis History of Present Illness: 67F w/hx refractory CLL c/b MDS and recurrent ascites, presenting with fevers, nausea, vomiting, dizziness, and relative hypotension with systolics in the upper 80s-low 90s (SBP normally in 90-100s). The patient last received etoposide and cytoxan five days ago, with subseqeunt neutropenia (ANC 310) on yesterday's labs. The patient had generally been feeling well, and was last seen in clinic yesterday, where she was reported as having a lot of energy and having no complaints. Today, she noticed a decreased appetite, and was nauseous with an episode of vomiting non-bloody emesis. She felt febrile and measured her temperature at 103. . In the ED, the patient was hypotensive below her low baseline, with the lowest SBP measured at 77. She was also tachycardic to 120s, which improved after 2 liters IVF. Blood and urine cultures were sent, and the patient was given cefepime. . On the floor, the patient reports improvement in her symptoms: she is now afebrile. Denies current lightheadedness, dizziness, dyspnea, chest pain, or palpitations. She does endorse worsening fluid accumulation in her abdomen since her last paracentesis on [**5-21**], but denies abdominal pain or nausea. . Review of sytems: (+) Per HPI. Also endorses decreased urine output since this morning. (-) Denies chills, night sweats, headache, cough, diarrhea, constipation, arthralgias or myalgias. . Past Medical History: 1. CLL. Please refer to OMR note [**2131-4-4**] for extensive details. Has had multiple treatments, most recent of which was bendamusine on [**2132-11-6**]. 2. Extrapulmonary TB diagnosed [**8-8**], now s/p 6 months of therapy with rifampin, INH, and moxifloxacin. 3. Hypothyroidism 4. Osteoarthritis 5. Status post ERCP with sphincterotomy for gallstone pancreatitis and cholangitis, [**4-10**] 6. Status post cholecystectomy [**2132-5-8**] 7. History of C. difficile 8. Recurrent ascites . Social History: Pt from [**Country 27587**]. Smoked [**1-5**] ppd for 45 years. No ETOH or drugs. Lives at home with her husband, daughter, and grandson. Owned and worked at her own business "helping hands" as a home health aide. Family History: Noncontributory. Physical Exam: Vitals: T:97.5 BP:90/56 P:87 R:22 O2:97% room air General: Very pleasant, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Poor dentition Neck: supple, no appreciable JVD or LAD Lungs: CTAB, good inspiratory effort and air movement. No wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Protruberant and distended, but soft. Dull to mildly resonant to percussion throughout. Non-tender, bowel sounds present, no rebound tenderness or guarding. +Palpable splenomegaly Ext: WWP, symmetric 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: WBC 0.3 (22P, 70L, 8M) Hct 24.6 (B/l high-mid 20s) Plt 40 ANC 66 . Na 133 K 4.6 Cl 104 HCO3 19 BUN 24 Cr 0.7 Glu 123 . Lactate 1.0 . Discharge labs: [**2133-6-5**] 06:00AM BLOOD WBC-0.7* RBC-2.64* Hgb-9.0* Hct-26.0* MCV-99* MCH-34.2* MCHC-34.7 RDW-18.4* Plt Ct-28* [**2133-6-5**] 06:00AM BLOOD Neuts-57 Bands-0 Lymphs-35 Monos-5 Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2133-6-5**] 06:00AM BLOOD Gran Ct-399* [**2133-6-5**] 06:00AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-139 K-4.0 Cl-110* HCO3-24 AnGap-9 [**2133-6-4**] 06:00AM BLOOD ALT-12 AST-15 LD(LDH)-116 AlkPhos-85 TotBili-0.3 [**2133-6-5**] 06:00AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.6* Mg-1.9 Micro: [**5-30**] BCx: neg [**5-30**] UCx: neg . Peritoneal fluid: [**2133-6-4**] 03:50PM OTHER BODY FLUID WBC-75* RBC-5100* Polys-2* Lymphs-78* Monos-10* Mesothe-10* [**2133-6-4**] 03:50PM OTHER BODY FLUID TotProt-2.3 Glucose-9 [**2133-6-4**] 3:50 pm PERITONEAL FLUID GRAM STAIN (Final [**2133-6-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): Images: [**5-30**] CXR: The lungs are clear. There is no focal consolidation, pleural effusion, or pneumothorax. Infrahilar right-sided opacity, in correlation with prior CT, likely corresponds to calcified lymph nodes which could be treated lymphoma. Heart size is normal. There is no pulmonary edema. Brief Hospital Course: Ms. [**Known lastname 31303**] is a 67 year old woman with refractory CLL on C1D6 of cyclophosphamide, etoposide, and prednisone, presenting with febrile neutropenia, nausea, vomiting, dizziness and hypotension. # Febrile neutropenia: Outpatient notes indicate that the patient had been experiencing intermittent low-grade fevers. She was recently started on empiric cefpodoxime and metronidazole out of concern for possible SBP. All recent culture data (blood, urine, peritoneal fluid) had been negative since [**Month (only) 404**]. CXR negative for focal consolidation or pulmonary edema. Urine analysis was not concerning for UTI. Patient was started empirically on cefepime/metronidazole for empiric coverage of an intra-abdominal process. Patient had no further fevers and was transferred to the BMT floor where her fevers resolved. She continued her chemo and was ultimately discharged on cefpodoxime/flagyl. Her peritoneal fluid did not have evidence of infection, but final cultures are pending and should be followed up by the pt's oncologist. # Hypotension: Patient was admitted directly to MICU because of relative hypotension with SBPs in 80s. She was given some IVFs and transferred to the BMT floor the next day with stable blood pressure in the 90s systolic. Patient was asymptomatic from hypotension, though she had noted symptoms of dizziness intermittently since her last chemotherapy dose; the dizziness symptoms were described as vertigo-like, does not appear to be related to hypotension. # CLL: Patient presented on Day#6 of Cycle#1 of her chemotherapy regimen. Her current regimen is as follows: Cyclophosphamide 500mg/m2 days 1, 8; Etoposide 50mg/m2 days 1 and 2 (hold day 3); Prednisone 60mg po days 1,2,3,4,5. Per OMR notes, the patient's disease has been generally stable on bendamustine and Rituxan for several months, though her most recent scan showed growth in size of lymph nodes and worsening malignant ascites. Her primary oncologist reports that her disease features chronic low counts due to a dysplastic marrow with poor reserve, and he has been attempting to support her counts with transfusions and GMCSF. Patient was continued on daily Neupogen and allopurinol. Her last monthly dose of pentamidine dose was [**2133-5-7**], she is to have this dose at her next oncology appointment. She refused nystatin for oral thrush but was started on clotrimazole on the BMT floor. # Ascites: Patient has malignant ascites with a previous diagnostic tap showing cytology similar to her lymphoma. Her last paracentesis was on [**5-21**], with peritoneal fluid analysis unrevealing for infection and cell counts repeatedly negative for SBP. She was started on cefepime and metronidazole empirically for SBP. Abdomen was very distended during this hospitalization but not painful; patient underwent ultrasound-guided paracentesis by Interventional Radiology which provided the pt with good relief. The fluid studies did not show evidence of infection but final cultures are pending and should be followed up. She is discharged on cefpodoxime/flagyl which can cover prophylactically for SBP as well. # Pancytopenia: Patient's hematocrit dropped from 24 to 20 in the setting of IVFs from the ED and the MICU. She was transfused 1u pRBCs in the ICU before transferred to floor. The patient was transfused with pRBC and platelets prn throughout admission. It is noted that the pt developed hives to plt transfusion which responded to benadryl. Medications on Admission: Medications (as of [**2133-5-21**]): ACYCLOVIR 400 mg PO Q8 hrs ALLOPURINOL 150 mg PO daily CEFPODOXIME 200 mg PO Q 12 hrs ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Qmonth FILGRASTIM - 300 mcg SC daily FOLIC ACID - 1 mg PO daily LEVOTHYROXINE - 175 mcg PO daily Mylan Generic - No Substitution LORAZEPAM - 0.5 mg PO QHS METRONIDAZOLE - 500 mg PO Q8 hrs NYSTATIN - 5 cc PO 3-4x/day swish and spit OLANZAPINE 2.5 mg PO QHS PRN insomnia PENTAMIDINE 300 mg inh monthly PREDNISONE - 5 mg Tablet PO daily PROCHLORPERAZINE MALEATE - 10 mg PO Q8 hrs PRN nausea & vomiting MAGNESIUM OXIDE - 400 mg PO BID Discharge Medications: 1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO Q1MO (once a month). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pentamidine 300 mg Recon Soln Sig: One (1) Recon Soln Inhalation Q1MO (once a month). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Prochlorperazine Maleate 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours). 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 15. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:*30 Troche(s)* Refills:*1* 16. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] Home Care Discharge Diagnosis: Primary Diagnosis: Neutropenic Fever Secondary Diagnoses: Chronic Lymphocytic Leukemia Malignant Ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 31303**], You were admitted to the hospital because you were having fevers and your blood counts were low while receiving chemotherapy. You were started on antibiotics and monitored and your fevers resolved without any apparent cause. You received your remained chemo doses. You also had blood and platelet transfusions as needed. Finally, you underwent a therapuetic paracentesis to remove fluid from your abdomen. You are to continue antibiotics at home. You should also continue your GCSF injections. Please take all medications as prescribed. Please follow up with all providers. Please do not hesitate to return to the hospital with any concerning symptoms at all. . Followup Instructions: Please be sure to keep all of your followup appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2133-6-8**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2133-6-8**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2133-10-5**] 8:20

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icd9cm

[ [ [] ] ]

[ "99.25", "54.91" ]

icd9pcs

[ [ [] ] ]

