ChanBeDu/relevant_section_length · Datasets at Hugging Face

45,013

120,099

37742

Discharge summary

report

Admission Date: [**2131-9-28**] Discharge Date: [**2131-10-10**] Date of Birth: [**2061-1-9**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Lipitor / Prednisone Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease/Thyroid mass Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 4(LIMA-LAD,SVG-OM1,y y-DG,SVG-OM2),Left thyroidectomy [**2131-9-28**] History of Present Illness: This 70 year old white female vasculopath underwent intervention for a left ankle ulceration in [**Month (only) **]. She had angina and ruled in for an infarct at that time. Catheterization then demonstrated significant left sided disease and preserved LV function. She also has a large substernal goiter, which by prior biopsy was not malignant. This was removed after sternotomy. She is admitted now for revascularization and partial thyroidectomy. Past Medical History: coronary artery disease thyroid mass hypertension Hyperlipidemia s/p balloon angioplasty of L superficial femoral and popliteal arteries [**2131-8-29**] carotid artery disease Noninsulin dependent diabetes mellitus chronic obstructive pulmonary disease s/p left mastectomy h/o gastrointestinal hemorrhage gastroesophageal reflux disease Vertigo s/p Left hand surgery for Ganglion cyst Social History: 75 pack year history nondrinker Family History: noncontributory Physical Exam: Admission: Pulse: 64 SR Resp: 14 O2 sat: 97% RA B/P Right: 172/84 Left: No BP s/p mastectomy Height:5'2" Weight:143 lbs General: NAD Skin: Warm, Dry, intact. Well healed mastectomy scar. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Mild thyroid fullness however no significant thyromegally palpated. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] with delayed expiration. Heart: RRR [X], Nl S1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Obese Extremities: Warm [X], well-perfused [X] 1+ Left and no right lower extremity edema. Left heal ulcer with granulation tissue present. Varicosities: Left thigh and lower leg grossly varicosed. Some right thigh and lower leg varicosities also noted. Neuro: Grossly intact, MAE, Mild balance issues as she is slightly unstable on standing. Falls forward to right. Pulses: Femoral Right: 2 Left: 2 **Bilateral bruits DP Right: trace Left: trace PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Right: + Bruit Left: + Bruit Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84547**] (Complete) Done [**2131-9-28**] at 11:42:34 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2061-1-9**] Age (years): 70 F Hgt (in): 63 BP (mm Hg): 140/62 Wgt (lb): 142 HR (bpm): 65 BSA (m2): 1.67 m2 Indication: Intraop CABG, partial thyroidectomy ICD-9 Codes: 440.0 Test Information Date/Time: [**2131-9-28**] at 11:42 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: [**Doctor Last Name **] 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.4 cm Left Ventricle - Fractional Shortening: 0.40 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Stroke Volume: 69 ml/beat Left Ventricle - Cardiac Output: 4.49 L/min Left Ventricle - Cardiac Index: 2.69 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm Aorta - Ascending: 2.6 cm <= 3.4 cm Aorta - Arch: 2.2 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 2 mm Hg Aortic Valve - LVOT VTI: 22 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: *2.1 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.7 m/sec Mitral Valve - Pressure Half Time: 100 ms Mitral Valve - MVA (P [**12-1**] T): 2.2 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 229 ms 140-250 ms Findings LEFT ATRIUM: Moderate LA enlargement. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. No atheroma in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. Conclusions Pre Bypass: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened and the posterior leaflet is heavily calcified. Physiologic mitral regurgitation is seen (trace to no mr). There is no mitral stenosis. There is no pericardial effusion. Post Bypass: Patient is paced on phenylepherine infusion. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician Brief Hospital Course: Ms.[**Known lastname 13393**] was taken to the Operating Room where Coronary artery bypass grafts x 4(Left Internal Mammary Artery was grafted to Left Anterior Descending ,Saphenous Vein Grafted to Obtuse Marginal1,Y-Diag, SVG-OM2) were performed. The thyroid mass was also resected after sternotomy. Cross clamp time=69 minutes. Cardiopulmonary Bypass time= 86 minutes. Please refer to the operative note for further details. The thyroid mass was excised after sternotomy and then revascularization was done. She weaned from bypass on neosynephrine and Propofol. Intubated and sedated, she was transferred to the CVICU in critical but stable condition, requiring pressors to optimize her cardiac hemodynamics. She awoke neurologically intact and was weaned to extubation. Beta- Blockade, statin, aspirin, and diuresis was initiated. All lines and drains were discontinued in a timely fashion. On POD#2 she developed rapid atrial fibrillation. She was treated with Amiodarone, Diltiazem, eventually converted into normal sinus rhythm. She slowly progressed and was transferred to the step down unit on day #3. Physical Therapy was consulted for evaluation for mobility and strength. The remainder of her postoperative course was essentially uneventful. Due to her slow progression in mobility and activity, rehabilitation is required to assist in improving her activities of daily living. Of note, right ventricular epicardial wires were cut and retracted, right atrial epicardial wires extracted. She remained in normal sinus rhythm and therefore anticoagulation was not necessary. Plavix was resumed for the recent angioplasties of her left popliteal artery and superficial left femoral artery in [**Month (only) **]. Final pathology on the thyroid specimen was that of a multinodular goiter with adenomatous changes. She developed sternal drainage with an elevated white blood cell count.A hematoma was palpable in the mid sternum. Vancomycin was started and a CT scan was perfomed on [**10-5**],which showed intact sternal wires and no fluid collection. A PICC line was placed on [**10-10**]. Vancomycin was stopped on [**10-10**] due to a trough level of 29 and Cipro was begun empirically. The sternal dressing was essentially dry, the sternum stable and patient afebrile, without leukocytosis. There was an eschar over the area and no discharge was able to be expressed. The left medial malleolar ulcer was clean at discharge and saline wet to dry dressings are adequate, the Silvadene dressings are stopped. She was started on Cipro for the sternal wound and written for a two week course, further need beyond that to be determined. She was ambulatory but weak and reahbilitation will be necessary for a short while prior to return home. We will see her on [**10-12**] and 16 for wound checks. Medications on Admission: Aspirin 81mg Daily Citalopram 20mg po daily Plavix 75mg po daily Advair Diskus 250/50 1 puff [**Hospital1 **] Glimeperide (Amaryl) 2 mg po daily HCTZ 2.5mg Daily Combivent 2 puffs QID Leflunomide ([**Last Name (un) **]) 10mg po daily Lisinopril 40mg po daily Meclizine 25mg po PRN Methotrexate Sodium 2.5mg tablets, 6 tablets once weekly on Monday, Metoprolol Tartrate 100mg po daily Naprosyn 500mg po daily Zantac 150mg Daily Reclast 5mg/100cc IV once yearly calcium infusion Citracal [**Hospital1 **] Omega 2 Vitamin E 1000mg- 5units MVI daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Tablet(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Leflunomide 10 mg Tablet Sig: One (1) Tablet PO daily (). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO daily (). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. 16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN flush Peripheral IV - Inspect site every shift 19. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig: Six (6) Tablets, Dose Pack PO once a week: 6 tablets every Monday. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts [**2131-9-28**] hypertension Hyperlipidemia s/p balloon angioplasty of L superficial femoral and popliteal arteries [**2131-8-29**] carotid artery disease Noninsulin dependent diabetes mellitus chronic obstructive pulmonary disease s/p left mastectomy h/o gastrointestinal hemorrhage gastroesophageal reflux disease Vertigo s/p Left hand surgery for Ganglion cyst multinodular goiter s/p thyroid resection rheumatoid arthritis Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital Ward Name 121**] 6 wound clinic on [**10-12**] and 16th Dr. [**Last Name (STitle) 84548**] [**Name (STitle) 17996**] in 2 weeks ([**Telephone/Fax (1) 6699**]) please call for appointments Dr. [**Last Name (STitle) **] as stated below Dr. [**Last Name (STitle) 5182**] as instructed by him Scheduled Appointments: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-10-18**] 11:15 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-10-18**] 12:30 Completed by:[**2131-10-10**]

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icd9cm

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[ "36.15", "99.62", "36.13", "06.51", "39.61", "38.93" ]

icd9pcs

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38573

Discharge summary

report

Admission Date: [**2161-5-8**] Discharge Date: [**2161-5-23**] Date of Birth: [**2083-1-8**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: s/p syncopal event Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 78m who presents as transfer from OSH with bifrontal contusions and traumatic SAH after a syncopal event. Pt does recalls feeling dizzy prior to falling and that is all he can remember. He currently complains of headache and nausea with two episodes of emesis here at [**Hospital1 18**]. He has no neck pain, no complaints of weakness in extremities, photophobia, b/b dysfunction, speech difficulty Past Medical History: AFIB previously on coumadin, PVD, CAD with CABG and stenting, HTN, Hyperlipidemia, CHF Social History: The patient has been sober since age 43. He smoked from ages 16-50 and smoked 3pcks/day at the max. Denies other drug use. Used to work for computer company but now works parttime. He lives with his wife. Family History: Father died age age 66 of liver CA and had heart disease prior to that. Otherwise non-contributory. Physical Exam: O: T: BP: 140/78 HR: 90 AFIB R 14 O2Sats 95 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs Appear full Neck: C collar in place, no cervical tenderness to palpation. 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 date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,2mm to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-7**] throughout. No pronator drift Toes downgoing bilaterally Pertinent Results: CXR [**5-18**]: No acute cardiopulmonary abnormalities. CTA CHEST [**5-18**]: 1. No evidence of pulmonary embolus, as questioned. No pneumonia, effusion, or pneumothorax. 2. Marked prominence of the right atrium, with relative diminutive caliber of the right ventricle. This could reflect Ebstein's anomaly, and correlation with echocardiography is recommended. 3. Intermediate density filling defect within the left atrial appendage, concerning for thrombus, which could also be further evaluated with echocardiography. CT Head [**5-17**]: Stable appearance of brain, with right frontal, subinsular, and parietal infarcts; bifrontal and right temporal hemorrhagic contusions; mild subarachnoid, subdural, and intraventricular hemorrhage; and 3-mm rightward shift of the falx cerebri, with slight entrapment and dilation of the left lateral ventricle. MR [**Name13 (STitle) 430**] [**5-16**]: Hemorrhagic contusions in the bifrontal and right temporal lobe. Other sequelae of trauma are stable. Acute infarcts in the right frontal and parietal lobe. MRA of the Circle of [**Location (un) 431**] demonstrates patency of the proximal intracranial vasculature. Distal vasculature cannot be assessed due to excessive motion artifact. MRA of the neck demonstrates no significant stenosis. Ct C/A/P 1. No acute injury in the abdomen or pelvis. 2. 5-mm right lower lobe pulmonary nodule and 3-mm left lower lobe pulmonary nodule. [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] criteria, followup with dedicated chest CT can be performed at 12 months if patient has no risk factors for malignancy. If patient has risk factors for malignancy, then dedicated chest CT is recommended in 6 to 12 months. 3. Abdominal aortic aneurysm measuring up to 4.5 cm. CT C-Spine 1. No acute fracture or malalignment. 2. Multilevel degenerative change with mild narrowing of the spinal canal. This can predispose to cord injury in the setting of significant trauma. CT head 1. Increasing size of hemorrhagic contusions within the frontal lobes bilaterally and in the right temporal lobe as described above. 2. Diffuse subarachnoid hemorrhage overlying the parietal, occipital, and temporal lobes bilaterally. 3. Stable appearance of nondisplaced fracture of the left frontal bone. Carotid ultrasound [**5-11**] Impression: Right ICA <40% stenosis. Left ICA <40% stenosis. Echocardiogram [**5-11**] The left atrium is markedly 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. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %) global hypokinesis most prominent in the inferior and infero-lateral walls. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Laboratory data: [**2161-5-8**] 03:10PM BLOOD WBC-10.2# RBC-3.87* Hgb-13.3* Hct-37.7* MCV-97 MCH-34.4* MCHC-35.3* RDW-13.4 Plt Ct-156 [**2161-5-19**] 05:35AM BLOOD WBC-13.8* RBC-3.95* Hgb-13.6* Hct-38.6* MCV-98 MCH-34.5* MCHC-35.3* RDW-13.3 Plt Ct-189 [**2161-5-8**] 03:10PM BLOOD Neuts-74.6* Lymphs-21.4 Monos-3.1 Eos-0.3 Baso-0.6 [**2161-5-8**] 03:10PM BLOOD PT-14.5* PTT-21.9* INR(PT)-1.3* [**2161-5-19**] 12:35PM BLOOD PT-15.0* PTT-64.4* INR(PT)-1.3* [**2161-5-8**] 03:10PM BLOOD Glucose-164* UreaN-20 Creat-1.1 Na-140 K-2.8* Cl-100 HCO3-21* AnGap-22* [**2161-5-19**] 05:35AM BLOOD Glucose-116* UreaN-25* Creat-1.1 Na-139 K-3.8 Cl-107 HCO3-21* AnGap-15 [**2161-5-18**] 06:05AM BLOOD ALT-22 AST-31 CK(CPK)-88 AlkPhos-75 [**2161-5-8**] 03:10PM BLOOD cTropnT-<0.01 [**2161-5-18**] 06:05AM BLOOD CK-MB-3 cTropnT-0.01 [**2161-5-8**] 03:10PM BLOOD Calcium-9.4 Phos-1.6* Mg-1.5* [**2161-5-19**] 05:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0 [**2161-5-12**] 05:45AM BLOOD calTIBC-302 Ferritn-456* TRF-232 [**2161-5-16**] 06:25AM BLOOD Ammonia-8* [**2161-5-10**] 09:39AM BLOOD freeCa-1.07* Brief Hospital Course: [**Known firstname **] [**Known lastname 28221**] is a 78-year-old man with past medical history notable for atrial fibrillation, who had been anticoagulated on Coumadin until approximately six days prior to his initial admission for colonoscopy, CHF, coronary artery disease status post CABG in [**2145**], and a prior stroke approximately 10 years ago with some residual right-sided weakness who is currently admitted to the neurology inpatient stroke service. In the setting of his Coumadin being held, he had sustained a fall and had significant hemorrhagic contusions to his bilateral frontal and anterior temporal lobes and had been taken care of by the neurosurgical service. During this time, his Coumadin was continued to be held. Neurology became involved in his care on [**5-16**] at which time there was some concern for a change in behavior including some greater lethargy. An MRI showed right-sided large wedge-shaped infarcts, likely cardioembolic in etiology. On general physical exam the morning of [**5-18**], the patient is afebrile, but is tachycardic to the low 100s with an irregularly irregular rhythm. His lungs sound clear; however, there is a machine-like murmur to his heart that seems to encompass both the systolic and diastolic phases of the rhythm. He is also somewhat tachypneic about 24 with peak respiratory rate of 30 breaths per minute last night. On neurological exam, the patient can make some brief verbal utterances, but is largely obtunded and inattentive. His left eye seems somewhat skewed upward at baseline; however, he appears to be able to look fully both to the right and to the left, with horizontal eye movements. He was uncooperative with the formal motor exam, though he was able to raise all extremities against gravity. Reflexes were symmetric, though he did appear to have an upgoing left toe. While on the Nsurg service he became more somnolent. He was found to have a partial Right MCA (inferior division territory) infarction. The exam findings of mild weakness on the left and extinction to DSS fit with a medium-sized right parietal infarct. A clot was seen in left atrial appendage on a CTA of the chest. Patient placed on heparin will montitor with CT in am of [**2161-5-19**] he was continued Keppra 500 [**Hospital1 **] for seizure prophylaxis. For the UTI he was kept on the antibiotic:bactrim (UTI/ESCHERICHIA COLI - end [**5-21**]). Patient was unable to swallow and required a feeding tube. Palliative care was consulted and goals of care were addressed. After lengthy discussions with the family the decision was made for comfort measures only and no escalation of care. He was therefore made comfortable and no further work up of his conditions was made. Medications on Admission: ?ASA 325 and Plavix 75, Albuterol MDI, Simvastatin, Benicar, Atenolol, Lasix Discharge Medications: 1. Lorazepam Intensol 2 mg/mL Concentrate Sig: 1-2 mg PO q2 hours as needed for anxiety. Disp:*30 mL* Refills:*0* 2. Morphine 20 mg/mL solution 4-10 mg/hr basal rate 2-5 mg bolus q 15 minutes as needed Dispense 100mL Refill 6 (six) *Hospice patient 3. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q2H (every 2 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: Bifrontal Contusions Traumatic Subarachnoid Hemorrhage Acute right frontal and parietal lobe infarctions UTI acute hypokalemia chronic diastolic heart failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 28221**], You were admitted to the hospital for bruises and bleeding in your brain after a fall. You were also found to have a stroke during your admission. It was determined with your family that your care would be focused on your comfort only. Followup Instructions: As determined by nursing home facility [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2161-5-23**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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40556