10319, 10385

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313, 328

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3153, 3153

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2503, 2521

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10406, 10406

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1761, 2255

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10,487

188,380

14053+56504

Discharge summary

report+addendum

Admission Date: [**2134-10-12**] Discharge Date: [**2134-10-16**] Date of Birth: [**2069-5-26**] Sex: F Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female who had an off-pump coronary artery bypass graft in [**2134-3-5**]. The patient did well initially. However, she soon developed recurrent infections of her sternal wound. She was last admitted in [**2134-6-5**] for sternal wound drainage and infection. At that time, she was started on intravenous antibiotics. She underwent sternal wound debridement and the placement of a VAC sponge. The patient was then discharged to home. She had her VAC sponges changed periodically for the following few weeks. After that, the VAC sponge was removed, and wet-to-dry dressings were applied to her sternal wound. The wound appeared to be healing slowly. However, prior to the current admission, the patient developed increased amount of greenish drainage from the wound. The patient was readmitted for the further management of her recurrent sternal wound infection. PAST MEDICAL HISTORY: 1. Hypercholesterolemia 2. Hypertension 3. Insulin-dependent diabetes mellitus 4. Methicillin resistant staphylococcus aureus 5. Gastroesophageal reflux disease 6. Congestive heart failure 7. Ovarian cancer 8. Postoperative atrial fibrillation following coronary artery bypass graft PAST SURGICAL HISTORY: 1. Coronary artery bypass graft x 3, off-pump 2. Status post cholecystectomy 3. Status post appendectomy 4. Status post right leg plate, open reduction and internal fixation 5. Status post bilateral cataract extraction ALLERGIES: 1. Percocet 2. Vioxx 3. Shrimp MEDICATIONS: 1. Protonix 40 mg by mouth once daily 2. Plavix 75 mg by mouth once daily 3. Lasix 40 mg by mouth twice a day 4. Lescol 40 mg once daily 5. Lopressor 75 mg by mouth twice a day 6. Insulin NPH 40 units in the morning, 14 units in the evening, sliding scale PHYSICAL EXAMINATION: Blood pressure 175/58, heart rate 60, afebrile. General: Elderly female, in no apparent distress. Head, eyes, ears, nose and throat examination: Within normal limits. Neck examination: No bruits, no jugular venous distention detected. Chest: Clear to auscultation bilaterally. Chest wound partially open, with yellowish drainage. Heart examination: Regular rate and rhythm. Abdominal examination: Bowel sounds present, soft, nontender, nondistended. Extremities: Warm and well perfused. Neurologically: Grossly intact. LABORATORY DATA: Hematocrit 31.2, white blood cell count 6.5, platelets 340. INR 1.1. Glucose 142, BUN 32, creatinine 1.2, sodium 145, potassium 4.6. HOSPITAL COURSE: The patient was admitted to Cardiac Surgery for further management of her sternal wound infection. On [**2134-10-12**], the patient underwent sternal wound debridement and placement of a VAC sponge. The procedure was without any complications. Postoperatively, in the recovery room, the patient complained of shortness of breath. She was 97% on 3 liters. The chest x-ray obtained at the time showed leftward deviation of sternal wires, but no sign of effusion or consolidation. The original plan was to move the patient to the regular floor from the recovery room. However, when the patient was being moved to the floor, she desaturated to 50s, had poor respiratory effort and poor air movement. Her rhythm exhibited some premature ventricular contractions initially, but then stabilized. The patient was transported to the Intensive Care Unit. In the Intensive Care Unit, her vital signs stabilized. She was in sinus rhythm, with a heart rate in the 60s to 70s, and stable blood pressure. Her oxygen saturation improved significantly. The patient was then transferred to the regular floor in stable condition. On postoperative day two, the patient went into atrial fibrillation. Of note is that the patient had a similar event last time postoperatively when she underwent her coronary artery bypass graft a few months ago. The patient was treated with amiodarone load in addition to a standing dose, and her Lopressor was increased. Her heart rate was originally in the 120s to 130s. We were able to bring her heart rate under 100. However, she still remained in atrial fibrillation/atrial flutter. Cardiology was consulted for possible external cardioversion. The patient was started on intravenous heparin. On [**2134-10-15**], the patient was cardioverted by Cardiology into sinus rhythm. Cardioversion was successful, and the patient remained in sinus rhythm until her discharge. The patient was continued on intravenous heparin. Her amiodarone was decreased to 400 mg twice a day, which she will continue to receive for two weeks, after which her dose will be decreased to 400 mg once daily for approximately three months, after which she will continue on a standing dose of 200 mg of amiodarone once daily. In addition, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor was placed for two weeks, to monitor the patient's rhythm, and the [**Location (un) 1131**] will be sent to her cardiologist daily. The VAC sponge was changed prior to discharge. The patient was discharged to home in stable condition on [**2134-10-16**]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home, with VNA services. DISCHARGE DIAGNOSIS: 1. Recurrent sternal wound infection status post debridement and VAC placement 2. Atrial fibrillation status post external cardioversion 3. Hypertension 4. Insulin-dependent diabetes mellitus 5. Gastroesophageal reflux disease 6. Congestive heart failure 7. Hypercholesterolemia DISCHARGE MEDICATIONS: 1. Protonix 40 mg by mouth once daily 2. Lasix 40 mg by mouth twice a day 3. Lescol 40 mg by mouth once daily 4. Lopressor 100 mg by mouth twice a day 5. Lisinopril 5 mg by mouth once daily 6. Aspirin 325 mg by mouth once daily 7. Amiodarone 400 mg by mouth twice a day for two weeks, then 400 mg by mouth once daily for three months, then 200 mg by mouth once daily 8. Dilaudid 2 mg by mouth every four to six hours as needed for pain 9. Colace 100 mg by mouth twice a day as needed for constipation 10. Insulin NPH 40 units in the morning, 14 units in the evening, plus regular insulin sliding scale DISCHARGE INSTRUCTIONS: 1. The patient is to follow up with her surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], in approximately four weeks. 2. The patient is to follow up with her cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], in approximately three to four weeks. 3. The patient is to follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in approximately one week. 4. The patient is to wear the [**Doctor Last Name **] of Hearts monitor for the next two weeks, with daily reports sent to the cardiologist for [**Location (un) 1131**]. 5. The patient is to have VNA services and her VAC dressings are to be changed as per instructions. 6. The patient is to follow up with her diabetes specialist. She was seen by the diabetes specialist while an inpatient. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 10097**] MEDQUIST36 D: [**2134-10-15**] 23:15 T: [**2134-10-16**] 00:00 JOB#: [**Job Number 41929**] Name: [**Known lastname **], [**Known firstname 634**] Unit No: [**Numeric Identifier 7583**] Admission Date: [**2134-10-12**] Discharge Date: [**2134-10-19**] Date of Birth: [**2069-5-26**] Sex: F Service: Cardiac Surgery The patient was discharged later than the originally planned date due to the unavailability of the VAC machine at home. The patient was discharged to home in stable condition on [**2134-10-19**]. The patient will have a VAC machine and VNA services at home. DISCHARGE MEDICATIONS: Lopressor 50 mg po bid, amiodarone 400 mg po bid x12 days, then 400 mg q day x3 months, then 200 mg q day, aspirin 325 mg po q day, lisinopril 5 mg po q day, Dilaudid 2 mg prn, Protonix 40 mg po q day, Lescol 40 mg po q day, insulin subQ as per instructions, Colace 100 mg po bid. ADDITIONAL DISCHARGE INSTRUCTIONS: The patient is to have her liver function tests drawn some time this week with the results forwarded to her primary care physician. [**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**] Dictated By:[**Last Name (NamePattern1) 1388**] MEDQUIST36 D: [**2134-10-19**] 08:21 T: [**2134-10-19**] 08:28 JOB#: [**Job Number 7584**]

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icd9cm

[ [ [] ] ]

[ "99.62", "93.59", "86.22" ]

icd9pcs

[ [ [] ] ]

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32873

Discharge summary

report

Admission Date: [**2188-12-27**] Discharge Date: [**2189-1-1**] Date of Birth: [**2127-9-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: endoscopy w/ clipping of gastric varix History of Present Illness: History limited and supplemented from records as patient is currently recovering from sedation for EGD. This is a 61 yo female with dCHF, ESRD on HD who presents with melena for two days and coffee-ground emesis today. She was recently admitted for a right foot infection status post right transmetatarsal amputation and discharged on vanco/cefepime for pneumonia, as well as metronidazole empirically for C diff given diarrhea. Regarding her current symptoms, on presentation she denied lightheadedness, fevers, abdominal pain, chills, CP, SOB. Patient uses clopidogrel and ASA, but no other NSAIDs. She has no history of melena or blood per rectum. . Patient initially went to [**Hospital1 2436**], where her BP dropped to 82 (responded to IVF), and was then transferred to [**Hospital1 18**] ED. In the [**Hospital1 18**] ED, initial vs were: 98.9 75 161/54 16 100% 2L NC. She had a melenic stool in the ED. NGL with maroon blood not clearing with 2L lavage. Hct dropping 26 (OSH ED) to 24. GI consulted and wanted emergent EGD on arrival to ICU. Was started on PPI bolus/gtt. Current VS: 86 150/80 18 99RA. Access is PICC and 20g PIV. Getting 2 units pRBCs. [**Hospital1 **] surgery notified and calling transplant surgery as well in case of surgical intervention for GI bleed. . In the ICU, patient is sedated after EGD, which revealed a bleeding gastric ulcer, which was treated with clips x3. She denies any current symptoms including n/v, abd pain Past Medical History: Past Medical History: - Hypertension - Hypothyroidism - Idiopathic dilated cardiomyopathy - Anemia of chronic disease - Chronic kidney disease (Stage V) - Diabetes mellitus type II - Peripheral [**Hospital1 1106**] disease - Chronic diastolic heart failure - Cdiff in [**12-19**] - PNA in [**12-19**] . Past Surgical History: - [**2188-12-12**] right TMA - [**2187-1-31**] left TMA - [**2187-3-22**] Right SFA, [**Doctor Last Name **], AT angioplasty and SFA stent placement - [**2187-6-28**] Angioplasty of left below-knee popliteal artery, stenting of left above-knee popliteal artery, primary stenting of left SFA, Angioplasty of left SFA - [**2187-11-5**] Right 1st toe amputation - [**2188**] R TMA Social History: Patient denies smoking, alcohol use. Currently in rehabilitation facility. She lives alone, but has a significant other who she sees usually a couple times weekly. No other support systems in place. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PE: ============= VS: HR:66 BP: 132/47 99% on RA General: Chronically ill appearing locations, month/year, no acute distress HEENT: MMM Lungs: Poor inspiratory effort but clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, trace LE edema, right foot bandaged over TMA DISCHARGE PE: ============= VS: 98.0 137/90 88 20 94RA General: Chronically ill appearing, in NAD HEENT: MMM, poor dentition Lungs: CTA bil, except for scat crackles at left base 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, trace LE edema, right with incision with escar healing and well approximated. There is no erythema or edema noted. Foot feels wall and has + cap refill. Pertinent Results: On admission: [**2188-12-27**] 05:00PM GLUCOSE-95 UREA N-36* CREAT-3.3* SODIUM-143 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-29 ANION GAP-12 [**2188-12-27**] 05:00PM WBC-8.3 RBC-2.61* HGB-7.7* HCT-24.3* MCV-93 MCH-29.6 MCHC-31.8 RDW-18.7* [**2188-12-27**] 05:00PM NEUTS-61.0 LYMPHS-31.5 MONOS-5.1 EOS-1.8 BASOS-0.6 [**2188-12-27**] 05:00PM PLT COUNT-416 [**2188-12-27**] 05:00PM PT-17.3* PTT-26.1 INR(PT)-1.6* [**2188-12-27**] 10:17PM LACTATE-1.1 DISCHARGE LABS: [**2189-1-1**] 06:05AM BLOOD WBC-5.3 RBC-3.30* Hgb-9.7* Hct-30.5* MCV-93 MCH-29.5 MCHC-31.9 RDW-20.1* Plt Ct-257 [**2188-12-31**] 05:15AM BLOOD WBC-5.1 RBC-3.13* Hgb-9.5* Hct-29.2* MCV-93 MCH-30.4 MCHC-32.6 RDW-19.9* Plt Ct-315 [**2188-12-30**] 06:40AM BLOOD PT-14.6* PTT-25.3 INR(PT)-1.3* [**2188-12-31**] 05:15AM BLOOD Glucose-55* UreaN-22* Creat-4.3* Na-142 K-4.3 Cl-107 HCO3-26 AnGap-13 [**2188-12-31**] 05:15AM BLOOD Calcium-8.0* Phos-4.6* Mg-2.1 . CARDIAC ENZYMES: [**2188-12-30**] 06:40AM BLOOD CK-MB-2 cTropnT-0.22* [**2188-12-29**] 04:45PM BLOOD CK-MB-3 cTropnT-0.25* [**2188-12-28**] 01:51PM BLOOD CK-MB-3 cTropnT-0.23* [**2188-12-28**] 01:27AM BLOOD CK-MB-3 cTropnT-0.18* . IMAGES/ STUDIES: ================ CXRAY ON [**2188-12-29**]: INDINGS: Low lung volumes result in bronchovascular crowding. A dialysis catheter projects over the right atrium, unchanged. The right PICC tip is not seen beyond the junction of the right brachiocephalic vein and superior vena cava. There is no focal consolidation, pleural effusion or pneumothorax. The cardiac and mediastinal silhouette and hilar contours are normal, allowing for low lung volumes. IMPRESSION: Right PICC tip is not seen beyond the junction of the right brachiocephalic vein and superior vena cava. EGD on [**12-27**] Esophagus: Normal esophagus. Stomach: Excavated Lesions A single bleeding ulcer was found in the stomach. There was a visible vessel. Three endoclips were successfully applied for the purpose of hemostasis. Duodenum: Normal duodenum. Impression: Gastric ulcer (endoclip) Otherwise normal EGD to third part of the duodenum REPEAT EGD ON [**2188-12-31**]: Schatzki ring noted in distal esophagus. Scope easily traversed. Gastric ulcer Ulcer in the lesser curvature of the body of the stomach Erosions in the stomach body Otherwise normal EGD to third part of the duodenum Brief Hospital Course: This is a 61 yo female with dCHF, ESRD on HD on plavix and aspirin who was admitted to the MICU for emergent EGD with with hypotension, melena and +NG lavage, found to have a bleeding gastric ulcer which was clipped and is now stable. . . # Upper GI bleed: Pt had a bleeding ulcer that had 2 clips placed. She also received a total of 2 units of PRBCs on [**12-27**] but has not required any additional blood transfusion since then. She was on Plavix and ASA given that she has prior stents for PAD and recent TMA. Her GI bleed was likely aggravated by to Plavix/Aspirin use. Her Hpylori serology was negative, so this is unlikely. Pt had two episodes of melanotic stools on [**12-30**], last one early in the afternoon. She remains HD stable and Hct is stable in the high 20s. So, this was discussed with GI and she was taken back to have an EGD on [**12-31**] given that she would need to be restarted on plavix and ASA. On the repeat EGD there was no bleeding noted on the gastric ulcer and clips appeared in place. There is another non-bleeding ulcer seen on the stomach. GI's recommendation is to continue to hold the ASA and plavix at this time until she is re-evaluated by GI on Tues of next week given that her risk of rebleeding is high. This was discussed with the [**Month/Year (2) 1106**] team who states that her risk of bleeding outweighs her risk of clotting at this time and she should be restarted on ASA and plavix as GI thinks this is safe. She will follow in the [**Hospital **] clinic on Tues of next week and she will need to have blood counts checked every other day until then with results sent to her PCP in [**Name9 (PRE) **] hospital as noted on the d/c instructions. - continue protonix 40mg Q12 PO - Diet as tolerated - hold aspirin and plavix until further indicated by GI - Check Hct every other day and have results sent to [**Hospital 1459**] hospital as noted above - She will also need to be close monitor for bleeding: dark/black tarry stools and coffee ground emesis . # C diff colitis: This was confirmed with rehab facility that patient had diarrhea and positive C. Diff toxin and should be on PO Vanco until [**1-1**]. Patient has had no bowel movements today. - Continue vancomycin PO until [**1-1**] - monitor for diarrhea . # Recent PNA: No cough or leukocytosis. She is breathing comfortably, and has scat crackles on Left base. She had one episode of fever with temp up to 100.7 on [**12-29**], but no leukocytosis and no other symptoms. She has been afebrile since then. Patient completed PNA ABX. . # Elevated troponins: CE now trending down. Her CE were elevated in the setting of ESRD as well as some possible demand ischemia from bleed and hypotension. PAtient denies chest pain and there are no ischemic EKG changes so not ACS. Her CE started to trend down and she has no other c/o . # Hypertension: Pt was initially hypotensive in the setting of bleeding and on [**12-29**] after having HD her SBP was 200. She was then restarted slowly on her home dose of antihypertensives. As per pt, she is on 40mg of lisinopril and as per discharge paper work from prior admission she was on 10mg Qday. She was given one dose of lisinopril 40mg on [**12-30**] which was changed to 10mg after confirming with her rehab facility. Her Carvedilol was restarted on [**12-31**] and her amlodipine can be restart if her BP remains stable and SBP remains above 100. For now she is normotensive. - Cont on lisinopril 10mg Qday and on carvedilol 37.5 mg [**Hospital1 **] - Restart on Amlodipine if BP remains stable and SBP>100 . . # Hypothyroidism: -cont levothyroxine . # ESRD: on HD [**Name (NI) 12075**], Pt had HD on [**12-29**] and on [**12-31**] and has tolerated well. She does not appear to be fluid overloaded at this time. - [**Month/Year (2) 12075**] HD - Dialysis fellow recs . # Diabetes mellitus type II: She was initially hypoglycemic in the setting of being NPO which has now resolved -humalog sliding scale while in the hospital . . # Peripheral [**Month/Year (2) 1106**] disease: Recent TMA. R foot appears to be healing well. Her surgical incision site looks well approximated with sutures. She will be following up with the [**Month/Year (2) 1106**] clinic on [**1-17**]. - Holding ASA, clopidogrel given GI bleed - continue simvastatin . # Chronic diastolic heart failure: Restarted on BB and ACE-I - Caution with IVF given HD dependence and diastolic HF . # Depression -continue citalopram . #FEN: her diet was advanced as tolerated, no IVF for now, dialysis for electrolyte abnormalities . #PPX: pneumoboots while inpatient given recent bleed, PO PPI, no bowel regimen for now . # CODE: FULL . # Communication: Patient and [**Hospital 4444**] Healthcare ([**Telephone/Fax (1) 76537**]) Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Vancomycin 250ml PO q6h . Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Please do not exceed 4 grams (4000mg) of this medication in 24 hours. 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day: WITH MEALS. 6. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Last day of therapy is on [**2189-1-1**]. 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please hold for SBP<100. 8. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): Please hold for SBP<100 and HR <60. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: Please hold for SBP<100. Discharge Disposition: Extended Care Facility: [**Hospital 4444**] Health Care Center Discharge Diagnosis: Primary: Upper GI bleed DM S/p TMA ESRD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 76499**], Thank you for allowing us to participate in your care. You were transferred to [**Hospital1 **] after having a gastric bleed. You were initially admitted to the intensive care unit and you had 2 units of red blood cells. You also have an endoscopy that showed that you had a bleeding ulcer in your stomach. You had 3 clips placed on the ulcer to stop the bleeding. You have done well and your blood counts have remained stable. We think that the aspirin and the plavix have contributed to your bleeding. These medications were stopped while you were in the hospital and you will be restarting then after being evaluated by the gastroenterologist next week. This was decided since your risk for bleeding outweighs your risk of forming clots. The [**Hospital1 1106**] team agrees with this decision and you have an appointment with them in [**Month (only) **] as listed below. We have made the following changes to your medication: - STOP taking aspirin and plavix until you see the gastroenterologist and have further recommendations from them - START protonix twice daily - Some of your medications for your blood pressure were held while your in the hospital due to your bleeding and have been added back slowly. You should be restarted on amlodipine 10 mg daily if your SBP remains >100 Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: GASTROENTEROLOGY When: TUESDAY [**2189-1-6**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need to follow up with your primary care doctor, Dr. [**Last Name (STitle) **], on THURS, [**1-8**] at 12:15 PM AT THE [**Location (un) **] OFFICE Location: DUTTON FAMILY CARE ASSOCIATES Phone: [**Telephone/Fax (1) 76504**] Department: [**Telephone/Fax (1) **] SURGERY When: FRIDAY [**2189-1-16**] at 9:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2189-1-27**] at 2:00 PM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need [**Month (only) 116**] fax lab results to [**Hospital **] hospital, ATT: Dr [**Last Name (STitle) 21448**] [**Telephone/Fax (3) 76538**] Completed by:[**2189-1-1**]