Discharge summary

report

Admission Date: [**2190-3-24**] Discharge Date: [**2190-3-31**] Date of Birth: [**2133-8-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cystoscopy, urethral dilation, Foley catheter placement [**2190-3-26**] Coronary artery bypass graft x4 (LIMA-LAD, SVG-LAD,SVG-Dg,SVG-OM1,SVG-OM2)[**2190-3-26**] History of Present Illness: This 56 year old gentleman has a history of coronary artery disease and is status post myocardial infarction in [**2180**] and [**2188**]. He has been experiencing chest pressure for the past 2 months, intermittent, occurring at rest and associated with shortness of breath, resolving without intervention. He developed chest tightness and shortness of breath on [**2190-3-22**] which did not resolve and he called 911. He was admitted to [**Hospital6 3105**] for further work-up. A cardiac catheterization was obtained which revealed severe three vessel coronary artery disease. Given the severity of his disease, he was transferred to the [**Hospital1 18**] for surgical management. Past Medical History: Coronary artery disease - 5 total stents STEMI with PCI with stents x 3 to circ [**2189-4-4**] at LGH MI [**2180**] with [**Hospital3 88789**] Hypertension Hyperlipidemia Chronic renal insufficiency Creat 1.5 BPH Pancreatitis from gall bladder stones COPD Past hx urinary tract infection Blind in left eye ? Right Nephrectomy - ? Wilms tumor as child Cholecystectomy Lysis of adhesions for small bowel obstruction - Dr. [**Last Name (STitle) **] [**2187**] Inguinal hernia repair [**2153**] Abdominal hernia repair [**2168**] Social History: Lives with: Wife and adult child in [**Hospital1 487**], 2 kids, 3 step kids Occupation: Maintenance Mechanic, currently working Tobacco: Active smoker. [**12-6**] - 1ppd x 42 years ETOH: none Family History: noncontributory Physical Exam: Pulse: 54 Resp: 18 O2 sat: 93% RA B/P Right:92/59 Left: Height: 63" Weight: 200 General: AAOx 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Left lid lag, left eye blindness Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Well healed midline abdominal scar Extremities: Warm [x], well-perfused [x] No Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: slight oozing at cath sit 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: [**2190-3-30**] 05:00AM BLOOD WBC-10.0 RBC-3.36* Hgb-10.3* Hct-29.9* MCV-89 MCH-30.8 MCHC-34.6 RDW-13.2 Plt Ct-163 [**2190-3-24**] 06:52PM BLOOD WBC-7.8 RBC-5.01 Hgb-15.6 Hct-44.7 MCV-89 MCH-31.1 MCHC-34.8 RDW-13.3 Plt Ct-158 [**2190-3-30**] 05:00AM BLOOD Plt Ct-163 [**2190-3-28**] 01:35AM BLOOD PT-14.9* PTT-25.9 INR(PT)-1.3* [**2190-3-24**] 06:52PM BLOOD PT-13.5* PTT-28.1 INR(PT)-1.2* [**2190-3-24**] 06:52PM BLOOD Plt Ct-158 [**2190-3-26**] 01:35PM BLOOD Fibrino-259 [**2190-3-31**] 05:30AM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-140 K-3.8 Cl-106 HCO3-26 AnGap-12 [**2190-3-24**] 06:52PM BLOOD Glucose-127* UreaN-13 Creat-1.0 Na-138 K-4.1 Cl-101 HCO3-30 AnGap-11 [**2190-3-24**] 06:52PM BLOOD ALT-41* AST-24 LD(LDH)-173 AlkPhos-57 Amylase-35 TotBili-0.6 [**2190-3-24**] 06:52PM BLOOD Lipase-42 [**2190-3-24**] 06:52PM BLOOD CK-MB-3 cTropnT-<0.01 [**2190-3-31**] 05:30AM BLOOD Mg-2.4 [**2190-3-28**] 01:35AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0 [**2190-3-24**] 06:52PM BLOOD %HbA1c-6.5* eAG-140* CXR FINDINGS: In comparison with study of [**3-28**], there has been placement of a right IJ catheter that extends to the mid-to-lower portion of the SVC. Improved lung volumes with small bilateral pleural effusions. Mild indistinctness of pulmonary vessels suggests some increased pulmonary venous pressure and there are continued mild atelectatic changes. Gastric dilatation is not appreciated on the current study. Echo Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. REGIONAL LEFT VENTRICULAR WALL MOTION: Conclusions PREBYPASS: The left atrium is normal in size. A patent foramen ovale is present. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 30 cm from the incisors. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Normal diastolic funcition with E' = 8cm/sec. No clot in LAA. Normal coronary sinus. Essentially normal exam with moderate LVH. POSTBYPASS: UNCHANGED, Normal systolic funciton with LVEF > 55%, no SWMA, no valvular abnormalities. No dissection seen after aortic cannula removed. Good hemodynamics with no swma following chest closure. PFT SPIROMETRY 7:50 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.78 3.84 72 FEV1 1.74 2.83 61 MMF 0.64 3.00 21 FEV1/FVC 63 74 85 LUNG VOLUMES 7:50 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 4.71 5.73 82 FRC 2.25 3.17 71 RV 1.83 1.90 97 VC 2.88 3.84 75 IC 2.46 2.57 96 ERV 0.41 1.27 33 RV/TLC 39 33 118 He Mix Time 2.00 DLCO 7:50 AM Actual Pred %Pred DSB 21.36 26.02 82 VA(sb) 4.42 5.73 77 HB 15.60 DSB(HB) 20.80 26.02 80 DL/VA 4.70 4.54 104 Brief Hospital Course: Following transfer from an outside hospital for surgical evaluation he underwent preoperative workup. On [**3-26**] he was brought to the Operating Room and underwent coronary artery bypass graft surgery. Please see the operative report for further details. Of note there was difficulty with catheter placement and urology was consulted. He underwent cystoscopy with urethral dilation with Foley catheter placement by urology in operating room. He received vancomycin and cefazolin for perioperative antibiotics and gentamycin due to urethral dilation. He was transferred to the intensive care unit for post operative management. Post operatively he was noted for collapse of the right upper lobe on postoperstive radiogram and with increased PEEP levels this reexpanded. His oxygen saturation level were adequate, despite paO2 of 60s. Preoperative PFTs demonstarted severly reduced FEV1 and DLCO. His lungs were stiff in the Operating Room, consistent with his 100+ pack year smoking. He was weaned from the ventilator on POD 1 after diuresis. Pulmonary toilet was aggressively persued with diuresis. He remained in the intensive care unit for respiratory monitoring. He was started on betablockers for heart rate management. Physical Therapy worked with him on strength and mobility. He was transferred to the floor on post operative day three for the remainder of his care. He continued to do well and was ready for discharge to rehab at [**Location (un) 7661**] Health and Rehab center on post operative day five. Plan for Foley catheter Foley catheter placed in operating room - please maintain catheter with leg strap and catheter care routinely until Monday [**4-5**] On Monday [**4-5**] please remove at 6 am - if fails to void in 8 hours please attempt once to place foley catheter using 14 or 16 french regular catheter (per urology) if unable to place please send to emergency room at [**Hospital1 18**] for evaluation by urology - please call with any questions or concerns Urology # ([**Telephone/Fax (1) 18591**] Medications on Admission: Aspirin 325mg daily Plavix 75mg daily Lisinopril 5 mg daily Zocor 40 mg daily Lopressor 25 mg [**Hospital1 **] Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever or pain. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. 12. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 7 days. Discharge Disposition: Extended Care Facility: [**Location (un) 7661**] Health and Rehab Center Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft surgery Urethral stricture requiring dilitation Hypertension Hyperlipidemia Myocardial infarction Chronic renal insufficiency Benign prostatic hypertrophy Pancreatitis from gall bladder stones Chronic obstructive pulmonary disease Blind in left eye Discharge Condition: Alert and oriented x3, nonfocal Ambulating with one assist Incisional pain managed with dilaudid as needed Incisions: Sternal - healing well, no erythema or drainage Leg Right EVH - healing well, no erythema or drainage. Edema + bilateral Lower extremities 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** Foley catheter placed in operating room - please maintain catheter with leg strap and catheter care routinely until Monday [**4-5**] On Monday [**4-5**] please remove at 6 am - if fails to void in 8 hours please attempt once to place foley catheter using 14 or 16 french regular catheter (per urology) if unable to place please send to emergency room at [**Hospital1 18**] for evaluation by urology - please call with any questions or concerns Urology # ([**Telephone/Fax (1) 18591**] Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) Thrusday [**2190-4-29**] 1:00 pm Cardiologist: Dr [**First Name (STitle) **] ([**0-0-**]) Thrusday [**2190-4-22**] 9:30 am Please call to schedule appointments with: Primary Care Dr [**Last Name (STitle) **] [**Last Name (STitle) 21448**] in [**3-9**] 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:[**2190-3-31**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "58.6", "57.32", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