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icd9cm

[ [ [] ] ]

[ "44.43", "39.95" ]

icd9pcs

[ [ [] ] ]

13044, 13109

6301, 11043

316, 356

13197, 13197

3944, 3944

14816, 16186

2805, 2887

11957, 13021

13130, 13176

11069, 11934

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4417, 4871

2191, 2571

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3389, 3925

265, 278

384, 1842

3959, 4400

13212, 13349

1887, 2168

2587, 2789

27,337

166,634

33006

Discharge summary

report

Admission Date: [**2200-9-8**] Discharge Date: [**2200-9-14**] Date of Birth: [**2153-12-30**] Sex: M Service: MEDICINE Allergies: trazadone / Serzone / metformin Attending:[**Doctor First Name 2080**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: EGD [**2200-9-9**] History of Present Illness: 46yo man with a h/o duodenal bulb ulcer (dx [**3-/2200**]) and cholecystal duodenal fistula (dx [**2200-8-21**]), psychiatric issues, polysubstance abuse, HCV/cirrhosis, remote EtOH abuse, and prior sternal osteo (due to IVDU, ~10 years ago, s/p flap for an open chest wound last year) admitted in the evening of [**9-7**] with coffee ground emesis 2 days PTA along with sharp RUQ pain. In the OSH ED, he had 600cc of coffee ground emesis with hypotension to 107/75 with tachycardia to the 140s. NG suctioned an additional 1L of dark red blood. At that time, EKG showed TWI in V3-V6 with 1mm ST depressions in V2-V3. He received 2L NS, 1 unit pRBC and general surgery felt teh cholecystoduodenal fistula was not the cause of his bleed. GI recommended medical therapy with endoscopy in the AM (of [**9-8**]). His HCT upon admission was 47.2, but by the afternoon the day after admission, his HCT decreased to 40, even in the setting of 1 unit pRBC. Pt was started on protonix gtt and GI performed EGD on [**2200-9-8**], which per accompanying report, showed no varicies, no current bleeding, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] C esophagitis, clotted blood int he entire stomach adn duodenum, with a large duodenal bulb ulceration/fistula just past pyloric channel with mild oozing, clot exudates. There was pyloric inflammation and concern for malignancy but no biopsies taken due to risk of bleeding. GI there recommended emergent surgery, but surgery declined and suggested IR angiography and embolization and so he was transferred here to [**Hospital1 18**] for further management. His most recent Hct 40%. Of note, pt had an admission to [**Hospital1 18**] from [**3-29**] to [**2200-4-4**] with a chief complaint of abdominal pain. He was admitted to the acute care service with mid-abdominal pain, nausea and vomitting. Upon admission, he was made NPO, given intravenous fluids and cat scan showed a contained perforation of a duodenal bulb ulcer. An NG tube was placed for bowel rest and decompression. On HD # 6, he underwent an upper GI study which showed no evidence of duodenal leak. His [**Last Name (un) **]-gastric tube was removed and he was started on clear liquids with advancement to a regular diet. Prior to transfer from OSH to [**Hospital1 18**], report was given that he had an additional 350cc out his NG tube and was given an additional 1L NS with vital signs reportedly stable. Tachycardic to 138 with SBP 100, and vomited 850cc of bright red blood and was getting 2 units pRBC en route. On arrival to the MICU, pt is tachycardic to the 130s with SBP in the 90s. He is mentating well and complaining of epigastric pain and nausea. However, pt continues to have episodes of hematemesis. He had one episode of hematemesis of 200-400cc. Surgery, GI, and IR was informed of the pt, and surgery arrived, placed an NG tube and about 800cc additionally of red blood was put out into the canister. Massive transfusion protocol was activated and pt was set up to receive 4 units pRBC and 2 units FFP. GI is preparing to do EGD, though pt will be intubated first. He denies any bleeding from the rectum, with the last BM occuring 2-3 days ago. Past Medical History: Non-healing right chest wound s/p right latissimus flap on [**2200-3-17**] complicated by hematoma Diabetes HTN HCV: dx 3 years ago, no liver bx, no treatment IVDU (HIV negative [**2196-6-5**]) Depression Agoraphobia h/o serotonoin syndrome Social History: Tobacco: 3 ppd. Etoh: sober x 10 years. However, drank recently. drugs: IV cocaine use daily, $50 worth, last use on the day of admission. H/o heroin use, non currently, last use in [**11-24**]. H/O methadone maintenance x 11 years until [**2191**]. The patient completed the 7th grade. He was never married. Has two children aged 20 and 19. He is close with his son. [**Name (NI) **] describes his daughter as wasting her life out on the street. He says he has no contact with her. He is close with his mother, but has a tenuous relationship with her as they often fight. H/o multiple deaths in his family. Patient is on disability for agoraphobia. He lives in an apartment with a roommate. He spent 2 months in jail many years ago for possession. No other legal problems. [**Name (NI) **] h/o violence. HCV positive. Family History: Non-Contributory Physical Exam: ADMISSION PHYSICAL EXAM General: Pale, alert, oriented, in moderate distress HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, TTP in RUQ, non-distended, bowel sounds present GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam O:98.1 102/60 72 20 97% on RA GENERAL NAD lying in bed HEENT - PEERLA, left sided IJ in place with some blood around the insertion site no palpable hematoma present HEART - RRR, no MRG appreciated skin graft well healed LUNGS - Rhonchourous throughout ABDOMEN - soft, nontender, nondistended EXTREMITIES - warm and [**Last Name (un) **] perfused. SKIN - well healed skin flap on the chest and incision scar R back in midback NEURO - awake, A&Ox3, no astreixis Pertinent Results: ADMISSION LABS [**2200-9-8**] 10:00PM BLOOD WBC-20.6*# RBC-3.81* Hgb-11.6* Hct-33.8* MCV-89# MCH-30.5 MCHC-34.4 RDW-16.6* Plt Ct-309 [**2200-9-9**] 02:18AM BLOOD WBC-14.0* RBC-4.00* Hgb-12.1* Hct-34.3* MCV-86 MCH-30.2 MCHC-35.2* RDW-15.7* Plt Ct-143*# [**2200-9-9**] 07:00AM BLOOD WBC-15.9* RBC-3.70* Hgb-11.2* Hct-31.9* MCV-86 MCH-30.2 MCHC-35.0 RDW-15.6* Plt Ct-172 [**2200-9-8**] 10:00PM BLOOD PT-11.7 PTT-34.5 INR(PT)-1.1 [**2200-9-8**] 10:00PM BLOOD Glucose-203* UreaN-29* Creat-1.3* Na-138 K-4.0 Cl-99 HCO3-35* AnGap-8 [**2200-9-8**] 10:00PM BLOOD ALT-20 AST-27 LD(LDH)-97 CK(CPK)-14* Amylase-183* [**2200-9-8**] 10:00PM BLOOD CK-MB-1 cTropnT-<0.01 [**2200-9-9**] 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2200-9-8**] 10:00PM BLOOD Albumin-2.6* Calcium-7.3* Phos-2.8 Mg-2.2 [**2200-9-8**] 10:00PM BLOOD TSH-0.16* [**2200-9-8**] 10:12PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-102 pCO2-49* pH-7.45 calTCO2-35* Base XS-8 Intubat-NOT INTUBA [**2200-9-8**] 10:12PM BLOOD Glucose-191* Lactate-2.5* K-4.0 [**2200-9-8**] 10:12PM BLOOD freeCa-0.88* Discharge labs: [**2200-9-14**] 02:30AM BLOOD WBC-5.9 RBC-3.44* Hgb-10.4* Hct-31.3* MCV-91 MCH-30.2 MCHC-33.1 RDW-15.9* Plt Ct-205 [**2200-9-14**] 02:30AM BLOOD Glucose-74 UreaN-9 Creat-1.0 Na-139 K-4.5 Cl-105 HCO3-28 AnGap-11 [**2200-9-14**] 02:30AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6 [**2200-9-9**] CXR: FINDINGS: Endotracheal tube tip lies approximately 4.5 cm above the carina. Nasogastric tube extends to the stomach, though the side hole is above the esophagogastric junction. There is some patchy opacification at the left base. Although this could merely be atelectasis, in the appropriate clinical setting, a developing pneumonia would have to be considered [**2200-9-9**] EGD Esophagus: Normal esophagus. Stomach: Contents: Coffee ground heme was seen in the stomach without evidence of active bleeding. Duodenum: Excavated Lesions A large cratered ulcer was found in the duodenal bulb with large amount of adherent clot. A fistula was found in the first part of the duodenum on the inferior edge and to the left, most likely representing communication with the gallbladder. This tract was in close proximity to the large cratered ulcer with overhanging edges. Brief Hospital Course: 46 yo M w/ HCV/cirrhosis, h/o duodenal bulb ulcer (dx [**3-/2200**]) and cholecystal duodenal fistula (dx [**2200-8-21**]) who presents from OSH with active upper GI bleed. #GI Bleed/Acute blood loss anemia due to duodenal ulcer - Pt with coffee ground emesis for 2 days PTA to OSH with decreasing HCT. Hemodynamic instability with acute blood loss reflected in tachycardia to 150s on admission to [**Hospital1 18**] with pressures in the low 80s systolic. Pt has hx of duodenal bulb ulcer that was not actively bleeding on OSH EGD, but this was deemed to be the most likely active source of bleeding. Transplant surgery, GI and IR were consulted for assistance with management of his acute GI bleed. He was transfused 3 units pRBCs at OSH and 4 units pRBCs here with 2 units FFP here on HD#1. CVL access was established in order to assist with resuscitation. Patient was intubated on HD#1 to allow for GI to perform EGD, which showed a duodenal bulb ulcer with adherent clot. GI felt that no further intervention was warranted at that time to dislodge the clot because if it were to dislodge, would likely be too big to control endoscopically. IR felt that given this bleed was venous in nature, they did not have a role in its management, and would be unable to embolize it. Given there were no varices seen on EGD, it was decided not to initiate octreotide in this patient. He was started on a pantoprazole drip, which was continued until HD#3 and then converted to IV twice daily. His sedation was weaned and he was successfully extubated on HD#2 without incident. On HD#3 the patient did experience a HCt drop from 29.5 to 25.5 without any incidence of melena or BRBPR. He was transfused 1 unit of pRBCs at that time with adequate response of his Hct. His hemodynamics were stablilized and he was called out to the floor on HD#3 and was stable for multiple days. #Choleduodenal fistula - Pt has recent dx of choleduodenal fistula ([**2200-8-21**]), which is not likely contributing to his bleed, but may need acute management while in the hospital. Possibility of chronic cholecystitis with erosion of gallstones into the lumen of the duodenum. Transplant surgery felt that this issue was non-contributory in his acute bleed, and recommended management as per GI and IR. #HCV - Diagnosed 3 years ago with cirrhosis documented on OSH CT abd/pelvis. Per history, no biopsy, no treatment. He had no evidence of decompensated liver disease during this admission. He refused his lactulose and had no asterixis. #Diabetes, type 2 controlled - Patient's FS were monitored and he was maintained on ISS with adequate glycemic control. #HTN - The patient was intermittently hypotensive in the setting of his resuscitation, and as such his anti-HTN medications were held. #Non-healing right chest wound s/p right latissimus flap on [**2200-3-17**] complicated by hematoma - Patient is on methadone therapy for chronic pain due to this issue, which was re-started once he was extubated. QTc was monitored daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methadone Dose is Unknown PO TID 2. Clonazepam 1 mg PO TID:PRN anxiety 3. Amoxicillin-Clavulanic Acid 875 mg PO Q12H 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN whezing 6. Vitamin D 5000 UNIT PO DAILY 7. CloniDINE 0.2 mg PO BID Discharge Medications: 1. Thiamine 100 mg PO DAILY RX *thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL 15 ml by mouth three times a day Disp #*1 Bottle Refills:*0 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN whezing 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Clonazepam 1 mg PO TID:PRN anxiety 8. Methadone 0 mg PO TID 9. Vitamin D 5000 UNIT PO DAILY 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer bleed 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 while you were here at [**Hospital1 18**]. You were transferred to our hosptial from another hospital for concern about your GI bleeding. You were seen by the GI specilists who looked with a camera within your stomach and small intestine and saw an area in the intestine which had likely been the source of the bleed. You required multiple blood transfusions for this serious bleed. You were monitored in the hospital as you started to eat again and had no further episodes of bleeding. You are now safe to go home. Please follow up with Dr. [**Last Name (STitle) 36818**] on Monday, [**2200-9-22**] (see details below) Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Address: [**Doctor Last Name 76758**], [**Hospital1 **],[**Numeric Identifier 24406**] Phone: [**Telephone/Fax (1) 47660**] Appointment: Monday [**2200-9-22**] 10:30am

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icd9cm

[ [ [] ] ]

[ "45.13", "96.71" ]

icd9pcs

[ [ [] ] ]

12041, 12047

7876, 10890

302, 323

12111, 12111

5623, 6675

12979, 13205

4658, 4676

11271, 12018

12068, 12090

10916, 11248

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4691, 5604

254, 264

351, 3540

12126, 12237

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3821, 4642

18,217

158,646

3847+3848

Discharge summary

report+report

Admission Date: [**2117-1-28**] Discharge Date: [**2117-2-26**] Date of Birth: [**2074-5-16**] Sex: F Service: SURGERY Allergies: Aspirin / Opioid Analgesics / Penicillins Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD-received slight mismatched kidney transplant Major Surgical or Invasive Procedure: [**2118-1-29**] ESRD s/p CKT History of Present Illness: see previous Past Medical History: 1. P-ANCA positive vasculitis. 2. End-stage renal disease secondary to ANCA-positive glomerulonephritis on HD 3. Status post uncomplicated parathyroidectomy on [**2113-8-14**] for hypercalcemia at [**Hospital6 1708**] 4. Pericarditis. 5. Asthma. 6. Perirectal abscess. 7. Gastrointestinal bleeding ulcer. 8. Resolved atrial fibrillation diagnosed six years ago. 9. Chronic renal failure, on hemodialysis for more then 15 years. 10. s/p catavaric renal transplant with one episode of humoral rejection treated with IV Ig and plasmaphoresis Social History: The patient is unmarried with no children. She has no immediate family in [**Location (un) 86**]. Her mother lives in [**Name (NI) 5170**]. She works at the train station as a collector. She has no IVDA, no drug use, and no significant alcohol abuse. She has been abstinent of smoking for greater than 10 years. Family History: The patient denies family history of diabetes, coronary artery disease, hypertension, cancer, or kidney disease. Physical Exam: see previous note Brief Hospital Course: Continuation of stat dictation on [**2117-5-13**], Urine and blood cultures were subsequently negative. A nuclear scan was done revealing "Prompt activity on blood flow images with poor function consistent with post transplant ATN (acute tubular necrosis). No evidence of urinary leak." A CD 4 stain was positive on [**2117-2-6**]. Flow cross match was done. A cxr showed mild chf and lasix was given with fair results. Renal function slowly improved. She develope a temperature of 102 o [**2-10**]. She was started on Vanco and Zosyn for broad spectrum coverage. Blood and urine cultures were repeated and subsequently negative. She continued to receive intermittent transfusions for persistent anemia. Epogen was started. Prograf was titrated to less than 10. A repeat u/s of the transplant was done for evaluation of flank pain. This revealed Normal Doppler appearance of the transplanted kidney. No interval change in the perinephric hematoma. There was no evidence of hydronephrosis. Pain was managed with dilaudid. On [**2117-2-16**] hct dropped from 28 to 18. A stat u/s revealed slight increase in the RI. No hydronephrosis and echogenic heterogeneous collection lateral to the transplanted kidney consistent with the hematoma measuring 10 x 9.8 x 9.6 cm. She returned to the SICU for management and received transfusions of PRBC with resulting hct of 30. A renal u/s was repeated showing stable appearance of heterogeneously echoic collection lateral to the transplant kidney consistent with a hematoma. And slight interval decrease in resistive indices with new slight tardus parvus waveforms. Due to worsening renal function and fluid overload, she developed fluid filled blisters along lower extremities. Lasix was increased and an UF session for fluid overload was done. Urine output gradually increased with continuation of plasmaphereis. Repeat duplex of transplant demonstrated no evidence of compression or obstruction of the renal transplant. Similar resistive indices among the intralobar arteries measuring 0.71 to 0.73; again noted, however, are tardus parvus waveforms, which were first seen on the most recent study. Norvasc was started for htn. Diarrhea ([**7-7**] bm/day) was negative for c.diff x4. She experienced sinus tachycardia related to volume overload. Hct was stable. Lasix was adjusted. A VQ scan was done. Impression was intermediate likelihood ratio for pulmonary embolism. On bilat LENIs there was no evidence of acute deep vein thrombosis. Suggestion of perhaps prior thrombosis at the right common femoral vein was noted.Edema was noted in the subcutaneous soft tissues. Urine output increased to 2.5L/day with a creatinine of 2.4. The crossmatch from [**2117-2-22**] was T 0.5 (weak pos 3.5-5.0)and B 2.4 (weak pos >10). She was discharged home on [**2117-2-26**] on hosp day 27 with stable vital signs, tolerating regular diet with ~ 2 stools per day. Pain was controlled and wound vac was to be changed at home by VNA. She was ambulatory and safe to go home per PT assessment. She was sent home on linezolid for vre in urine by culture from [**2117-2-22**]. Medications on Admission: refer to previous note Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: [**2-1**] Tablets 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. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 13 days: D/c on [**2117-3-7**] after last dose. Disp:*26 Tablet(s)* Refills:*0* 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO Q6H (every 6 hours). 11. Calcitriol 0.25 mcg Capsule Sig: [**2-1**] Capsules PO DAILY (Daily). 12. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days: d/c after the last dose on [**2117-3-10**]. Disp:*28 Tablet(s)* Refills:*0* 16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 19. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 20. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 42F sp Renal Tpx for ESRD. h/o highly sensitized 87% c/b Humoral rejection requiring multiple plasmophoresis PMH: CRT in [**2109**], failed in 99, HD since [**2111**], s/p infected left AV Graft, patent R AV graft. Bronchitis, HTN PSH: prev Renal Tpx '[**09**]->lasted for 1.5 yrs, Parathyroidectomy, T&A Discharge Condition: good Discharge Instructions: Call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, shortness of breath, decreased urine output, weight gain of 3 pounds in a day, bleeding/pus or increased drainage from abdominal wound. Please obtain labs every Monday and Thursday and have lab results faxed immediately to the transplant surgery-obtain labs at [**Hospital Ward Name **] basement Followup Instructions: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-3-5**] 9:30 Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2117-3-5**] 11:30 Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2117-3-5**] 1:20 Completed by:[**2117-5-13**] Admission Date: [**2117-1-28**] Discharge Date: [**2117-2-26**] Date of Birth: Sex: Service: CHIEF COMPLAINT: Admitted for potential kidney transplant. HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old female with end-stage renal disease secondary to P-ANCA glomerulonephritis currently getting hemodialysis on Monday, Wednesday, and Friday via right upper extremity AV fistula. She had a previous kidney transplant in [**2109**] which failed approximately 1.5 years posttransplant. She does not void and has high sensitization. PAST MEDICAL HISTORY: Vasculitis secondary to P-ANCA, status post partial parathyroidectomy in [**2103**] at [**Hospital6 **], history of pericarditis, perirectal abscess, GI bleed, Afib resolved, chronic renal failure x15 years, AV fistula graft. ALLERGIES: PCN and amoxicillin, codeine. MEDICATIONS AT HOME: Calcium 600 p.o. q.i.d., Nephrocaps 1 daily, calcitriol 0.25 mg p.o. daily, Tylenol p.r.n., and Benadryl p.r.n. BRIEF HOSPITAL COURSE: Patient was preop'd and received plasmapheresis. Pretransplant for high sensitization. Nephrology was consulted and followed throughout this hospital course. She was taken to the OR on [**2118-1-29**]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. She received a cadaveric renal transplant. She received induction immunosuppression per protocol. The kidney perfused well and made urine immediately. Posttransplant, she received IV IG, ATG, Solu-Medrol, and CellCept per protocol. She received plasmapheresis and rituximab. Plan was to complete 5 plasmapheresis treatments posttransplant. She developed hematuria. A renal ultrasound demonstrated no hydronephrosis, fluid collections, or stones. Initially, urine output was low averaging about 30 cc per hour. Urine output slowly increased to approximately 1,200 cc per day. She continued to receive plasmapheresis. Prograf was started at 7 mg p.o. b.i.d. Creatinine decreased to 5.7. Creatinine continued to trend down to 3.7. She continued on plasmapheresis, receiving IV calcium gluconate for hypocalcemia. Her hematocrit trended down to 22. She was transfused. On postop day 7, renal function stabilized with a creatinine of 3.7. She underwent a renal biopsy without difficulty under ultrasound guidance. Biopsy report demonstrated acute antibody-mediated humeral rejection type I. A repeat duplex demonstrated slight increase in resistive indices. No hydronephrosis was noted. The heterogeneous collection lateral to the transplanted kidney was consistent with hematoma measuring 10 x 9.8 x 9.6 cm. She continued on plasmapheresis. On postop day 9, she developed pain over the incision. A firm and distended area was noted along the incision. She started to have some bleeding from the incision. A Foley was inserted and a hematocrit was sent off STAT. This hematocrit was 22.1. Her incision was opened at the bedside for approximately 75 cc of clot. A wound VAC was placed, and she was again, transfused and started on Epogen. On [**2117-2-7**], a CT of the abdomen and pelvis was done. This demonstrated a large hematoma in the subcutaneous tissues underneath the right flank incision. No evidence of intraabdominal hematoma was noted. No evidence of hydronephrosis or hematoma compressing the kidney transplant was noted. On [**2117-2-8**], she was transferred to the SICU for closer monitoring for decreased hematocrit. She was transfused and continued on plasmapheresis. Acute renal failure was felt to be secondary to pyelonephritis. She was started on Levaquin. A urine culture demonstrated ... INCOMPLETE REPORT. DICTATOR WAS CUT OFF. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2117-5-13**] 16:34:20 T: [**2117-5-13**] 17:03:08 Job#: [**Job Number 17272**]