10220, 10295

6825, 8869

321, 485

10645, 10904

2753, 5063

12231, 12801

1978, 1995

9031, 10197

10316, 10624

8895, 9008

10928, 12208

5102, 6802

2010, 2734

270, 283

513, 1201

1223, 1751

1767, 1962

54,964

156,297

36318

Discharge summary

report

Admission Date: [**2142-4-28**] Discharge Date: [**2142-5-5**] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4760**] Chief Complaint: hydronephrosis, acute renal failure Major Surgical or Invasive Procedure: Ureteral stent placement Sigmoidoscopy History of Present Illness: 86 year old woman with a history of [**First Name3 (LF) 499**] cancer and breast cancer presents with acute onset left flank pain x 1 day. She awoke yesterday morning with intermittant flank pain, as well as nausea and vomiting (non bloody non bilious) x2. Her VNA came for her usual visit, and noted that the patient looked unwell, so the patient was brought to [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital in [**Location (un) 1110**] where she has received most of her medical care. She notes today that she had been having about 3 months of hematuria, but had no dysuria. She also says she has been having daily BRBPR x >1 month, and was scheduled for a colonoscopy on [**4-7**] however was bumped to [**5-7**] due to scheduling reasons. She reports intermittant aches and pains, over her legs and back, but nothing as intense as the flank pain yesterday. She has depression, and stated to the night float that she cries frequently, wondering why she should go on, "but the I pick myself up and get over it." . OSH COURSE: She presented to OSH ed where a non con CT showed new metastatic disease to the liver, enlargement of known adrenal mass, and a soft tissue mass blocking the L ureter leading to acute left hydronephrosis. She was given NS 500 ml, toradol 30 mg IV and Zofran 4 mg IV. The OSH did not have urology so she was transfered to [**Hospital1 18**]. . In the [**Hospital1 18**] ED, initial VS:Pain [**6-13**], T 97.3 HR 75 BP 158/90 RR 16 98% RA. Labs were obtained; notable for Cr 1.9, INR 2.5. UA positive for RBC, WBC, bacteria. Urology was consulted, and recommended cipro and pain control overnight; they planned to see the patient in the morning. She was given cipro 500 mg IV, morphine 2 mg iv, ativan 0.5 mg iv. . Overnight, her pain has resolved and she feels sleepy and sad, but well. She has no pain at present and denies further nausea. Past Medical History: [**Month/Year (2) **] cancer - approx 3 y ago - s/p surgical resection and chemotherapy. Has indwelling port. Breast Cancer - [**2137**] - s/p L lumpectomy, radiation and tamoxifen. in remission. h/o blood clots - As per patient she had a PE +/- IVC filter clot. Clots were peri-operative after hip replacment. on coumadin. depression h/o ccy h/o R hip replacement [**12-11**] spinal stenosis hypothyroid constipation Social History: lives alone. Has supportive daughter, [**Name (NI) **] (who is currently in [**Name (NI) **]). Has VNA. Independent in ADLs and housekeeping. Has not driven since hip replacement in [**12-11**]. No tobacco, etoh or drugs. . Family History: nc Physical Exam: Vitals - T: 97.0 BP: 154/78 HR: 82 RR: 20 02 sat: 97% RA GENERAL: elderly woman in bed, nad HEENT: EOMI, MMM CARDIAC: RRR LUNG: clear b/l ABDOMEN: soft, nt/nd BACK: no CVA tenderness EXT: No LE edema. 1+ DP pulses. Pertinent Results: [**2142-4-27**] 10:20PM BLOOD WBC-4.2 RBC-3.81* Hgb-11.4* Hct-35.8* MCV-94 MCH-29.9 MCHC-31.8 RDW-16.4* Plt Ct-261 [**2142-4-27**] 10:20PM BLOOD Neuts-72.1* Lymphs-19.6 Monos-7.2 Eos-0.7 Baso-0.4 [**2142-4-27**] 10:20PM BLOOD PT-25.5* PTT-33.7 INR(PT)-2.5* [**2142-4-27**] 10:20PM BLOOD Plt Ct-261 [**2142-4-27**] 10:20PM BLOOD Glucose-112* UreaN-32* Creat-1.9* Na-133 K-4.6 Cl-98 HCO3-25 AnGap-15 [**2142-4-28**] 05:35AM BLOOD ALT-13 AST-19 LD(LDH)-221 AlkPhos-115 TotBili-0.6 [**2142-4-28**] 05:35AM BLOOD Albumin-4.3 Calcium-9.1 Phos-4.1 Mg-2.2 . Radiographic: OSH CT abdomen over-read: IMPRESSION: 1. Acute left hydronephrosis and hydroureter to the level of a left retroperitoneal nodal metastasis which may be tethering the left ureter and obstructing it. No renal stones identified. 2. Metastatic disease with multiple hepatic masses, large right adrenal mass and right para-aortic low density mass at the level of the diaphragm. 3. Soft tissue mass abutting/tethering the rectum and potentially tethering small-bowel loops in the pelvis, concerning for local recurrence. . CT abdomen/pelvis with contrast [**2142-4-28**]: CT OF THE ABDOMEN: There is a large fat containing Bochdalek hernia. Low density 2.8 x 1.5 cm right para-aortic mass may represent a necrotic lymph node. There is dependent atelectasis at the lung bases. No pulmonary nodules identified. Low attenuation of intracardiac blood reflects anemia. There are multiple low- density hepatic masses measuring 3 x 2.9 cm in segment IVb/V (2:24), 3.3 x 2.8 cm in segment VII (2:15) and 2.8 x 3 cm in segment VII at the right dome (2:11). There is no appreciable intrahepatic bile duct dilation. The gallbladder has been removed. The spleen is not enlarged. The pancreas is unremarkable. There may be a duodenal diverticulum. The right kidney is unremarkable. There is acute hydronephrosis of the left kidney which is moderately severe, with moderate perinephric stranding. Right hydroureter ends in the vicinity of an 18 x 16- mm left common iliac nodal mass (2:44) and may be tethered by this metastatic node. No ureteral stone is identified. The left adrenal gland is thickened diffusely. There is a soft tissue mass occupying the right adrenal gland measuring 4 x 3.1 cm, consistent with metastasis. The IVC is expanded with high-density material within it, also extending into the left renal vein, concerning for thrombus. There are multiple calcified periaortic and paracaval lymph nodes measuring up to 8 mm in the left para- aortic nodal station (2:32). There are abdominal wall collaterals. CT OF THE PELVIS: Suture material is seen at the rectosigmoid junction. There is soft tissue mass tethering the rectum to the right pelvic side wall, consistent with local recurrence, measuring approximately 3.4 x 2.2 cm (2:60). Small- bowel loops also may be tethered to this mass. There are multiple small-bowel loops in the pelvis with fecalization. Evaluation is limited due to artifact from the right hip prosthesis. A Foley catheter and air are seen within the bladder. The bones are osteopenic. A total right hip prosthesis is noted, with no evidence of hardware complication. There are no suspicious lytic or sclerotic lesions. IMPRESSION: 1. Acute left hydronephrosis and hydroureter to the level of a left retroperitoneal nodal metastasis which may be tethering the left ureter and obstructing it. No renal stones identified. 2. Metastatic disease with multiple hepatic masses, large right adrenal mass and right para-aortic low density mass at the level of the diaphragm. 3. Soft tissue mass abutting/tethering the rectum and potentially tethering small-bowel loops in the pelvis, concerning for local recurrence. Brief Hospital Course: 86yo female with a history of multiple medical problems including [**Name2 (NI) 499**] cancer and breast cancer was transferred from OSH ureteral stent placement by urology. After admission had several episodes of BRBPR. She was discharged home with hospice. . # Hydronephrosis/UA positive - Soft tissue mass causing renal obstruction and hydronephrosis - likely necrotic lymph node. Seen by urology, with stent placed. Given instrumentation, she was treated with cipro (will complete a 10 day course). Urine culture was negative. . #Metastatic cancer: History of [**Name2 (NI) 499**] and breast ca, most likely this is metastatic [**Name2 (NI) 499**] ca based on her history. She had abdominal CT scan which showed the node likely causing hydronephrosis, as well as a mass in the rectum, tethering the small bowel. Her primary oncologist was contact[**Name (NI) **] and provided information regarding her prior diagnosis, and prior decision against chemotherapy. Family meeting was conducted, with goal of elucidating goals of care. She and her family opted for palliative care and transition to hospice. Prior to discharge, she underwent sigmoidoscopy to evaluate for obstructive symptoms, and sigmoidoscopy showed a large mass at the anastamotic site, but at the blind limb, which was not obstructing the functional limb. . #Renal failure - Cr 2.0 on admission. Baseline Cr 0.95 as of [**1-12**] (called [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**] hospital). Patient with good UOP, no history of renal disease in past. Her renal function returned to normal with IV hydration and stent placement. Final creatinine was 1.0. . # GI bleed - Has had slow bleed w/BRBPR for months, but had brisk bleeding on [**4-29**] associated w/Hct drop from baseline 37 -> 29. Her vital signs were stable during this episode. Her coumadin was held and she received 2U of FFP. She was evaluated by GI who planned for sigmoidoscopy (as per above showed a large mass at the anastamotic site, non-obstructive). Her bleeding improved after the discontinuation of coumadin, with stable hematocrit. . # Depression - likely situational. Continued paxil. . # h/o clot, now w/evidence of IVC clot extending into L renal vein on CT. Coumadin held in setting of GI bleed. Per primary oncologist, clot has been present for at least 5 months. Given risk and benefit of bleeding with large mass, coumadin was discontinued with family and patient understanding of the risk of clot. . # hyponatremia - Resolved with IV fluids. .. # hypothyroid - continued synthroid . #constipation - bowel regimen Medications on Admission: Paxil 60 mg daily Ativan 0.5 mg twice daily as needed ambien 10 mg at nnight miralax daily MV Senna as needed synthroid 112 mcg daily timolol eye drops aspirin 325 mg daily coumadin Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Miralax 17 gram (100 %) Powder in Packet Sig: Seventeen (17) gram PO once a day. Disp:*30 packets* Refills:*2* 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:*50 Tablet(s)* Refills:*1* 9. 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* 10. 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* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: acute renal failure hydronephrosis Recurrent [**Hospital 499**] cancer Acute blood loss anemia Gastrointestinal bleed IVC clot Discharge Condition: Tolerating diet, stable labs, ambulating with physical therapy. Discharge Instructions: You were admitted for the hospital for kidney failure related to a blockage of your ureter which backed up into your kidney. We had our urologists evaluate you and they placed a stent in your ureter to help keep it open. You also had an episode of bleeding from your rectum, and a sigmoidoscopy revealed a recurrent tumor where you had previously had surgery. Your bowel was not blocked by the tumor and you did not need a stent to keep it open. You were taken off coumadin and aspirin, and the bleeding improved. . You are being discharged home with hospice care. Followup Instructions: You will need to see Dr [**Last Name (STitle) 11189**] in 3 months for a follow-up visit. Please call his office at ([**Telephone/Fax (1) 7707**] to schedule this appoinment. . You are being discharged to hospice care at home with [**Hospital 3005**] Hospice.

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icd9cm

[ [ [] ] ]

[ "45.24", "59.8", "45.23" ]

icd9pcs

[ [ [] ] ]

10942, 11000

6931, 9539

274, 315

11171, 11237

3202, 6908

11853, 12116

2948, 2952

9771, 10919

11021, 11150

9565, 9748

11261, 11830

2967, 3183

199, 236

343, 2250

2272, 2691

2707, 2932

25,935

188,026

51947

Discharge summary

report

Admission Date: [**2121-3-16**] Discharge Date: [**2121-3-20**] Date of Birth: [**2062-2-8**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: malaise and hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 50416**] is a 59 year-old man with COPD (no PFTs), DM2 s/p bilateral BKA, who presents with generalized malaise for 3 days. He states that he feels less able to transfer back and forth to his wheelchair to make his usual trips to [**Company 2486**]. He also notes nausea and nonbloody vomitting after every meal over this same time period. He denies abdominal pain or diarrhea. He further denies shortness of breath. He denies fevers or cough. He further denies chest pain, palpitations, abdominal pain, urinary pain In the ED, VS were initially: 97.9, BP 114/56, HR 75, RR 24, O2 95% on NRB, falling to mid-80s on RA. On lung exam, he had diffuse rales and rhonchi. CXR showed posible LLL infiltrate. Labs notable for creatinine elevated to 2.1 and potassium of 5.6, ABG 7.38/49/202. He was given 750 mg IV levofloxacin, 125 mg IV methylprednisone, and 1 round of albuterol/ipratropium nebulizers. He was also given 10 units insulin and 1 amp D50 for the hyperkalemia as well as Zofran 4 mg IV and Tetanus vaccination. EKG was similar to baseline. NIPPV was tried for comfort, but patient did not cooperate with it. Thus, the patient was changed to nonrebreather. 97.9. 79, 110/56, 19, 100% NRB . On admission to the MICU patient states that he feels better. He denies current nausea, vomitting, chest pain, shortness of breath, abdominal pain, or other symptoms. Past Medical History: Past Medical History: 1. Diabetes, insulin dependent, with neuropathy, retinopathy, nephropathy, and diabetic foot ulcers. s/p bilateral BKAs due to nonhealing ulcers. LBKA [**2113**], RBKA [**2118**] 2. h/o IVDU/morphine addiction: On methadone. 3. COPD: 1 ppd / 40 years. No PFTs on file 4. Chronic renal insufficiency: Recent baseline 1.2. Multiple hospitalizations with bumps into the 2s. 5. HTN 6. PVD: h/o recurrent leg ulcers, cellulitis 7. ? Hepatitis C 8. GERD 9. h/o MRSA and VRE infection 10. h/o decubitus ulcer, now healed Social History: Lives with his girlfriend, [**Name (NI) **], who helps him with ADLs. Has VNA care who he says helps wash him, give him medications and prepare his meals. He has spoked 1ppd x 40 years. Denies Etoh use. Denies recreational drug use currently. Family History: NC Physical Exam: Admission exam: VS: O2 Sat 88-92% on 5L NC, bP 100/50, RR 20, GEN: Middle-aged man in NAD, awake, alert, appears depressed. Very poor hygiene. HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, large tongue, moist mucosa NECK: Supple CV: Distant heart tones, regular, no murmurs. CHEST: distant breath sounds. Faint expiratory rhonchi. ABD: obese, soft, nontender, + bowel sounds [**Name (NI) **]: R 2nd and 3rd fingers black from cigarettes, multiple cigarette burns on fingers, bilateral BKA stumps erythematous, multiple abrasions, 1.5 cm ulcer on bottom of R stump, no significant discharge, L forearm cut marks SKIN: R groin erythematous rash in skin folds with satellite lesions NEURO: CNs II-XII grossly intact, alert and oriented, conversant Pertinent Results: Admission labs: [**2121-3-16**] 01:25AM GLUCOSE-231* UREA N-34* CREAT-2.1* SODIUM-138 POTASSIUM-6.2* CHLORIDE-103 TOTAL CO2-30 ANION GAP-11 [**2121-3-16**] 01:25AM WBC-11.0# RBC-4.48* HGB-13.3* HCT-41.0 MCV-92 MCH-29.6 MCHC-32.3 RDW-15.6* [**2121-3-16**] 01:25AM NEUTS-83.9* LYMPHS-9.5* MONOS-4.8 EOS-1.4 BASOS-0.4 [**2121-3-16**] 01:25AM PT-12.3 PTT-28.2 INR(PT)-1.0 Brief Hospital Course: Mr.[**Known lastname 50416**] is a 59 year-old gentleman w/ DM2 who presented w/ malaise and hypoxia. 1. Hypoxia, hypercarbia: Initial ABG 7.38/49/200 on nonrebreather. Patient was immediately weaned to 5L NC in the MICU with O2 Sats 88-92%. Although mental status was initially excellent, after ~5 hours in MICU patient suddenly became obtunded and was not arousable to sternal rub. O2 Sats remained ~90%. ABG showed 7.29/66/44. Actue hypercarbia was likely secondary to a combination of baseline COPD and severe upper airway obstruction in the setting of a large tongue and oral soft tissues as well as poor posture. Patient likely additionally has both obstructive sleep apnea and/or obesity-hypoventilation syndrome. BiPap was used intermittently with improvement in mental status and ventilation. On transfer to the floor, pt was satting in mid 90's on room air and using BiPAP at night. Mr. [**Known lastname 50416**] was treated empirically for COPD exacerbation including standing nebulizers, azithromycin for a 5-day course, and prednisone 60 mg taper. Sleep consult was obtained to organize home nocturnal CPAP vs bipap. Prior to discharge, follow-up was made with pulmonary (Dr. [**Last Name (STitle) 4507**], pulmonary function lab for PFTs and sleep [**Last Name (STitle) **] for outpatient sleep studies. He will have home BiPAP arranged by sleep clinic. 2. Nausea and vomitting: This may have been secondary to viral illness or generalized malaise secondary to intermittent hypercarbia at home. None since arrival. UA was not consistent with a urinary tract infection as the etiology. 3. Acute on chronic renal insufficiency: Creatinine 2.1 on admission, from 1.2 when last checked ~14 months ago. Creatinine rose after 2L fluid challenge. Urine lytes were not consistent with pre-renal etiology. This was thought to be most likely secondary to ATN in the setting of hypoension at home from nausea and vomitting. He continued to make 30 cc/h urine. Renal ultrasound demonstrated no evidence of hydronephrosis. Creatinine continued to improve during hospital course as it dropped to 1.5 the day before discharge. 4. Chronic pain: Methadone and gabapentin were recently increased by pt's PCP. [**Name10 (NameIs) **] were held in the setting of altered mental status as well as acute renal failure initially. On transfer to general medical wards, pain medication was restarted as creatinine improved from 2.1 on admission to 1.5. Pt was restarted on outpatient regimen of 90mg. 5. Poor self-care: Patient reported that his girlfriend / visiting nurse take care of him. However, on admission he smelled bad and was covered in several layers of dirt. He also had multiple cigarette burns and cuts on his arms, likely indicative of attempts at self harm. He denied suicidality on admisison. He is likely depressed and he will need psychiatric follow-up. # Type II Diabetes Mellitus: Novolin and humalog SS were continued per home regimen. He was discharged on home dose of 70/30 40 units in the AM and 20 in PM. He has close PCP follow up on [**3-27**] and will have Electrolytes, BUN and Cr labs drawn by VNA on [**3-24**] and these will be faxed to his PCP's office. On admission, patient stated his desire to be DNR/DNI. He further ellaborated that he would want no invasive lines or procedures including arterial lines or central venous lines. This was documented in the ICU consent in his chart. Medications on Admission: albuterol 90 mcg dfa prn ascorbic acid 500 mg daily clotrimazole cream ferrous sulfate 325 mg daily fluocinodnide .05% daily gabapentin 800 mg tid lisinopril 40 mg daily methadone 180 mg daily (split TID) miconazole 2% topical TID neosporin to wounds percocet 10-325, 2 tabs daily ranitidine 150 mg [**Hospital1 **] simvastatin 80 mg daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. [**Hospital1 **]:*3 Tablet(s)* Refills:*0* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). [**Hospital1 **]:*1 disk* Refills:*0* 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Hospital1 **]:*1 device* Refills:*0* 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. [**Hospital1 **]:*4 Tablet(s)* Refills:*0* 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. [**Hospital1 **]:*3 Tablet(s)* Refills:*0* 14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. [**Hospital1 **]:*3 Tablet(s)* Refills:*0* 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 16. Methadone 10 mg Tablet Sig: Nine (9) Tablet PO BID (2 times a day). 17. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Forty (40) units Subcutaneous QAM. 18. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Twenty (20) UNITS Subcutaneous QPM. 19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 20. Percocet 10-325 mg Tablet Sig: 1-2 Tablets PO once a day as needed for pain. 21. Hospital Bed Semi-Electric Hospital Bed with Gel Mattress; Diagnosis: Diabetes Mellitus, s/p bilateral BKA 22. Outpatient Lab Work Please check Electrolyte panel, BUN/Cr within one week of hospital discharge ([**2121-3-20**]) and fax results to patient's primary care physician: [**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**] Fax [**Telephone/Fax (1) 3382**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY: dyspnea, COPD, sleep apnea SECONDARY: diabetes Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair (pt has B/L BKAs and is wheelchair-bound) Level of Consciousness: Alert and interactive Mental Status: Clear and coherent Discharge Instructions: It was a pleasure being involved in your care, Mr. [**Known lastname 50416**]. You were admitted to the hospital with malaise and difficulty breathing which was likely secondary to COPD and OSA, for which we treated you with steroids, nebulizers and antibiotics as well as a BiPAP mask to wear at night. The Sleep [**Known lastname **] doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **] with BiPAP recs. Your medications have CHANGED as follows: 1. We ADDED Spiriva- take 1 cap daily 2. We ADDED Advair- take 1 puff twice per day 3. We ADDED amlodipine-take 5mg by mouth daily 4. We HELD your lisinopril (due to kidney function) 5. We ADDED prednisone 40mg x2 days, 20mg x3 days, 10mg x 3days Take this as follows: 1. 40mg by mouth for 2 more days ([**3-20**], [**3-21**]) 2. 20mg by mouth for the next 3 days ([**3-22**], [**3-23**], [**3-24**]) 3. 10mg by mouth for the following 3 days ([**3-25**], [**3-26**], [**3-27**]) Please continue taking your other medications as you have been before. Followup Instructions: Please keep the following appointments with your PRIMARY CARE DOCTOR, PULMONARY (lung) DOCTORS AND [**Name5 (PTitle) 9523**] [**Name5 (PTitle) 662**] DOCTORS: PCP: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2121-3-27**] 1:40 Sleep: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2121-4-11**] 10:00 Pulmonary: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/ [**2121-3-26**] 11:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2121-5-2**] 8:40 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2121-3-20**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

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53002

Discharge summary

report

Admission Date: [**2159-1-6**] Discharge Date: [**2159-2-9**] Date of Birth: [**2087-4-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: Thoracentesis, pleuroscopy, chest tube placement History of Present Illness: History of Present Illness: Mr. [**Known lastname 109257**] is a 71yo male with PMH significant for CAD, DM, HTN, CVA, & dementia. He presents with failure to thrive on this admission. Patient was recently discharged from OSH after being admitted for fatigue and unable to stand. Course of hospital course is not known. He was discharged to rehab on [**12-17**] and since then has had minimal PO intake and is unable to stand. He presented to geriatrics clinic yesterday and was referred to the ED for further work-up. . In the ED his initial vitals were T 98.2 BP 102/53 AR 68 RR 16 O2 sat 97% RA. He received ASA 325mg PO x1. Past Medical History: 1)CAD s/p CABG in [**2136**] 2)Type 2 DM 3)s/p CVA in [**2153**] and [**2156**]- Left basal ganglia affected. Patient has paresis of his right side. 4)Hypertension 5)Frontal lobe dementia 6)Hypercholesterolemia 7)GERD 8)Weight loss: Patient has had a greater than 20 pound weight loss over the past three to four months. Social History: Patient has been at rehab facility since he was discharged from [**Hospital3 **]. He lives with his wife on the bottom floor of a two family house. He was independent with ADLs. No current tobacco or alcohol use. Ambulates with cane. Family History: NC Physical Exam: vitals T 97.3 BP 112/70 AR 69 RR 22 O2 sat 100% RA Gen: Eyes closed, responsive to voice, difficult to understand speech HEENT: MM dry Heart: nl s1/s2, no s3/s4, +systolic murmur Lungs: decreased BS in RLL posteriorly with dullness to percussion Abdomen: soft, NT/ND, +BS Extremities: no edema, 2+ DP/PT pulses Neuro: Pt awake but unable to follow commands Pertinent Results: CT Chest on [**2159-2-2**]: IMPRESSION: 1. Despite new small caliber right apical pleural drain, large right hydropneumothorax persists, with interval increase in air component and large layering fluid component containing clot. 2. Asbestos-related pleural plaques. No pleural mass. 3. Right middle and lower lobe collapse and upper lobe segmental atelectasis due to combination of retained secretions and compression by effusion. Bronchoscopy should be helpful to evaluate and clear the endobronchial components. 4. Decreasing small left pleural effusion. 5. Stable, fusiform 4.8cm dilatation, ascending thoracic aorta. CT Chest on [**2159-1-6**]: IMPRESSION: Large bilateral pleural effusions, right greater than left, with extensive continuous pleural plaque calcification due to asbestos exposure. Differentiation between mass (mesotelioma , lung ca. ) , and collapsed lung is difficult without IV We cannot exclude a mass in the right lower lobe. Depending on the results of pleural effusion cytology, contrast-enhanced CT is recommended. Dilatation of the ascending aorta. Extensive coronary calcifications. Extensive calcification of the aortic valve. [**2159-2-6**] 02:37AM BLOOD WBC-10.4 RBC-3.68* Hgb-11.0* Hct-32.9* MCV-89 MCH-30.0 MCHC-33.5 RDW-16.5* Plt Ct-193 [**2159-2-6**] 02:37AM BLOOD Glucose-206* UreaN-41* Creat-1.1 Na-147* K-3.9 Cl-118* HCO3-20* AnGap-13 [**2159-2-2**] 01:12PM BLOOD CK-MB-3 [**2159-2-2**] 06:09PM BLOOD CK-MB-25* MB Indx-11.2* cTropnT-0.26* [**2159-2-3**] 01:51AM BLOOD CK-MB-49* MB Indx-17.0* cTropnT-0.60* [**2159-2-4**] 02:34PM BLOOD CK-MB-5 cTropnT-0.34* Pleural Fluid Chemistry Protein 1.0 Glucose 105 LD(LDH): 167 TUBE 4 Pleural Fluid WBC 100 RBC [**Numeric Identifier **] Poly 24 Lymph 64 Mono 12 EOs Pleural Fluid WBC 100 RBC [**Numeric Identifier 14123**] Poly 12 Lymph 80 Mono 8 EOs Brief Hospital Course: Mr. [**Known lastname 109257**] is a 71yo male with PMH as listed above who presents with FTT and was found to have a large R sided pleural effusion on cxray. . #)R pleural effusion: Patient found to have large R sided pleural effusion on cxray. In context of recent weight loss and lethargy concerned about underlying malignancy. He has a past history of smoking cigars but currently has no tobacco use. Pt now s/p thoracentesis. Afebrile and has no leukocytosis. Cytology from thoracentesis and pleural biopsies were negative, although gross findings concerning for malignancy. Chest tube and pleurex catheters were placed. Chest tube has been pulled after drainage plateaued and pleural catheter still in place to drain fluid as needed. Fluid studies from [**2-1**] show gram + cocci in clusters, cell count with diff is pending. Pleural fluid hematocrit is 16 and also high counts concerning for empyema. Patient subsequently became hypotensive and was transferred to MICU service for further management of empyema/hypotension. Chest-tube was placed. Patient eventually succumbed to complications from empyema and expired. . #)Anemia: Baseline Hct in low 30's. Hct on admission~35 and dropped to 31, 28, and then 22, received 2 units PRBC and bumped to 29. Had recurrent hemothorax that eventually led to patient becoming hypotensive and transferred to the ICU. . #)Weight loss: Per OMR and fellow's note patient has had significant weight loss over the past several months. Per OMR, when he saw his geriatrician in [**11-22**] he had lost ~20lbs at that time. Likely underlying malignancy given new pleural effusion. [**Name (NI) **] sister who is healthcare proxy has refused PEG tube placement in the past. Started low-dose megestrol for appetite stimulation, as patient's sister has specifically requested this. Liver enzymes elevated, particularly alkaline phos, source unclear. Could be due to biliary stasis due to decreased PO intake, as GGT also elevated. Nutrition supplements with Ensure. Nutrition consulted. Malignancy workup as above. . #)Lethargy: Patient initially extremely tired and not responsive to commands. Likely related to large R sided pleural effusion. Has improved somewhat after thoracentesis. He has also had significant weight loss with poor PO intake over the past few weeks. TSH WNL. Anemia work-up as below . #)Frontal lobe dementia: Continue home regimen of memantine. . #)CAD: s/p CABG. Patient denies chest pain on this admission. Patient had troponin leak after hypotensive episode. Continue ASA, beta blocker . #) History of CVA: Ct ASA 325mg PO daily . #)Hypertension: Patient does not appear to be on any medications at home although history of HTN documented in OMR. He was started on beta-blocker in ED. Continue Metoprolol 12.5mg PO BID with hold parameters. . #)Type 2 DM: Patient on Metformin at home. Per OMR, BSs~120's. Given poor PO intake concerned that his BSs may drop. Held oral regimen; restarted at time of discharge . #)Communication: Sister [**Telephone/Fax (1) 109258**] Medications on Admission: Ecotrin 325 mg daily Ferrous sulfate 325 mg daily Metformin 500 mg [**Hospital1 **] Prilosec 20 mg daily Vitamin B compex 1 tab daily Namenda 5 mg [**Hospital1 **] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Empyema Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2159-2-18**]

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icd9cm

[ [ [] ] ]

[ "96.6", "34.91", "34.24", "34.04", "03.31", "34.21", "38.93", "34.09" ]

icd9pcs

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54679

Discharge summary

report

Admission Date: [**2111-10-2**] Discharge Date: [**2111-10-7**] Date of Birth: [**2087-4-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Sore throat Major Surgical or Invasive Procedure: Endotracheal Intubation/Extubation Direct Laryngoscopy History of Present Illness: 24 year old male transferred from [**Hospital1 6687**] by med flight intubated after presentation with epiglottitis. According to the wife, he had been having sore throat x 4 days which had been improving in the past two days until today when the pain worsened. She had brought him throat spray and ibuprofen which he took on the day of admission. Within hours, breathing acutely worsened, and he appeared to be in respiratory distress and was brought to the [**Hospital1 6687**] ED. By report, in the [**Hospital1 6687**] ED initial vitals were T:98.9 P:70 BP142/79 SaO2100%RA, he was gasping, stridorous and tripoding. He was given racemic epi nebs x2, methylprednisolone 125mg IV, and amp/sulbactam 3g IV. Xray showed epiglotits, he was taken to the operating room and prepared for cricotomy however was intubated with rapid sequence with 10mg Vercuronium, without difficulty by anesthesia using a 7.0 ETT. He as then given 200mg fentanyl and 2mg midazolam and transferred to [**Hospital1 18**]. On arrival to the [**Hospital1 18**] ED, he had a CXR to confirm placement of the ET tube and was seen by ENT who recommended decadron 10g Q8H. He was admitted to the MICU for further management. Vitals on transfer were P75 BP119/54 On arrival to the MICU, he was intubated, sedated and unable to contribute to the medical history. Past Medical History: Denies history of coronary artery disease, diabetes or allergy. Social History: Employed in construction, he smokes marijuana 4-5 times daily and does not smoke cigarettes. Does not drink or do any other substances. Family History: denies history of coronary artery disease, diabetes or allergy. Physical Exam: Physical Exam: Vitals: T:98.6 BP:99/64 P:100 R:18 O2:100% 500x25 PEEP 5, 50% FiO2 General: Intubated, sedated, withdrawing to pain, moving all extremities HEENT: PEERL, anicteric sclera, ET tube 23 at the teeth. Neck: supple, 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: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: ADMISSION LABS =============== [**2111-10-2**] 08:00PM BLOOD WBC-29.2* RBC-5.66 Hgb-15.8 Hct-47.1 MCV-83 MCH-28.0 MCHC-33.7 RDW-13.1 Plt Ct-312 [**2111-10-2**] 08:00PM BLOOD Neuts-92.6* Lymphs-4.7* Monos-2.1 Eos-0.3 Baso-0.2 [**2111-10-2**] 08:00PM BLOOD Glucose-126* UreaN-14 Creat-0.9 Na-139 K-3.6 Cl-103 HCO3-24 AnGap-16 CT NECK: FINDINGS: The visualized intracranial contents are grossly unremarkable. The lenses and globes are normal. A small mucus retention cyst is seen within the right maxillary sinus, otherwise, the imaged paranasal sinuses and mastoid air cells are well aerated. The submandibular and parotid glands are symmetric and unremarkable. The vocal cords are normal. The internal carotid arteries and jugular veins are normal. The thyroid is normal. The imaged lung apices are unremarkable. An endotracheal tube is present with its tip terminating 3.2 cm above the carina. An orogastric tube is also present but the distal tip was not imaged. The epiglottis appears to be enlarged and effaces the left piriform sinus, although this may be related to the endotracheal tube. There is obscuration of the fat in the paraglottic space, consistent with stranding; however, no abscess or rim enhancing fluid collection is seen. The epiglottis itself does not avidly enhance. There are scattered cervical lymph nodes, at all levels, which do not meet CT size criteria for lymphadenopathy, but may be reactive. A small amount of oral secretions are seen at the level of the ET tube balloon. IMPRESSION: Findings consistent with known epiglottitis without abscess formation. Brief Hospital Course: Mr. [**Known lastname **] is a pleasant 24 year old male with no significant medical history who presented with epiglotitis. # Epiglottitis: The patient initially presented to [**Hospital1 **] with respiratory distress after 4 days of sore throat. He had a plain film which confirmed the diagnosis of epiglotitis. He was endotracheally intubated and then transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**] he had a CT scan which did not show any evidence of abscess. He had improvement in his airway swelling after 48 hours of antibiotics and steroids and he was able to be extubated on [**2111-10-5**]. He was initially covered empirically with IV ceftriaxone and clindamycin. No organism was identified on blood cultures. Monospot test was negative. On [**2111-10-6**] antibiotics were narrowed to just Clindamycin PO. Upon further discussion, Augmentin was also started to cover the most common bacterial causes (Strep, MSSA, MRSA, H. flu). The patient was discharged with prescriptions to complete a 14 day course of Clindamycin + Augmentin. He was also treated with high dose dexamethasone to reduce swelling which was transitioned to a prednisone taper which he continued at discharge for 3 more days. # Prophylaxis: Subcutaneous heparin # Communication: wife [**Name (NI) 111816**] [**Telephone/Fax (1) 111817**] # Code: Full code TRANSITIONAL ISSUES - F/U with PCP s/p epiglotits requiring intubation - F/U with ENT Medications on Admission: none Discharge Medications: 1. Clindamycin 450 mg PO Q6H RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hours (4 times a day) Disp #*138 Capsule Refills:*0 2. PredniSONE 30 [**2111-10-8**] PO daily Duration: 1 Doses Start: In am RX *prednisone 10 mg [**2-10**] tablet(s) by mouth take 3 tabs on [**10-8**] tabs on [**10-9**] tab on [**10-10**] Disp #*6 Tablet Refills:*0 3. PredniSONE 20 [**2111-10-9**] PO daily Duration: 1 Doses Start: After 30 [**2111-10-8**] tapered dose. 4. PredniSONE 10 [**2111-10-10**] PO daily Duration: 1 Doses Start: After 20 [**2111-10-9**] tapered dose. 5. Amoxicillin-Clavulanic Acid 875 mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablets(s) by mouth every 12 hours (twice a day) Disp #*24 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary - Epiglottitis 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 here at [**Hospital1 18**]. You initially went to the hospital with sore throat and difficulty breathing. This was due to an infection of your epiglottis called epiglottitis. This was causing your airway to obstructed and making it difficult to breathe. For this reason you had a breathing tube put in. You were then transferred to our hospital. You were given antibiotics to treat the infection and another medication (prednisone) to treat the swelling. With these treatments you improved and we were able to remove the breathing tube. You will need to finish a full course of antibiotics to be sure that your infection resolves, and complete a taper of prednisone. You should also follow-up with your primary care doctor in the next week, and follow up with the ENT specialists here after that. Please speak with your PCP regarding if you were vaccinated for H.flu, which is a bacteria that may cause epiglottitis. Followup Instructions: Name: [**Last Name (LF) 12925**],[**First Name3 (LF) **] J. Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 54491**] Phone: [**Telephone/Fax (1) 52946**] Appointment: Tuesday [**2111-10-13**] 11:30am Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 10827**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Known lastname **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 2349**] Appointment: Tuesday [**2111-10-27**] 2:45pm *Please arrive about 20 minutes prior to your appointment to fill out new patient paperwork. Please also bring your insurance card with you to the appointment.