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icd9cm

[ [ [] ] ]

[ "93.56", "00.93", "86.59", "55.23", "99.07", "86.04", "55.69", "39.95", "99.76", "99.04" ]

icd9pcs

[ [ [] ] ]

6643, 6701

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351, 382

7050, 7057

7491, 8056

1332, 1446

4688, 6620

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4641, 4665

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1461, 1480

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1002, 1316

29,620

197,690

34151

Discharge summary

report

Admission Date: [**2199-4-26**] Discharge Date: [**2199-5-11**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: upper GI bleed, NSTEMI Major Surgical or Invasive Procedure: [**2199-4-26**] EGD [**2199-4-28**] open L femoral & iliac embolectomy [**2199-4-30**] small bowel enteroscopy [**2199-5-3**] ultrasound-guided imaging for [**Month/Day/Year 1106**] access, contralateral second order arteriography from a brachial approach, abdominal aortogram with pelvis followed by a left iliac stent [**2199-5-6**] colonoscopy History of Present Illness: [**Age over 90 **]M first noticed dark black stools associated with progressive SOB and fatigue 3 months ago. On [**4-6**], he presented to [**Hospital1 882**] and was noted to be newly anemic (Hct 26, reported baseline 37). He was transfused 4 units with stabilization of Hct at 30. EGD demonstrated a non-bleeding duodenal ulcer with overlying clot; no biopsy or H. pylori stain was performed. Given no active bleeding, he was managed with daily PPI. Both aspirin and coumadin were discontinued. His beta-blocker was also discontinued due to asymptomatic bradycardia (HR 50s). He was discharged home on [**2199-4-9**]. He felt well initially following discharge, but continued to have dark black stools and developed slowly progressive fatigue, malaise, and dizziness. Three prior to admission, he had dyspnea and substernal chest pressure associated with walking across the room and relieved by rest. Denies nausea, vomiting, or diaphoresis. He presented to [**Hospital1 882**], where he was found to have Hct 24, CK 119, troponin 25. ECG was unchanged from prior. He was transfused 1U PRBC and transferred to [**Hospital1 18**] for further management. On arrival to [**Hospital1 18**], he was afebrile and hemodynamically stable. Stool was guiaic positive with Hct 26. NG lavage was negative. He was transfused 1U PRBC. Troponin was 1.23 and CK 107 with MB 11 (MB index 10). ECG demonstrated afib, q V1-2, unchanged from prior. He was admitted to the MICU. Past Medical History: HTN, hypercholesterolemia, atrial fibrillation, h/o bleeding duodenal ulcer, CAD, colon ca s/p colectomy (20 years ago), h/o pleural effusion, s/p back surgery Social History: Retired [**Location (un) 86**] policeman. Daughter lives upstairs. Non-smoker. Rare EtOH (1-2 drinks/week). Family History: NC Physical Exam: On admission: 97.2 75 140/65 18 98%RA Gen: well nourished, NAD HEENT: NC, PERRL Lymph: cervical WNL CVS: irregular rhythm, distant S2 Pulm: CTA b/l, symmetric expansion Abd: soft, NT, ND, +BS, formed black stool prior to exam Ext: no cyanosis/clubbing, no muscle wasting Skin: warm Neuro: attentive, follows simple commands, responds to verbal stimuli, oriented On discharge: ____________________________ Gen: NAD, A&O CVS: RRR Pulm: CTA b/l Abd: soft, NT, ND, +BS Ext: no cyanosis/clubbing, 2+ edema b/l LE, L DP & PT palpable, R DP & PT [**Name (NI) **], b/l feet warm, incisions healing well c/d/i Pertinent Results: On admission: [**2199-4-25**] 09:59PM BLOOD WBC-6.3 RBC-2.83* Hgb-8.6* Hct-26.0* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.6* Plt Ct-304 [**2199-4-25**] 09:59PM BLOOD Neuts-76.5* Lymphs-16.6* Monos-5.2 Eos-1.3 Baso-0.4 [**2199-4-25**] 09:59PM BLOOD PT-12.6 PTT-23.1 INR(PT)-1.1 [**2199-4-25**] 09:59PM BLOOD Glucose-108* UreaN-51* Creat-1.6* Na-141 K-4.8 Cl-107 HCO3-20* AnGap-19 [**2199-4-25**] 09:59PM BLOOD ALT-32 AST-67* LD(LDH)-442* CK(CPK)-107 AlkPhos-83 TotBili-0.6 [**2199-4-25**] 09:59PM BLOOD Lipase-39 [**2199-4-25**] 09:59PM BLOOD CK-MB-11* MB Indx-10.3* [**2199-4-25**] 09:59PM BLOOD TotProt-6.5 Albumin-4.1 Globuln-2.4 Calcium-9.2 Troponin [**2199-4-25**] 09:59PM BLOOD cTropnT-1.23* [**2199-4-26**] 05:21AM BLOOD CK-MB-8 cTropnT-1.23* [**2199-4-28**] 01:43PM BLOOD CK-MB-6 cTropnT-1.26* [**2199-4-28**] 07:20PM BLOOD CK-MB-13* MB Indx-3.9 cTropnT-1.05* [**2199-4-29**] 04:45AM BLOOD CK-MB-8 cTropnT-1.08* [**2199-4-29**] 09:50PM BLOOD CK-MB-6 cTropnT-0.85* [**2199-4-30**] 05:15AM BLOOD CK-MB-5 cTropnT-0.87* [**2199-5-1**] 04:26AM BLOOD CK-MB-3 cTropnT-0.56* CK [**2199-4-28**] 01:43PM BLOOD CK(CPK)-255* [**2199-4-28**] 07:20PM BLOOD CK(CPK)-331* [**2199-4-29**] 04:45AM BLOOD CK(CPK)-950* [**2199-4-29**] 09:50PM BLOOD CK(CPK)-514* [**2199-4-30**] 05:15AM BLOOD CK(CPK)-362* [**2199-5-1**] 04:26AM BLOOD CK(CPK)-129 [**2199-4-26**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2199-4-29**]): NEGATIVE BY EIA. [**2199-4-26**] ECHOCARDIOGRAM The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). 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 aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild global hypokinesis and boderline low cardiac index. Moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Moderate to severe pulmonary hypertension. [**2199-4-28**] URINE CULTURE (Final [**2199-4-30**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2199-5-1**] CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS CHEST: There is a moderate-sized right and a small left pleural effusion, with associated compressive atelectasis. No focal airspace opacification or suspicious nodule is seen. There are non-pathologically enlarged mediastinal lymph nodes. Heart is at the upper limits of normal in size. ABDOMEN: Liver, spleen, pancreas, and adrenal glands are unremarkable. Gallbladder is present. There is no biliary dilatation. No lymphadenopathy or abnormal mass. Right kidney contains numerous cysts and several subcentimeter hypodensities which are too small to completely characterize but likely cysts. There is no hydronephrosis or nephrolithiasis. The left kidney has some surrounding nonspecific perinephric stranding, and an ill-defined area of decreased attenuation at the lower pole, which may represent a small infarct or focal pyelonephritis. The remainder of the cortex is thin but enhances normally. There is no hydronephrosis or delayed excretion when compared to the contralateral kidney. No surrounding nodes. PELVIS: The bowel loops are unremarkable. There are coarse calcifications within the prostate. Foley catheter balloon is within a nondistended bladder. There is diffuse bony demineralization and degenerative changes of the thoracolumbar spine with slight anterolisthesis of L2 on 3 and slight retrolisthesis of L4 on 5, as well as L5 on S1. There is near complete disc space obliteration at L4-5 and L5-S1. SI joints are fused superiorly. Notable degenerative changes of the glenohumeral joint with small loose body seen in the right glenohumeral joint. CT ANGIOGRAPHY: Thoracic aorta maintains normal course and caliber with conventional arterial arch anatomy. There is a small amount of calcified atherosclerotic plaque at the arch and within the descending thoracic aorta. No large vegetations are seen on the aortic valve, although echocardiography would be much more sensitive modality. Great vessels are widely patent. Below the diaphragm, there is both soft and hard atherosclerotic plaques with a small penetrating aortic ulcer posteriorly at or just beyond the level of the celiac axis. Celiac axis and SMA are patent. Just beyond the SMA origin, there is a focal narrowing due to large area of mural thrombus. Beyond this mural thrombus, a replaced right hepatic artery originates. Renal arteries maintain patency. [**Female First Name (un) 899**] is contrast opacified. There