[ "288.60", "464.31", "518.81", "458.29", "276.52" ]

icd9cm

[ [ [] ] ]

[ "31.42", "96.71" ]

icd9pcs

[ [ [] ] ]

6532, 6538

4255, 5714

317, 374

6605, 6605

2630, 4232

7768, 8557

1996, 2062

5769, 6509

6559, 6584

5740, 5746

6756, 7745

2092, 2611

265, 279

402, 1738

6620, 6732

1760, 1826

1842, 1980

58,597

172,267

36803

Discharge summary

report

Admission Date: [**2105-7-18**] Discharge Date: [**2105-7-25**] Service: SURGERY Allergies: Biaxin / Penicillins / Coumadin / Haldol / Caffeine Attending:[**First Name3 (LF) 301**] Chief Complaint: 84 year-old female presents as transfer from ED at [**Hospital3 **] Hospital for severe abdominal pain. Major Surgical or Invasive Procedure: ex lap, L colectomy, Hartmann's pouch History of Present Illness: HPI: 84 year-old female presents as transfer from ED at [**Hospital3 **] Hospital for severe abdominal pain. Pain began this AM and was very sharp and diffuse in nature. Pain was associated with vomiting and constipation - she has had only small liquid BMs over the past day. Patient has had decreased urinary output over the course of the day. No fevers or chills. Patient also notes decreased appetite over the course of this past week. She has never had pain like this before. Patient was guaiac positive on rectal exam at OSH. She underwent CT scan that showed stranding in LLQ. Given patient's significant vascular history, she was transferred to [**Hospital1 18**] out of concern that she may have mesenteric ischemia. Past Medical History: PMHx: Malignant hyperthermia, breast CA, prior MI, ?CHF, CVA, DM, HTN, PMR Social History: Soc Hx: No ETOH, No tobacco, lives at home with her daughter Family History: N/C Physical Exam: Exam: No evidence of cardiopulmonary activity. No evidence of neural reflex to painful stimuli, no pupillary reflex. Pertinent Results: [**2105-7-25**] 02:53AM BLOOD WBC-24.6* RBC-3.74* Hgb-10.2* Hct-32.5* MCV-87 MCH-27.2 MCHC-31.3 RDW-16.5* Plt Ct-191 [**2105-7-25**] 02:53AM BLOOD Calcium-7.8* Phos-6.5*# Mg-2.2 [**2105-7-25**] 09:04AM BLOOD Type-ART pO2-56* pCO2-74* pH-6.95* calTCO2-18* Base XS--18 [**2105-7-25**] 09:04AM BLOOD Lactate-9.3* K-4.2 STAPH AUREUS COAG +. SECOND MORPHOLOGY. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. STAPH AUREUS COAG +. [**7-18**]: CTA Abdomen IMPRESSIONS: 1. Inflammatory change along the descending colon likely due to acute diverticulitis. No free air, drainable fluid collection, pneumatosis, or portal venous gas. Fluid tracking also along the liver, the spleen, the paracolic gutters and into the pelvis. There is diffuse distention of the colon, without wall thickening. 2. Atherosclerotic disease with narrowing of the SMA, and with calcified as well as noncalcified plaque along the visualized aorta. [**Female First Name (un) 899**] not definitely visualized. Status post aortobifemoral graft placement, with flow demonstrated through the grafts. 3. Atrophic pancreas with calcifications of the uncinate probably due to chronic pancreatitis. Pancreatic ductal dilatation and multiple small hypodense pancreatic lesions, which may represent side branch IPMNs. Recommend MRCP for further evaluation. 4. Subcentimeter likely hyperdense cyst of the left kidney, too small to accurately characterize. 5. Fibrotic changes in the visualized lung bases, with bronchiectasis and areas of mucus plugging noted in the left lower lobe. [**7-21**]: MRA head and neck Multiple small acute infarcts, in the right anterior cerebral and the posterior cerebral arterial territories, in the frontal, parietal, and occipital lobes likely embolic. Occlusion of the right common carotid, the cervical and intracranial portions of the internal carotid artery, with reformation of the supraclinoid segment. Patent anterior and middle cerebral arteries, anterior communicating, posterior communicating and arteries of the posterior circulation. Please note that the TOF MR angiogram of the head and neck are technically limited and hence assessment is limited. A small portion of the petrous carotid, on the right side may be patent. However, this can be further evaluated with CTA of the head and neck, if considered necessary for management. The patient needs vascular/INR consult. [**7-21**]: CTA Head and neck 1. Approximately 66% stenosis of the right internal carotid artery with significant amounts of soft and calcified plaque. 2. Severe atherosclerotic disease throughout the aorta and bilateral carotid arteries as described above. 3. Emphysematous changes within the lung. Could consider dedicated study if clinically indicated. [**7-22**]: CT Abd 1. No evidence for abscess. 2. Small amount of fluid in the pericolic gutters and pelvis. 3. Left pleural effusion. 4. Layering of the gallbladder, likely representing small stones or biliary sludge. 5. Dilated pancreatic duct and pancreatic cyst, grossly unchanged from previous study. [**7-24**]: Pathology Colon, segmental resection: I. Transverse (A-F): Colonic segment with ischemic colitis demonstrating ulceration, focally transmural extension and serositis, and involving one of two resection margins. No definitive perforation identified. Three regional lymph nodes with no malignancy identified. II. Descending (G-J): Colonic segment with extensive ischemic colitis with focally transmural necrosis and serositis; ischemic changes extend to both stapled resection margins. Two regional lymph nodes with no malignancy identified. III. Sigmoid (K-P): Colonic segment with extensive ischemic colitis with focally transmural necrosis and serositis; ischemic changes extend to one of two stapled resection margins. Uninvolved colonic mucosa with hyperplastic changes. Six regional lymph nodes with no malignancy identified. IV. Rectal stump (Q-S): Colonic segment with ischemic colitis with focally transmural necrosis and serositis. Viable stapled resection margins demonstrating focal, mild active colitis. Note: The differential includes a vascular insult, certain infections (e.g. C. difficile) or, less likely, a severe drug effect. Clinical correlation is suggested. Brief Hospital Course: [**7-19**]: Admitted to SICU under Dr. [**Last Name (STitle) **], Cardiac r/o for bradycardic episodes in ED, Start empiric Cipro/Flagyl, Patient treated conservatively with NPO, NGT decompression, IVF. Serial exams and hematocrits. Evaluated by vascular surgery. CT scan shows descending colon diverticulitis w narrowing of SMA and celiac arteries. Celiac and SMA calcifiction present, however both opacify w contrast, no intervention required. [**7-21**] Neurology consulted new onset weakness in her LEFT hemibody weakness; rec's CTA and MRA, q1h neuro checks.MRI/MRA showed occlusion of the right common carotid there is string of pearls sign on DWI suggesting hypoperfusion stroke. Patient evaluated for possible R CEA by vascular surgery. The patient continued to have abdominal tenderness throughout her hospital course. Hematocrits remained stable. On [**7-24**] patient's symptoms worsened, and given peritoneal signs underwent ex-lap, revealing ischemic sigmoid colon.Left colectomy, Hartmann procedure, Transverse colostomy were performed. Following surgery, patient was weaned off of sedation but remained unresponsive. Following a thorough discussion with the family regarding patient prognosis and benefits and alternatives to continued treatment, the family made a decision to withdraw care. The patient was changed to comfort measures only and expired at 10:34a on [**2105-7-25**]. Medications on Admission: Humalog 50/50, ASA 81 mg qd, Ventolin, K Dur 20 mg qd, Simvastatin 20 mg qday, Omeprazole 20 mg qd, Lasix 20 mg qd Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Gangrenous colon, sepsis Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A

[ "038.11", "729.89", "427.32", "557.1", "276.8", "780.09", "433.11", "995.91", "428.0", "V12.54", "440.0", "725", "562.11", "401.9", "412", "414.01", "250.00", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "45.75", "38.93", "46.13" ]

icd9pcs

[ [ [] ] ]

7512, 7521

5912, 7317

361, 400

7590, 7600

1513, 5889

7652, 7658

1356, 1361

7484, 7489

7542, 7569

7344, 7461

7624, 7629

1376, 1494

218, 323

428, 1162

1184, 1261

1277, 1340

81,173

157,750

41526

Discharge summary

report

Admission Date: [**2123-4-14**] Discharge Date: [**2123-4-20**] Date of Birth: [**2050-8-3**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2123-4-14**] Aortic Valve Replacement (21 CE Magna Pericardial) History of Present Illness: 72 year old man has a history of aortic stenosis,hypertension, hyperlipidemia, diabetes. He initially felt exertional dyspnea while walking fast started about 1 year ago. He attributed his shortness of breath to being overweight. He lost some weight and his shortness of breath improved, however he continued to feel exertional dyspnea with activity. In addition, he presently notes occasional lightheadedness as well as some mild chest discomfort at rest. He denies palpitations,claudication, edema, orthopnea, PND. Based on the the patient worsening aortic stenosis seen on echo noted below, he is now referred for a cardiac catheterization and possible surgical evaluation. Past Medical History: Aortic Stenosis Hypertension Hyperlipidemia GERD Diabetes Sleep Apnea - CPAP Peripheral Autonomic Neuropathy Osteoarthritis Mild Anemia Depression Tonsillectomy as a child Right Hip Replacement [**2117**] Social History: Race:Caucasian Last Dental Exam:1 year ago Lives with:wife Occupation:semi-retired; He works as a school bus driver Tobacco:quit 35 years ago ETOH: occasionally - 3 beers every week Family History: His father had an MI at 62 and died at age 71 of MI Physical Exam: Height: 5 feet 9 inches Weight: 217 lbs Pulse:68 Resp:18 O2 sat: 99/RA B/P Right:133/69 Left: 144/66 General: Elderly 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 3/6 systolic ejection murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit: transmitted murmurs bilaterally Pertinent Results: [**2123-4-14**] Intraop TEE [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT PRE-CPB: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple 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 severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. POST-CPB: There is a bioprosthetic valve in the aortic position. The valve is well-seated, the leaflets are normally mobile, and there is no paravalvular leak. The peak gradient across the aortic valve is 24mmHg, the mean gradient is 11mmHg with a CO of 4.8.The LV chamber size is small, consistent with hypovolemic state. The LV systolic function appears normal, the estimated EF>55%. The RV size and function appear normal. There is no evidence of aortic dissection. . [**2123-4-20**] WBC-7.2 RBC-3.16* Hgb-9.7* Hct-27.8* RDW-13.7 Plt Ct-197 [**2123-4-19**] WBC-7.8 RBC-3.12* Hgb-9.6* Hct-28.0* RDW-14.1 Plt Ct-159 [**2123-4-17**] WBC-10.9 RBC-3.20* Hgb-9.8* Hct-28.6* RDW-14.0 Plt Ct-130* [**2123-4-16**] WBC-10.5 RBC-3.12* Hgb-9.8* Hct-27.8* RDW-14.0 Plt Ct-106* [**2123-4-20**] 05:45AM BLOOD PT-23.3* INR(PT)-2.2* [**2123-4-19**] 05:23AM BLOOD PT-18.9* INR(PT)-1.7* [**2123-4-18**] 04:50AM BLOOD PT-15.0* INR(PT)-1.3* [**2123-4-17**] 05:20AM BLOOD PT-13.8* INR(PT)-1.2* [**2123-4-20**] Glucose-126* UreaN-36* Creat-1.1 Na-139 K-4.2 Cl-98 HCO3-33* [**2123-4-19**] Glucose-136* UreaN-33* Creat-1.0 Na-139 K-4.4 Cl-103 HCO3-29 [**2123-4-17**] Glucose-129* UreaN-35* Creat-1.1 Na-137 K-4.2 Cl-103 HCO3-26 [**2123-4-16**] Glucose-153* UreaN-26* Creat-1.2 Na-140 K-4.2 Cl-105 HCO3-28 [**2123-4-20**] Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 90328**] was a same day admit and on [**2123-4-14**] he was brought to the operating room where he underwent an aortic valve replacement (Aortic Valve Replacement #21 CE Magna Pericardial)with Dr. [**Last Name (STitle) **]. Please see operative report for surgical details. Following surgery, he was transferred to the CVICU intubated and sedated. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated without incident. He was weaned off pressors and on post-op day one he was resumed on beta-blockers/statins/aspirin. Chest tubes and epicardial pacing wires were removed per protocol. He was transferred to the step down unit for further monitoring. He developed postop atrial fibrillation. Beta blockade was advanced for rate control and he was started on Coumadin. INR was monitored daily and Coumadin was dosed for a goal INR between 2.0 and 3.0. Amiodarone was initially loaded but discontinued due to several pauses(all less than three seconds) as recommended by the [**Location (un) 2274**] cardiology service. There was no indication for pacemaker or any other antiarrhythmic at this time. Due to volume overload, he required several days of aggressive diuresis. Renal function remained stable. He continued to make clinical improvements and was eventually cleared for discharge to rehab([**Hospital 66**] Rehab and Nursing Center) on postoperative day six. Following discharge, he will followup with [**Location (un) 2274**] cardiology in approximately one month. If he remains in atrial fibrillation at that time, he will be evaluated for possible cardioversion. Following discharge from rehab, Dr. [**Last Name (STitle) 32467**] has agreed to monitor Coumadin as an outpatient. Prior to discharge, all appointments have been confirmed. Medications on Admission: AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once daily BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice daily GLIMEPIRIDE - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth twice daily HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once daily LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once daily METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth as directed take [**2-14**] tablet orally in the AM and 1.5 tabletes in the PM METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth twice daily MOM[**Name (NI) **] - (Prescribed by Other Provider) - 0.1 % Ointment - apply topically once daily OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once daily PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once every evening TRIAMCINOLONE ACETONIDE - (Prescribed by Other Provider) - 0.1 % Cream - apply to affect area twice daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once daily BLOOD-GLUCOSE METER [ONE TOUCH ULTRA SYSTEM KIT] - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE [SUPER CALCIUM] - (Prescribed by Other Provider) - Dosage uncertain GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE 1500 COMPLEX] - (Prescribed by Other Provider) - 500 mg-400 mg Capsule - 2 Capsule(s) by mouth twice daily LANCETS [ONE TOUCH ULTRASOFT LANCETS] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Dosage uncertain NIACIN - (Prescribed by Other Provider) - 1,000 mg Tablet Sustained Release - 2 Tablet(s) by mouth at bedtime OMEGA-3-DHA-EPA-FISH OIL - (Prescribed by Other Provider) - 1,000 mg (120 mg-180 mg) Capsule - 1 Capsule(s) by mouth three times per day Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. metformin 500 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 10. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to affected area. 11. glimepiride 1 mg Tablet Sig: Two (2) Tablet PO daily (). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**7-21**] hours as needed for pain/temp. 13. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Daily dose may vary according to INR. Adjust for goal INR between 2.0 - 3.0. 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: Please titrate accordingly. Preop weight approximately 98.6kg. 15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day: Titrate accordingly with Furosemide. Hold if K > 4.5. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Postop Atrial Fibrillation Hypertension Hyperlipidemia GERD Diabetes Sleep Apnea - CPAP Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage 2+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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) **] on [**2123-5-13**] at 1pm [**Telephone/Fax (1) 170**] . Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 90329**] and/or Dr. [**Last Name (STitle) 30448**] office will call patient with appt . Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 32467**] in [**5-18**] weeks, [**Telephone/Fax (1) 17663**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** . Labs: PT/INR for Coumadin ?????? indication Afib Goal INR 2.0 - 3.0 *** Prior to discharge from rehab, please arrange Coumadin followup with Dr. [**Last Name (STitle) 32467**]. Plan confirmed with office *** Completed by:[**2123-4-20**]

[ "401.9", "327.23", "715.90", "E878.1", "272.4", "530.81", "250.00", "424.1", "337.9", "496", "997.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

9892, 9981

4401, 6205

322, 390

10158, 10331

2292, 4378

11170, 12020

1539, 1593

8352, 9869

10002, 10137

6231, 8329

10355, 11147

1608, 2273

263, 284

418, 1096

1118, 1324

1340, 1523

28,224

162,603

18259

Discharge summary

report

Admission Date: [**2195-7-25**] Discharge Date: [**2195-8-7**] Date of Birth: [**2121-6-15**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: confusion, headaches Major Surgical or Invasive Procedure: s/p PEG tube placement History of Present Illness: Patient is a 74 yo woman with PMH of Alzheimer's Disease, Colon CA, who has had a rapid decline in her cognition. She is followed by Dr [**Last Name (STitle) **] from Neurology for her dementia. According to her husband and her daughter, she has had an acceleration in her decline over the last 4 months. There was some concern that this might be secondary to the Xeloda and [**Last Name (LF) 49565**], [**First Name3 (LF) **] these were stopped about 2 months ago. Since that time she has coninued to decline and over the last 5 days she has had a particularly rapid decline in speech, confusion and gait. Her speech is much more limited and she has trouble expressing herself meaningfully. This was particularly worse today. Her gait is more unsteady over the last few days but she can still walk unassisted. This prompted imaging. Although there is no CT in our system, her husband says that she had a CT somewhere that showed concern for bleeding. An MRI here [**2195-7-21**] was abnormal with extensive white matter hyperintensities. The patient is unable to give any account as to why she is here. She has no complaints or pain. The patient's family does not note any focal weakness. She complained of a headache this morning, but now denies this and has not complained of headaches any other days this week. She denies any neck stiffness. ROS: HA as above. No neck pain. NO cough. No fevers, chills, nausea, vomitting, diarrhea. Past Medical History: Alzheimer's Disease Colon Cancer: no known mets. Of chemo agents (Xeloda and [**Month/Day/Year 49565**]) for 2 months now. Hypercholest TAH/BSO 30 yr Hypothyroid Social History: She has stayed at home raising a number of her grandchildren. She quit smoking about ten years ago after smoking one pack per day. She drinks alcohol only very rarely. Family History: Her mother developed [**Name (NI) 2481**] disease in her early 80s. Her father died at a young age from an accident. Physical Exam: T- 96.0 BP- 199/82 HR- 77 RR- 16 O2Sat 97 RA Gen: Lying in bed, NAD, smiling HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with majority of exam, inappropriately laughing or smiling on occasion. Oriented to self and husband, but does not recognize her daughter and does not know month, year or place. Her husband feels that the disorientation to place and year is likely baseline, but no knowing her daughter might be new. She is fluent to about 6 words and has some spontaneous speech which is gramatically correct and somewhat appropriate to the situation. She follows simple 1 step commands midline, but mixes left/right commands and cannot do two step commands. She names watch but not parts. She cannot read without her glasses. She repeats a simple sentence. She does not have unilateral neglect. Mild grasp. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Could not cooperate with fundoscopy. Visual fields are full to threat. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Palate elevation symmetrical. trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift. No asterixis. Was full strength in the triceps, bicpes, Ips, DF and PF, but could otherwise not test formally. Sensation: Intact to light touch and cold. Could not cooperate with DSS testing. Reflexes: +2 and symmetric throughout UE. 3+ knees. 2+ ankles. Crossed adductors bilaterally. Toes mute bilaterally Coordination: reaches for my finger without ataxia but cannot test more specifically. Gait: Moderate based, mildly unsteady. Romberg: not attempted. Pertinent Results: [**2195-7-25**] 11:29PM ALBUMIN-3.6 [**2195-7-25**] 11:29PM PHENYTOIN-12.8 [**2195-7-25**] 05:35PM CK(CPK)-33 [**2195-7-25**] 05:35PM CK-MB-NotDone cTropnT-<0.01 [**2195-7-25**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2195-7-25**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2195-7-24**] 10:32PM PT-12.7 PTT-25.1 INR(PT)-1.1 [**2195-7-24**] 09:20PM GLUCOSE-99 UREA N-13 CREAT-0.9 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2195-7-24**] 09:20PM ALT(SGPT)-16 AST(SGOT)-17 ALK PHOS-87 TOT BILI-0.8 [**2195-7-24**] 09:20PM LIPASE-41 [**2195-7-24**] 09:20PM CK-MB-2 cTropnT-<0.01 [**2195-7-24**] 09:20PM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.3 [**2195-7-24**] 09:20PM TSH-4.1 [**2195-7-24**] 09:20PM FREE T4-1.2 [**2195-7-24**] 09:20PM WBC-9.3 RBC-5.06 HGB-14.6 HCT-44.5 MCV-88# MCH-28.9# MCHC-32.9 RDW-13.7 [**2195-7-24**] 09:20PM NEUTS-58.2 LYMPHS-35.2 MONOS-5.0 EOS-1.3 BASOS-0.3 [**2195-7-24**] 09:20PM PLT COUNT-299 [**2195-8-4**] 06:45AM BLOOD PT-20.2* PTT-34.5 INR(PT)-1.9* [**2195-8-6**] 06:55AM BLOOD PT-17.3* PTT-30.0 INR(PT)-1.6* [**2195-8-5**] 07:55AM BLOOD Phenyto-11.8 [**2195-8-5**] 03:04PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017 [**2195-8-5**] 03:04PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2195-8-5**] 03:04PM URINE RBC-[**12-31**]* WBC->50 Bacteri-MANY Yeast-NONE Epi-0 URINE CULTURE (Final [**2195-8-6**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Non-contrast CT head [**2195-7-24**]: IMPRESSION: 1. Evaluation slightly limited by motion artifact. 2.7-cm rounded focus of right frontal hyperdensity is most consistent with parenchymal hemorrhage. Though no definite underlying lesion was seen on MRI from [**2195-7-21**], that assessment was incomplete without intravenous contrast, and this focus of hemorrhage may be associated with an underlying lesion. 2. Relatively symmetric distribution of white matter disease, with subcortical involvement, is more consistent with extensive chronic small vessel ischemic change, perhaps of Binswanger-type, likely with focal areas of chronic infarction, than an unusual edema pattern related to occult metastatic disease. Non-contrast head CT [**2195-7-25**]: IMPRESSION: 1. No interval change in the right frontal intraparenchymal hemorrhage, with associated edema. 2. Extensive periventricular and subcortical white matter low attenuation, which likely reflects extensive chronic small vessel ischemic changes. However, foci of metastatic disease cannot be excluded. MRI head [**2195-7-25**]: IMPRESSION: Markedly limited study due to patient motion. 2.8 x 2.3 cm intraparenchymal hemorrhage of the right frontoparietal lobe as before. There is a central area of T1 hyperintensity within the hematoma which may represent blood versus enhancement. A followup study after the resolution of the hematoma can be obtained to assess for any underlying lesions. EEG [**2195-7-26**]: IMPRESSION: This is an abnormal portable EEG due to the disorganized, low voltage, and slow background consistent with a mild encephalopathy and suggestive of dysfunction of bilateral subcortical or deeper midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features and no electrographic seizure activity was noted. CXR [**2195-7-24**]: FINDINGS: Portable chest radiograph is reviewed without comparison. Cardiomediastinal contours are unremarkable. Pulmonary vascularity is normal. Lungs are grossly clear, though note is made of slight elevation of the left hemidiaphragm. There is no pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: A non-contrast CT of the head in the emergency room showed a 2.7 x 2.2 cm right frontal intraparenchymal hemorrhage. While in the emergency room, the patient had a witnessed generalized tonic-clonic seizure, and was loaded with Dilantin, then ultimately started on 100 mg TID for maintenance. Post-ictal confusional state was noted. The patient was admitted to the neurologic ICU for further evaluation and management. Her blood pressure was closely watched with a goal MAP less than 130. She underwent repeat imaging on [**7-25**], including an MRI of the head, which showed a stable right frontal hemorrhage and again raised concern for amyloid angiopathy. She remained encephalopathic, which was attributed to both underlying illness and medication effect. An EEG confirmed her persistent encephalopathic state, but no subclinical seizures or epileptiform changes were seen. On [**2195-7-27**], the patient was determined to be stable for transfer to the floors for further management. The patient failed multiple swallowing evaluations attributed to her impaired level of alertness and attentiveness. She was maintained npo, but the family did not want a nasogastric tube placed due to concerns for discomfort. Over the next days, the patient continued to remain encephalopathic. She was generally hypertensive, and standing IV metoprolol was titrated upward. She did not follow commands or interact with those around her. On [**2195-8-3**], the staff and family held a meeting regarding the direction of her care. Her outpatient neurologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was among those present. The family expressed concern that she seemed to continue to decline, even after arrival at [**Hospital1 18**]. After an extensive discussion, her husband expressed a strong desire to proceed with PEG placement in an effort to see how his wife might do in the coming weeks and months of supportive care. At this time, the patient's INR was rising; after evaluation, this was thought to be due to subcutaneous heparin, which was subsequently discontinued. The patient was given fresh frozen plasma to reverse her INR (1.9) prior to PEG placement by interventional radiology. However, the patient developed a transfusion reaction in response, with swollen eyes and hives noted. She was given benadryl with good effect and remained hemodynamically stable. PEG placement was delayed, but did occur on [**2195-8-5**]. Tube feeds and medications were initiated through the PEG tube later that day. The patient was noted to have cloudy urine and a urinalysis suggestive of a urinary tract infection (remained afebrile with normal WBC); she was started on a 5-day course of antibiotic (ciprofloxacin). Based on her MRI scans, there was concern for the possibility of amyloid angiitis that could be responsive to high-dose steroids. However, after extensive discussion, it was decided not to pursue a trial of steroids given possible risks associated with steroid treatment and the difficulty in assessing possible response to treatment. The patient remained stable with her encephalopathy over the final days of her stay. The patient was generally awake, with eyes open, occasionally attending to her environment. There was no spontaneous coherent speech, though the patient occasionally smiled. She was deemed stable for discharge to rehabilitation on [**2195-8-7**]. Medications on Admission: All: NKDA Meds: Aricept 10 daily lipitor 10 daily Citalopram 20 Levoxyl 75 mcg daily Memantine 10 [**Hospital1 **] Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Miconazole Nitrate 200-2 mg-% (9 g) Combo Pack Sig: One (1) Combo Pack Vaginal HS (at bedtime) for 2 days. 9. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3 times a day): Please dose so that patient receives 100 mg TID . 10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 3145**] Nursing Home - [**Location (un) 3146**] Discharge Diagnosis: Right frontal intracerebral hemorrhage Discharge Condition: Stable. Awake, intermittently alert, not speaking or following commands, weakly moving all four extremities, right side more than left Discharge Instructions: Please administer the medications as prescribed and have the patient follow-up with appointments as scheduled. If the patient experiences any new, worsening, or concerning symptoms, such as increasng somnolence or weakness, please contact the patient's neurologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 50382**]) or bring the patient to the nearest emergency room for further evaluation. Followup Instructions: Neurology Follow-Up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2195-9-15**] 9:30 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "V10.05", "331.0", "348.5", "E879.8", "294.10", "780.39", "999.8", "277.30", "431", "272.0", "348.30", "244.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11", "99.07" ]

icd9pcs

[ [ [] ] ]