is no aneurysmal dilatation of the abdominal aorta. At the aortic bifurcation, there is a moderate amount of mural thrombus with a focal linear filling defect in the left common iliac (3, 173). Distal to this, there is significant narrowing of that vessel with large amount of thrombus. The ipsilateral hypogastric artery is thrombosed, although the distal hypogastric does opacify, likely through collateral vessels. The left external iliac does opacify thoroughly, as does the femoral and proximal SFA/profunda. There are post-procedural changes around the left SFA with edema and fluid/gas within the subcutaneous soft tissues. The right internal and external iliac arteries are patent, as are the right common, profunda, and superficial femoral arteries. There is mild atherosclerotic plaque involving these vessels. There is a small right hydrocele. IMPRESSION: 1. No aneurysmal dilatation seen as a source for thrombus. There is dissection and mural thrombus involving the proximal left common iliac artery with significant narrowing, as well as thrombosis of that ipsilateral internal iliac artery. Findings discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. This may be the source of recently removed thrombus in the left iliac artery. 2. Marked narrowing of the SMA beyond the origin due to soft plaque, good opacification of the distal vessels, however. 3. Ill-defined area of decreased enhancement at the lower pole of the left kidney which is suspicious for focal pyelonephritis or infarct. 4. Bilateral pleural effusions, right greater than left. ECHOCARDIOGRAM [**2199-5-2**] There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Compared with the prior study (images reviewed) of [**2199-4-26**], left ventricular function has improved. No LV thrombus identified. VENOUS DUP EXT UNI (MAP/DVT) LEFT [**2199-5-6**] 10:51 AM FINDINGS: Duplex evaluation was performed in the left lower extremity veins as well as the left groin arterial vessels. In the left groin, the common femoral artery and vein as well as the superficial femoral artery and vein were visualized noted to be widely patent with triphasic arterial waveforms. No evidence of pseudoaneurysm or arteriovenous fistula. Analysis of the venous structures reveals normal compression and augmentation of the common femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins. There is normal phasicity of the common femoral veins bilaterally. IMPRESSION: No evidence of left lower extremity deep vein thrombosis. No evidence of left groin pseudoaneurysm or arteriovenous fistula. On discharge: [**2199-5-8**] 06:35AM BLOOD WBC-4.9 RBC-3.00* Hgb-9.1* Hct-26.6* MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-252 [**2199-5-7**] 05:35AM BLOOD Glucose-404* UreaN-13 Creat-1.2 Na-136 K-4.3 Cl-106 HCO3-23 AnGap-11 [**2199-5-7**] 05:35AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7 Brief Hospital Course: Patient was admitted to [**Hospital 30166**] transferred to the [**Hospital Ward Name 516**] Hospitalist Service on HD 1, transferred to [**Hospital Ward Name **] Surgery on HD 3, and discharged home with services on HD 16. CVS: Cardiology was consulted. His NSTEMI was attributed to demand ischemia [**2-9**] anemia. Recommendations were to transfuse to Hct >30, trend cardiac enzymes, and obtain an echo to evaluate wall motion. Anticoagulation was held given his GI bleed. Beta blocker and ACE inhibitor were held in the setting of recent hypotension. Statin was continued. On HD 1, his echo demonstrated mild symmetric LVH with mild global hypokinesis (LVEF 40-45%), borderline low CI (2-2.5), moderate MR, moderate to severe TR, and moderate to severe pulm HTN. Cardiac enzymes trended down. He was placed on heparin gtt on HD 3 given acute LLE embolus, which was continued postoperatively. Metoprolol and ASA were started as recommended by Cardiology. Echo was repeated on HD 7, and demonstrated improved LVEF (>55%), normal LV size & wall motion, and no masses/thrombi. GI: Intravenous PPI was started on a [**Hospital1 **] schedule. He underwent upper endoscopy on HD 1, which was normal to the 3rd portion of the duodenum. H. pylori was sent, which was negative. On HD 5, he underwent small bowel enteroscopy, which was normal to the jejunum. Colonoscopy performed on POD 8/PPD 3 demonstrated several benign appearing sessile polyps. These were not biopsied in the setting of GIB. No source of bleeding was identified. On POD 9/PPD 4, patient underwent capsule endoscopy. It had not been read by the time of discharge. The patient's PCP will follow up on the results and determine whether or not it is appropriate to restart Coumadin. Renal: His Cr was 1.6; as his baseline was unknown, it was unclear whether this was acute or chronic in nature. Lasix and lisinopril were held on admission. Cr improved with fluid resuscitation. On HD 3, he was started on Cipro for E.coli UTI. Lisinopril was restarted on HD 4 as per postoperative Cardiology consult. Cr was 1.2 on discharge. [**Hospital1 **]: On HD 3, patient developed L leg pain. [**Hospital1 **] Surgery was consulted. His foot was noted to be cool with decreased cap refill, and no [**Hospital1 **] signals below the popliteal. Heparin gtt was started. He went emergently to the OR for L femoral and iliac embolectomy. Postoperatively, he was admitted to the VICU. Heparin gtt was restarted, held for significant oozing from the L groin overnight on POD 0, and restarted on POD 1. On POD 3, his Foley was d/c'd. He was started on Keflex for L groin cellulitis. He underwent CTA demonstrating dissection and mural thrombus in the proximal L CIA and IIA. On POD 5, he underwent angiography with placement of L iliac stent. Postoperatively, heparin gtt was not restarted [**2-9**] to bleeding from the L groin incision. It was restarted on POD 7/PPD 2 with goal PTT 40-60. On POD 8/PPD 3, patient was noted to have significant LLE edema. Ultrasound was negative for DVT and pseudoaneurysm. It was felt to be [**2-9**] reperfusion. ACE bandages were applied. Heparin gtt was held for colonoscopy and restarted afterwards. He remained on heparin gtt until discharge, when he was started on Lovenox. He will follow up with his PCP regarding Coumadin after his capsule endoscopy results are finalized. At the time of discharge, patient was afebrile with stable vital signs, had palpable L pedal pulses, was tolerating regular diet, and was cleared by PT for d/c home with home PT & RN services (which he had prior to his hospital stay). Medications on Admission: Lasix 20', lisinorpil 15', omeprazole 20', Zocor 40', Coumadin 1' (on hold since discharge from [**Hospital1 882**] [**2199-4-9**]) Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: Primary: PVD, acute ischemia of L lower extremity, GI bleed . Secondary: CAD s/p NSTEMI, Afib, h/o bleeding duodenal ulcer, hypercholesterolemia, HTN, colon ca s/p colectomy/ostomy/reversal, s/p back surgery Discharge Condition: Afebrile, vital signs stable, L pedal pulses palpable, tolerating regular diet, ambulating, pain well controlled on PO medication. Discharge Instructions: Division of [**Location (un) **] and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-10**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-12**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call [**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-30**] 10:45 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-30**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-30**] 11:30 Completed by:[**2199-5-20**]

[ "V58.61", "416.0", "401.9", "599.0", "272.0", "532.30", "443.9", "578.9", "998.2", "427.31", "443.22", "V12.71", "424.0", "998.11", "E870.0", "424.2", "410.71", "285.1", "211.3", "041.4", "V45.72", "414.01", "V10.05", "444.22" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.47", "88.77", "45.13", "45.23", "39.31", "39.79", "38.08" ]

icd9pcs

[ [ [] ] ]