13240, 13326

8548, 11980

337, 362

13409, 13546

4447, 8525

14041, 14329

2235, 2355

12147, 13217

13347, 13388

12006, 12124

13570, 14018

2370, 2735

276, 299

390, 1845

3520, 4428

2774, 3504

2759, 2759

1867, 2031

2047, 2219

57,764

103,584

38701

Discharge summary

report

Admission Date: [**2126-2-1**] Discharge Date: [**2126-5-14**] Date of Birth: [**2100-2-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: Multiple gunshot wounds of the abdomen and chest. Major Surgical or Invasive Procedure: [**2126-3-26**] Right AKA [**2126-3-19**] PTSG [**2126-3-15**] ORIF left elbow [**2126-3-13**] flex sig - WNL [**2126-2-21**] evac hematoma RLE [**2126-2-19**] washout, sump drain out, perioduo [**Doctor Last Name 406**] [**2126-2-15**] washout, duodenal repair, sump drain [**2126-2-12**] washout, trach, partial abd closure [**2126-2-10**] second look, washout, hemostasis, VAC replacement [**2126-2-9**] duodenal repair/[**Location (un) **] patch, partial closure [**2126-2-7**] washout, R colectomy, GJ tube, ortho closure except RLE [**2126-2-5**] washout, CCY, dressing change [**2126-2-2**] repair of R diaphragmatic laceration [**2126-2-2**] repair of duodenal injury [**2126-2-2**] repair of R renal vein injury [**2126-2-2**] LUE decompressive fasciotomy [**2126-2-2**] R ileofemoral thrombectomy, patch angioplasty of SFA [**2126-2-1**]: 1. Exploratory laparotomy. 2. Small-bowel resection. 3. Resection of transverse colon. 4. Right femoral line arterial line placement. History of Present Illness: This man was brought to the emergency room with multiple gunshot wounds to the chest and wounds in the back as well. He was taken to the operating room emergently and underwent a laparotomy first because his abdomen was positive. Past Medical History: PMH: HTN PSH: none Social History: married Family History: NC Brief Hospital Course: He was admitted to the Trauma service and taken immediately to the operating room for exploratory laparotomy, small-bowel resection, resection of transverse colon, and right femoral line arterial line placement. He was transferred to the Trauma ICU postoperatively sedated and vented. He was again taken back to the operating room on [**2-2**] for repair of right diaphragmatic laceration, repair of duodenal injury with lateral duodenostomy and wide drainage, repair of right renal vein injury, decompressive fasciotomies x4. On [**2-3**] he was noted with acute ischemia of his right lower extremity and was taken back to the operating room by Vascular surgery for ultrasound-guided puncture of left common femoral artery, contralateral second-order catheterization of right external iliac artery, abdominal aortogram, right lower extremity angiogram, iliofemoral thrombectomy on the right and vein patch angioplasty of right common femoral artery into the superficial femoral artery. He required multiple follow up procedures by orthopedics for debridement of the bony injuries and VAC placement of his right elbow injury. He underwent percutaneous tracheostomy on [**2-9**] with partial closure of abdomen and application of open abdominal dressing and again returned back to the operating room on [**2-15**] for exploratory laparotomy with drainage of his abdominal cavity. TPN was initiated early on. He was eventually weaned from the ventilator and evaluated by Speech for a Passy Muir valve. He would later be transferred to the regular nursing unit where he continued to require extensive nursing care. During the week of [**3-11**] he was sent back to the ICU with concern of sepsis. He was started on broad spectrum antibiotics (linezolid/Meropenem) and fluid resuscitated. CT scan of his torso demonstrated only small RLL opacity and 2 small intraabdominal fluid collection consistent with his ongoing leak. CT was otherwise unchanged. On [**3-13**] he underwent flex sigmoidoscope which was within normal limits. A RUQ ultrasound was done which demonstrated on biliary ductal dilation. He improved quickly, cultures were sent off which did not grow out anything. He then went back to the OR on [**3-15**] for planned ORIF of his right elbow. At that time his wound VAC was changed again and showing signs of improvement, although he still had persistent duodenal leak and drainage from the distal enterotomy. He was sent back to the floor several days later. His TFs had to be stopped because he was leaking them into his abdominal dressing. He was started back on TPN at that time. On [**3-19**] he was taken back to OR and underwent skin grafting of his entire abdomen using STSG from his non-functional RLE. A wound VAC was placed over Xeroform and he was planned to be on strict bedrest and lying flat for a total of 5 days in order to allow the grafts to take. He continued TPN and remained NPO. The VAC required multiple re-reinforcements during this week for leakage however remained intact. Vascular surgery has also been following and planned for RLE amputation. On [**3-25**] the abdominal VAC was replaced and the skin graft was assessed and appeared to be taking well especially on the left side and remained well vitalized. On [**3-26**] patient underwent right above knee amputation by vascular surgery. He tolerated the procedure well. On [**3-27**] his trach and Foley were removed and he was restarted on tube feeds. He continued to have leakage of his tube feeds via his fistula requiring multiple dressings changes throughout the day. He was evaluated by the wound/ostomy nurses who became creative in devising an appliance to help control the leakage and protect his skin. He was evaluated early on by Physical and Occupational therapy who worked with him on a regular schedule. He was eventually fitted for a prosthesis and at time of discharge was independent with wheelchair transfers and ambulation with assistive device. Social work remained closely involved throughout his hospital stay; multiple family/team meetings took place as there were many patient and family issues. Prior to discharge it was determined that there was a safe discharge plan in place when patient was ready to leave the hospital. At time of discharge he was on a regular diet, his TPN was stopped and he was independent with his dressing changes and activity of daily living. He was provided detailed instruction for follow up. Medications on Admission: none Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q 8H (Every 8 Hours): Dx: Chronic pain syndrome; s/p Above knee amputation on right w/ phantom limb pain. Disp:*qs Capsule(s)* Refills:*2* 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-9**] hours as needed for fever, pain. 4. Stump shrinker Dx: s/p Right Above Knee Amputation 5. Standard wheelchair Dx: s/p Right above knee amputation 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. Discharge Disposition: Home Discharge Diagnosis: s/p Multiple gunshot wounds Right diaphragmatic laceration Small bowel injury x3 Colon injury x1 Right renal vein laceration Duodenal injury Right elbow fracture Respiratory failure Sepsis Enterocutaneous fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (crutches, walker or cane). Discharge Instructions: You were hospitalized following multiple gunshot wound assault. Your injuries were very extensive requiring mulitple operations. Because of your injuries you have an abdominal wound that continues to leak fluid due to a fistula; this will eventually close as the others did. It is important that you continue to eat a well balanced diet with adequate protein and calories to facilitate in healing. You will follow up with Dr. [**Last Name (STitle) **] in 2 weeks and at least every 2-4 weeks thereafter to monitor the progress of your wounds. Plans for future surgery will be discussed over the next several months. If you notice that the drainage output from the fistula increases please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] or if at night you should call the page operator and ask to have the Acute Care service resident paged by calling [**Telephone/Fax (1) 13471**]. For questions or concerns during the weekdays you may also contact [**Name (NI) 17148**] [**Last Name (NamePattern1) 2819**], Nurse Practitioner for Trauma at [**Telephone/Fax (1) 67547**]. You were fitted with a shrinker for your stump in preparation for being fitted for a prosthesis over the next 8 weeks or so. You will require Physical therapy for training with the prosthesis once you have this. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **] for evaluation of your abdominal wound/fistula. Call [**Telephone/Fax (1) 600**] for an appointment. Follow up in 4 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Ortho Trauma for your right elbow; call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 4 weeks with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Vascular Surgery for your right leg amputation site; call [**Telephone/Fax (1) 2625**] for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2126-9-23**]

[ "285.1", "287.5", "999.31", "728.88", "868.14", "537.4", "780.65", "785.52", "E878.1", "863.30", "276.7", "354.0", "276.2", "577.8", "863.31", "584.5", "276.8", "E965.0", "599.0", "995.92", "862.1", "518.5", "518.81", "958.92", "867.2", "902.42", "569.81", "567.23", "998.12", "863.51", "958.91", "868.12", "276.1", "902.54", "813.11", "864.00", "863.50", "038.0" ]

icd9cm

[ [ [] ] ]

[ "00.14", "99.15", "83.45", "31.1", "45.62", "44.39", "46.23", "83.09", "84.17", "46.39", "77.67", "38.93", "45.73", "34.82", "88.42", "54.11", "39.50", "00.41", "96.72", "46.71", "54.62", "86.69", "45.74", "83.39", "79.32", "48.23", "04.43", "51.22", "38.95", "39.95", "39.32", "56.82", "83.65" ]

icd9pcs

[ [ [] ] ]

6913, 6919

1720, 6183

363, 1349

7176, 7176

8699, 9421

1693, 1697

6238, 6890

6940, 7155

6209, 6215

7368, 8676

273, 325

1377, 1609

7191, 7344

1631, 1652

1668, 1677

19,794

168,236

20370+57149

Discharge summary

report+addendum

Admission Date: [**2104-1-11**] Discharge Date: [**2104-1-16**] Date of Birth: [**2025-4-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1654**] Chief Complaint: Shortness of breath, Epigastric tenderness Major Surgical or Invasive Procedure: Blood transfusion History of Present Illness: 78 F presented to [**Hospital 4068**] Hospital with complaints of increasing shortness of breath, malaise, and some epigastric tenderness that she developed over night prior to her admission. For the last week she has been treated for pneumonia and a UTI with Levofloxacin. She denies any nausea, vomitting, change in stools, or urinary symptoms. Past Medical History: Significant for CAD, s/p CABG x 2, s/p MI, s/p PTCA, MDS, osteoporosis, colonic polyps, hypercholesterolemia, h/o L. hip fracture, s/p ORIF, dementia, and a hysterectomy for a prolapsed uterus. Social History: Significant for being a widow for the past 25 years. She has 6 children who are close to her but live quite a distance away from her. She lives alone. She denies any tobacco use but does admit to occasional alcohol use. Family History: Significant for Parkinson's disease in her sister, ovarian cancer in another sister, and [**Name2 (NI) 499**] cancer in a third. She also has family history of CAD, DM, and osteoarthritis. Physical Exam: At the time of acceptance to medicine team: PE: 74 24 130/80 99% on 2L Gen: Elderly woman in bed with NC in place in NAD HEENT: EOMI, anicteric sclera, no [**Doctor First Name **] Neck: Supple, R IJ site covered with sterile gauze Pulm: CTAB but very limited inspiration and poor positioning CVS: Irregularly irregular HR, +s1/s2, no g/m/r noted Abd: +BS, NT/ND/NR, no mass, no pulsation, no [**Doctor Last Name 515**] Ext: trace edema, +2 DP b/l, [**6-14**] stregnth thoughout ext Neuro: a&ox3, maew Pertinent Results: [**2104-1-11**] 05:09AM GRAN CT-650* [**2104-1-11**] 05:09AM PT-19.9* PTT-36.1* INR(PT)-2.8 [**2104-1-11**] 05:09AM PLT COUNT-23*# [**2104-1-11**] 05:09AM WBC-1.5* RBC-2.41* HGB-8.4* HCT-23.1* MCV-96# MCH-34.8* MCHC-36.3* RDW-20.1* [**2104-1-11**] 05:09AM TRIGLYCER-81 [**2104-1-11**] 05:09AM ALBUMIN-2.6* CALCIUM-7.5* PHOSPHATE-3.1 MAGNESIUM-1.6 [**2104-1-11**] 05:09AM CK-MB-NotDone cTropnT-0.41* [**2104-1-11**] 05:09AM LIPASE-63* [**2104-1-11**] 05:09AM ALT(SGPT)-645* AST(SGOT)-748* CK(CPK)-61 ALK PHOS-322* AMYLASE-84 TOT BILI-1.1 [**2104-1-11**] 05:09AM GLUCOSE-167* UREA N-24* CREAT-0.9 SODIUM-134 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12 [**2104-1-11**] 05:28AM freeCa-1.08* [**2104-1-11**] 05:28AM GLUCOSE-173* LACTATE-1.5 [**2104-1-11**] 05:28AM TYPE-[**Last Name (un) **] PH-7.40 [**2104-1-11**] 09:00AM HCV Ab-NEGATIVE [**2104-1-11**] 09:00AM HBsAg-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2104-1-11**] 02:32PM CK-MB-NotDone [**2104-1-11**] 02:32PM LIPASE-62* [**2104-1-11**] 02:32PM CK(CPK)-59 AMYLASE-85 [**2104-1-11**] 09:01PM PLT COUNT-19* [**2104-1-11**] 09:01PM WBC-1.3* RBC-2.34* HGB-7.8* HCT-23.0* MCV-98 MCH-33.5* MCHC-34.1 RDW-20.1* [**2104-1-11**] 09:01PM CALCIUM-7.7* PHOSPHATE-2.3* MAGNESIUM-1.7 [**2104-1-11**] 09:01PM CK-MB-3 cTropnT-0.48* [**2104-1-11**] 09:01PM LIPASE-63* [**2104-1-11**] 09:01PM ALT(SGPT)-539* AST(SGOT)-572* LD(LDH)-629* ALK PHOS-278* AMYLASE-95 TOT BILI-1.1 [**2104-1-11**] 09:01PM GLUCOSE-119* UREA N-21* CREAT-0.8 SODIUM-136 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12 [**2104-1-11**] MRCP: IMPRESSION: 1. Dilated common hepatic duct with smooth tapering to the pancreatic head. No choledocholithiasis present. Please note that the study is somewhat suboptimal due to non-breath hold technique. The above descrived findings may be secondary to sphincter dysfunction or ampullary stenosis. There is no mass in the region of the distal CBD or pancreatic head. 2. Cholelithiasis without evidence of cholecystitis. 3. Left adrenal nodule which is not well characterized on the current exam. Given the spiculated right lung mass, an evaluation with a dynamic CT is recommended to exclude metastatic disease involving the adrenal gland. [**2104-1-11**] ECHO: Conclusions: The left atrium is mildly dilated. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Resting regional wall motion abnormalities include septal akinesis/hypokinesis, apical akinesis, mid to distal anterior and anterolateral hypokinesis and inferior and inferolateral hypokinesis/akinesis. No definte left ventricular thrombus identified but cannot exclude. The right ventricle is dilated Right ventricular systolic function is probably preserved(however intrinsic function may be depressed given severity of tricuspid regurgitation). The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Mild to moderate ([**2-11**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: On [**2104-1-11**], Ms. [**Known lastname 23333**] was admitted to the surgical ICU under the care of Dr. [**Last Name (STitle) **]. With her epigastric tenderness, a troponin of 0.41, and shortness of breath, her exact diagnosis was unclear. Cardiology was consulted and felt that she experienced a troponin leak [**3-14**] demand ischemia. She was not having an acute coronary syndrome. A GI consult was obtained for a possible ERCP after an MRCP revealed cholelithiasis without evidence of cholecystitis. It was determined that with her overall condition (MDS, CAD) and improving exam, an ERCP was not indicated at this time. Since there was no evidence of cholecystitis or cholangitis, there was no indication for any surgical intervention either. On HD 3, Ms. [**Known lastname 23333**] was transferred out of the ICU and care was transferred to the medical service. On the floor Ms. [**Known lastname 23333**] began the receipt of a 7 day regimen of Levo and Flagyl for possible cholecystitis as per surgery rec. Otherwise, the pt was pain free and stable. A discussion about palliative care was held with the family who decided that rehab with a bridge to hospice would be their ideal plan (pt. still to have hct's followed and be transfused PRN). The pt was placed back on her most of her home medications except select blood pressure medications because of SBP in the low 100's. The pt received 1U PRBC's the day of discharge for a slowly decreasing hematocrit secondary to her myelodysplastic disease. Pt was then discharged to rehab. Medications on Admission: Lopressor 50 mg po BID Zestril 7 mg po QD Calcium with Vit D MVI Mevacor 40 mg po QD Aricept 10 mg po qd ASA QOD Fosamax 35 mg po qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Zestril 7 mg po qd Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Primary Diagnosis: 1)Cholelithiasis Secondary Diagnosis: 1)dementia 2)MDS with RAEB dx'd in [**12-15**] 3)CAD $)s/p CABG x 2 in the mid 70s and mid 80s. She also has apparently had stents and multiple ? myocardial infarctions. Had "mild MIs following hip repair in [**2100**]" as per her son. 5)Osteoporosis 6)Colonic polyps Discharge Condition: stable. Pt is pancytopenic with MDS, but is pain free, in good spirits, and has stable vitals Discharge Instructions: You were were admitted to the hospital for abdominal pain, fever and elevated liver enzymes suggestive of an infection of your gallbladder. You had an MRCP scan which showed that you do not have a blockage or infection of your gallbladder, but that you do have gall stones. Your pain improved and your liver enzymes are markedly decreasing without any invasive intervention. . Please take all of you medication as perscribed. . Please follow up with your doctor within the next 2 weeks. . Please call your doctor or return to the ER for any of the following: -Unbearable abdominal pain, fever/shakes/chills, inability to eat, inability to urinate, extreme fatigue or weakness or any other worsening of your condition Followup Instructions: 1) Please follow up with your Doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2 weeks. Dr. [**Last Name (STitle) **] can be reached at [**Telephone/Fax (1) 719**] Name: [**Known lastname 10191**],[**Known firstname **] Unit No: [**Numeric Identifier 10192**] Admission Date: [**2104-1-11**] Discharge Date: [**2104-1-16**] Date of Birth: [**2025-4-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10193**] Addendum: Please see page one and discharge plan for most current med list. Changes from "meds on discharge" as seen in discharge summary include Procrit and Toprol rather than metoprolol. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - Acute Rehab [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10194**] MD [**MD Number(1) 10195**] Completed by:[**2104-1-16**]