15862, 15917

12036, 15680

284, 632

16169, 16302

3111, 3111

18938, 19330

2466, 2470

15938, 16148

15706, 15839

16326, 18328

18354, 18915

2485, 2485

11744, 12013

222, 246

660, 2139

3125, 11730

2161, 2322

2338, 2450

65,535

175,280

1390

Discharge summary

report

Admission Date: [**2204-1-20**] Discharge Date: [**2204-1-25**] Date of Birth: [**2126-7-31**] Sex: F Service: MEDICINE Allergies: Ticlid / Bactrim / Dilantin Kapseal Attending:[**First Name3 (LF) 613**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: - None History of Present Illness: Ms. [**Known lastname 8350**] is a 77 yo female w/ h/o DMII, CHF, CAD, and s/p AVR who presented to the ED for a question of syncopal epsidose and was transferred to the MICU for managment of hypotension. The patient has dementia and is a poor historian. She got up to go to the bathroom today, was sitting on the toilet and was reported to have a wittnessed syncopal episode. She declines ever passing out, but does note that she was weak and unable to move for a period of time when she was on the toilet. It is unclear who witnessed the episode. The patient was evaluated by EMS; her sbp was 60 and glucose was 168. No upper respiratory symptoms. No sick contacts (other than living in nursing home). No f/c/n/v/cp/sob. No travel. . In the ED, initial VS were: [**Age over 90 **] F, 94/43, hr 78, rr 22, saturation 90% 2L NC. She was treated with levofloxacin 750mg iv for questionable LLL infiltrate and with metronidazole 500mg iv once. In the ED her lowest blood pressure was 74/47. She recieved 4L IVF. Pressures increased to systolic 100 range. Her lactate decreased from 4.8 to 4.1 with 2L IVF. She also began to have profuse watery diarrhea mixed with loose stools. It was guaiac negative. A CTA of the abdomen and pelvis was performed to rule out AAA and other vascular . On arrival to the MICU, she continued to have diarrhea. She complained of lower abdominal cramping with the abdominal pain. . 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. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: squamous cell carcinoma chf DMII h/o squamous cell carcinoma HTN CAD status post PCI in [**2189**] restrictive lung disease Social History: Lives in a nursing home. Family History: NC Physical Exam: Vitals: T: BP: P: R: 18 O2: 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: VSS GEN: Obese female resting in bed in NAD. Pleasant. HEENT: NCAT. MMM. COR: Holosystolic blowing murmur heard throughout the precordium. PULM: CTAB, no c/w/r. [**Last Name (un) **]: Obese. +NABS in 4Q. Soft, NTND. EXT: WWP, trace to 1+ LE edema. Pertinent Results: Admission Labs [**2204-1-21**] 12:00AM GLUCOSE-197* UREA N-38* CREAT-1.3* SODIUM-139 POTASSIUM-6.2* CHLORIDE-106 TOTAL CO2-21* ANION GAP-18 [**2204-1-21**] 12:00AM CK(CPK)-99 [**2204-1-21**] 12:00AM CK-MB-4 cTropnT-<0.01 [**2204-1-21**] 12:00AM CALCIUM-7.4* PHOSPHATE-4.3 MAGNESIUM-1.8 [**2204-1-20**] 04:59PM URINE HOURS-RANDOM [**2204-1-20**] 04:59PM URINE UHOLD-HOLD [**2204-1-20**] 04:59PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2204-1-20**] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2204-1-20**] 04:59PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-<1 [**2204-1-20**] 04:59PM URINE GRANULAR-1* HYALINE-12* [**2204-1-20**] 04:59PM URINE MUCOUS-RARE [**2204-1-20**] 04:03PM LACTATE-4.1* [**2204-1-20**] 02:25PM COMMENTS-GREEN TOP [**2204-1-20**] 02:25PM LACTATE-4.8* [**2204-1-20**] 02:15PM GLUCOSE-292* UREA N-35* CREAT-1.4* SODIUM-139 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* [**2204-1-20**] 02:15PM estGFR-Using this [**2204-1-20**] 02:15PM ALT(SGPT)-16 AST(SGOT)-26 CK(CPK)-110 ALK PHOS-54 TOT BILI-0.3 [**2204-1-20**] 02:15PM LIPASE-68* [**2204-1-20**] 02:15PM CK-MB-3 cTropnT-<0.01 [**2204-1-20**] 02:15PM WBC-10.7 RBC-4.85# HGB-14.2# HCT-44.2 MCV-91 MCH-29.3 MCHC-32.1 RDW-13.4 [**2204-1-20**] 02:15PM WBC-10.7 RBC-4.85# HGB-14.2# HCT-44.2 MCV-91 MCH-29.3 MCHC-32.1 RDW-13.4 [**2204-1-20**] 02:15PM NEUTS-56.6 LYMPHS-37.1 MONOS-2.4 EOS-3.1 BASOS-0.9 [**2204-1-20**] 02:15PM PT-10.5 PTT-31.5 INR(PT)-1.0 [**2204-1-20**] 02:15PM PT-10.5 PTT-31.5 INR(PT)-1.0 DISChARGE LABS: [**2204-1-25**] 07:30AM BLOOD WBC-13.6* RBC-3.75* Hgb-10.9* Hct-33.7* MCV-90 MCH-29.0 MCHC-32.3 RDW-13.4 Plt Ct-266 [**2204-1-24**] 06:00AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 TTE: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis (expected upper limit is <23 mmHg). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a mild mitral inflow gradient due to mitral annular calcification. Mild (1+) mitral regurgitation is seen (but may be underestimated). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2202-6-15**], findings are similar. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: 77 year old female with h/o CAD, CHF, DMII, dementia admitted to the MICU for management of hypotension and lower GI bleed. ACUTE DIAGNOSES: # Hypotension & Syncope: Very likely secondary to diarrhea of unknown duration in the setting on continued administration volume depleting medications. Lactate normalized with fluids and 1 unit of prbc. Hypotension resolved with fluids. # Diarrhea: Thought to be viral gastroenteritis. IV cipro & flagyl were initially started given mild leukocytosis & concern for possible diverticulitis. Her diarrhea became bloody during hospitalization. GI was consulted & recommended stool cx which were sent (she was c.diff negative), ischemic colitis was thought to be the most likely culprit. She received 1 unit of pRBCs without further recurrence of symptoms. CT abdomen was negative for diverticulitis but was positive for diverticulosis and significant atherosclerotic disease in the abdomen. Antiobiotics were discontinued. # Lower GI Bleed: Thought to represent ischemic colitis in setting of significant atherosclerotic disease in the abdomen & hypotension on admission. Pt received 1 unit of packed RBCs in the ICU. Had several small episodes of old blood on the floor, but normal bowel movements by the time of discharge. # Syncope: Pt syncopal event was poorly relayed in history. Her hypovolemia, in combination with her preload dependence due to aortic stenosis, likely caused her to zyncopize. # Aortic Stenosis: A repeat echo was obtained to determine if there was interval worsening in the degree of aortic stenosis. It was largely unchanged from prior. # Acute Kidney Injury: Most likely prerenal given hypotension on admission. Resolved with fluids. # Aortic Stenosis: Pt with known history of aortic stenosis s/p prosthetic valve placement. A repeat TTE was obtained that showed similar findings CHRONIC DIAGNOSES: # Chronic CHF: Furosemide was held given diarrhea, hyponatremia. The plan will be to restart lasix as outpatient after evidence of weight gain weight gain (2 pounds) from admission weight at [**Location (un) 583**] House. Restarting amlodipine and lisinopril as above. Discharged on atenolol. # Dementia: Monitor clinically # DMII: Glipizide held in house but restarted on discharge. ISS in house. # Depression: Continued citalopram # CAD: Continued baby aspirin, simvastatin # GERD: Continued pantoprazole # Chronic low back pain: Continued percocet TRANSITIONAL ISSUES: # Follow Up: She was given follow up appointments with her PCP & cardiologist. # Code Status: DNR/DNI Medications on Admission: percocet 5/325 1 tab qid advair 250/50 1 puff [**Hospital1 **] amlodipine 7.5mg daily asa 81mg daily atenolol 25mg daily citalopram 40mg daily colace furosemide 40mg daily glipizide 5mg daily lisinopril 40mg daily simvastatin 20mg daily acetaminophen prn nitroglycerin prn Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: please hold for loose stools. 7. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual as directed as needed for chest pain: Q5MIN PRN chest pain for up to 3 tablets. 11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Please restart on [**2204-1-27**]. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please take weight daily and restart when weight increases 2 lbs from admission weight. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Rehab & Nursing Center Discharge Diagnosis: PRIMARY DIAGNOSES: - Gastroenteritis - Ischemic colitis - hypovolemia - acute renal failure SECONDARY DIAGNOSIS: - chronic diastolic Congestive Heart Failure - Atherosclerosis - DM II Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 8350**], it was a pleasure to participate in your care while you were at [**Hospital1 18**]. You came to the hospital because you passed out after having episodes of nausea, vomiting, & diarrhea. When you came to the hospital your blood pressure was very low. You were admitted to the ICU where your blood pressure improved with intravenous fluids, but you then developed bloody stool. Our gastroenterology team evaluated you and felt the blood from your rectum was caused by a condition called "ischemic colitis" which can happen when the blood flow to your intestines is low. You slowly improved MEDICATION INSTRUCTIONS: - Medications ADDED: None. - Medications STOPPED: ---> Please restart lisinopril on [**2204-1-27**] and furosemide after gaining 2 pounds Followup Instructions: Please call to reschedule if you are not able to make any of your follow-up appointments: Department: CARDIAC SERVICES When: TUESDAY [**2204-2-21**] at 10:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] Specialty: INTERNAL MEDICINE Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 608**] **Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.** [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "V43.3", "009.0", "584.9", "348.31", "428.0", "458.9", "276.1", "401.1", "276.2", "428.32", "562.10", "294.20", "250.00", "276.52", "557.0", "285.1", "518.89", "724.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10319, 10398

6133, 8614

305, 313

10627, 10627

3284, 4911

11625, 11691

2358, 2362

9064, 10296

10419, 10512

8766, 9041

10812, 11437

4928, 6110

2377, 2999

3015, 3265

8649, 8740

11716, 12555

8635, 8637

1771, 2151

256, 267

342, 1752

10533, 10606

11462, 11602

10642, 10788

2173, 2299

2315, 2342