[ "428.0", "284.8", "V45.81", "414.00", "238.7", "574.20" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

10324, 10556

5700, 7246

358, 378

8667, 8763

1954, 5677

9528, 10301

1226, 1416

7430, 8201

8318, 8318

7272, 7407

8787, 9505

1431, 1935

276, 320

406, 754

8376, 8646

8337, 8355

776, 972

988, 1210

27,446

115,371

50208

Discharge summary

report

Admission Date: [**2117-7-4**] Discharge Date: [**2117-8-5**] Date of Birth: [**2065-6-17**] Sex: F Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 3561**] Chief Complaint: Altered mental status, septic shock Major Surgical or Invasive Procedure: Intubation, central line placement, tunnelled line placement, deep tissue biopsy of thigh, CVVH, hemodialysis. tracheostomy History of Present Illness: 52 year old woman with hx of lupus nephritis, multiple sclerosis, hypertension who is presenting with altered mental status, fever, and shock. The patient was in her usual state of health until yesterday when she noticed a rash late in the evening which she mentioned to her family. Per family, at that time she had no other symptom that she mentioned including headache or vomiting. Early on the day of admission, the patient was found minimally responsive and moaning on her bed. EMS was called. . Of note she was recently seen in her nephrology clinic on [**2117-6-30**] at which time her blood pressure was 150/90 with HR 68. At the time she had 3+ bilateral lower extremity edema. Her lisinopril was increased from 5mg to 10 mg daily and her lasix was increased from 20 mg to 40 mg daily. . In the ED, her initial vital signs were 104 140 60/palp 16 86% on 100%. She received 6L of NS. She was intubated for airway protection. A RIJ central line was placed after a failed attempt at the left IJ. A CXR, CT head/torso were done. She received vancomycin and ceftriaxone at meningitic dosing. She received decadon 10mg x1. A FAST u/s showed free fluid in the abdomen. Past Medical History: SLE Lupus nephritis (baseline Cr 0.9->1.2 on [**2117-5-29**]) Multiple sclerosis Depression Panic disorder Social History: Stopped smoking [**2109**]. Degree in computer programming. Immigrated from [**Location (un) 104733**] at 10 years of age. Lives with son. Family History: Unremarkable Physical Exam: T 99.9 HR 133 BP 74/37 RR 30 O2sat 100% vent: AC 450x20 PEEP 5 FIO2 0.7 PIP 16 GEN: intubated HEENT: AT, NC, PERRLA (4->2mm bilat), no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits. trachea midline. RIJ in place. small evidence of LIJ attempt. no subcutaneous crepitus. mild neck stiffness CV: regular tachy, nl s1, s2, no m/r/g PULM: coarse crackles bilaterally ABD: soft, ND, + BS, no HSM EXT: cool, dry, +2 distal pulses BL, no femoral bruits. 3+ pedal edema NEURO: intubated/sedated. opens eyes to command. pupils round and reactive. oculocephalics intact. withdrawals to noxious stimuli. unable to do strength or sensory testing. SKIN: multiple erythematous lesions on right thigh. petechial rash to lower back. PSYCH: unable to assess Pertinent Results: [**2117-7-4**] CXR - 1. ET tube approximately 1 cm above the carina. NG tube in appropriate position and IJ catheter within the cavoatrial junction. 2. Left suprahilar increased rounded density and left mid lung zone 1.7 cm nodule. Dedicated lateral view may be of use in determining what these structures are. . [**2117-7-4**] CT torso - 1. Moderate pleural effusions, pericardial effusion, ascites, subcutaneous edema, and mild interstitial pulmonary edema are all consistent with volume overload. 2. Small anterior left pneumothorax. 3. Consolidation in the lower lobes of the lungs bilaterally, most suggestive of aspiration, probably with a component of atelectasis as well. Infection cannot be excluded. 4. Fibroid uterus. . [**2117-7-4**] CT head - Limited study without evidence of hemorrhage or mass effect. . [**2117-7-6**] CT abdomen/pelvis: 1. Worsening of bibasilar effusions and associated airspace disease, most likely atelectasis, underlying infection cannot be excluded. Slight decrease in pericardial effusion. 2. Persistent, diffuse simple ascites, with new ascending/transverse colitis without dilatation or perforation. No definable abscess or focal collection, as clinically questioned. Findings are suspicious for infectious colitis; however, this could also be seen with ischemic bowel as a result of prior hypoperfusion episode and/or ongoing vasculitis, given the history of SLE. Diffuse mild small bowel thickening is felt to be due to third spacing. 3. Delayed enhancement and no evident excretion of contrast through the kidneys at this time, compatible with ATN. 4. Fibroid uterus. . [**2117-7-6**] CT Right lower extremity: 1. Surgical wound as described above in the mid thigh anteriorly with packing material. No soft tissue or muscle fluid collection or abscess. 2. Diffuse low-attenuation throughout the muscles of the thigh, which may represent muscle edema. Muscle infarct is not entirely excluded. 3. Fluid tracking in both the deep and superficial fascial compartments of the anterior and posterior thigh. No soft tissue gas is present. 4. Probable bone infarct of the proximal tibia. . [**2117-7-4**] echo: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe(3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion, mostly posterior (minimal anterior fluid seen). There are no echocardiographic signs of tamponade. IMPRESSION: Cardiomyopathy. Moderate pericardial effusion without overt tamponade. . [**2117-7-14**] echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 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 appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Brief Hospital Course: 52 year old woman with history of multiple sclerosis, SLE c/b nephritis presenting with altered mental status found to be in shock complicated by multi-organ failure. . # Septic shock: [**2-27**] serratia bacteremia presumably from GI source given pancolitis on CT abdomen/pelvis. Shock requiring max dose 4 pressors on presentation and she was initially started on broad spectrum antibiotics and stress dose steroids until blood cultures grew serratia bacteremia. Also cardiogenic in setting of sepsis as EF was severely depressed on initial echo obtained upon presentation to the ED (since normalized s/p treatment of sepsis). Serratia was initially covered with cefepime which was then changed to ciprofloxacin given sensitivities as per ID recs. She completed a full 2 week course of the above antibiotics with resolution of her shock and discontinuation of pressor support. Of note, she also grew serratia from right leg deep tissue biopsy (performed by surgery on presentation), but suspect leg was seeded from blood as opposed to leg as source of bacteremia. CT right LE was negative for fluid collection/abscess/air. At the time of discharge, her BP was stable, she was afebrile, and there was no leukocytosis. . # Livedo necrosis: Right lower extremity biopsied on initial presentation out of concern for necrotizing fasciitis and source of sepsis. General surgery and dermatology were consulted and deep tissue biopsy did not show e/o nec fasciitis however did also grow serratia to lesser degree than in blood. CT right lower extremity was unrevealing for abscess and air was leg was presumably seeded from bacteremia as opposed to leg as source. Aggressive wound care was performed daily. She will need follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (surgery) as outpt. for wounds (ph# [**Telephone/Fax (1) 2723**]). Will need wound care per wound care recommendations. . # Fungemia: [**Female First Name (un) 564**] albicans grew from [**7-19**] blood cultures presumably from line source as initial cultures were drawn from tunnelled line. She was started on caspofungin pending [**Female First Name (un) **] sensitivities and tunnelled, PICC and A-line were all discontinued. Surveillance cultures were monitored without subsequent growth after initial positive. Caspofungin was then changed to fluconazole as it was sensitive and she completed a 2 week course from date of first negative blood culture. . # RIJ/Rt brachial DVT: Developed in the setting of right sided tunnelled line. She was started on heparin gtt and tunnelled line was discontinued. She was started on coumadin, and the heparin gtt until INR [**2-28**]. goal PTT should be between 50-70. . # Anemia/hct drop: Has baseline anemia from underlying renal dz and renal failure however now with acute drop while on heparin gtt. She did have bloody oral secretions but not enough to lose that amount of blood (23.5-->19). She has had no gross blood per GI tract however concerning is the increase in her BUN. No other clear source of blood loss. Prior to discharge, she had some frank blood from her tracheostomy, and heparin gtt was stopped. Her HCT remained stable. Repeat bronchoscopy did not show any areas of frank bleeding, and it was thought to be secondary to trauma from the tube. Heparin was stopped for 2 days, and then restarted without incident. Her HCT remained stable. . # Respiratory failure: Initially intubated on presentation in the setting of altered mental status. She was extubated, however failed x1 and was reintubated due to profound respiratory muscle weakness, copious oral secretions and inability to clear them. She was again extubated however had probable aspiration event with acute hypoxia and brdaycardia again requiring reintubation. given her prolonged intubation, she was trached and a PEG was placed by interventional pulmonology. She tolerated this well, and at the time of discharge, she was on a tracheosty mask at 35% FiO2. The tracheostomy tube was replaced with a shorter tube on the day of discharge. . # Acute renal failure/Lupus nephritis: patient had rising Cr thought to be lupus nephritis prior to this admission. She became oliguric on admisison requiring initiation of CVVH which she tolerated well and was transitioned to HD. In the setting of fungemia, however, her tunnelled line was discontinued and her UOP continued to improve. Her cellcept was held on presentation and briefly restarted before again being held in the setting of fungemia. Stress dose steroids were initiated on presentation and hydrocortisone was subsequently titrated down to prednisone 10mg daily and she was discharged on cellcept 500mg qid. She should also receive epogen per her regular schedule and follow up with her nephrologist. . # Oral ulcers: During her course, she developed severe oral ulcers involving her lips and within the oropharynx. HSV1 was cultured from lip ulcers and she was started on valtrex for a 14-21 day course. Topical viscous lidocaine was used for pain control. She is currently on a prophylactic dose of valtrex. . # Pancytopenia: Leukopenia on presentation secondary to sepsis/DIC vs. due to lupus vs. in setting of cellcept. Her cellcept was held and her sepsis was treated and her WBC count and hct improved. Platelet recovery lagged however improved to the 100K range where they remained stable. . # SLE: With lupus nephritis as above. Off cellcept temporarily given fungemia and on hydrocortisone. She was discharged on prednisone 10mg qdaily and cellcept [**Pager number **] qid. . # MS: Stable without active issues. . # nutrition: A PEG tube was placed and she tolerated tube feeds. She was started on an oral diet after a speech and swallow evaluation. When she has adequate nutritional intake by mouth her tubefeeds can be weaned. She had some discomfort surrounding her PEG tube and was evaluated several times by interventional pulmonology and no problems were found. This is likely due to pain at the surgical site. . # hypertension: maintained with good blood pressure control on his current medications. Medications on Admission: celexa 10 mg daily lasix 40 mg daily prednisone 20 mg TID Cellcept [**Pager number **] mg [**Hospital1 **] omeprazole 20 mg daily aspirin 81 mg daily multivitamin daily lisinopril 10 mg daily (increased from 5 daily on [**2117-6-30**]) Discharge Medications: 1. Mupirocin Calcium 2 % Cream [**Date Range **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1) Appl Ophthalmic PRN (as needed). 3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**1-27**] PO BID (2 times a day). 4. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Lidocaine HCl 2 % Solution [**Month/Day (2) **]: One (1) ML Mucous membrane TID (3 times a day) as needed. 7. Atovaquone 750 mg/5 mL Suspension [**Month/Day (2) **]: Ten (10) ml PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Valacyclovir 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily (). 10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 11. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 14. Prochlorperazine 10 mg IV Q6H:PRN 15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [**Last Name (STitle) **]: Five Hundred (500) units/hour Intravenous continuous infusion. 17. Morphine Sulfate 1 mg IV Q4H:PRN 18. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 19. Warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 20. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 21. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Hospital1 **]: One (1) PO QID (4 times a day). 22. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 23. Papain-Urea 830,000-10 unit/g-% Ointment [**Hospital1 **]: One (1) Appl Topical DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 **], [**Location (un) 701**] Discharge Diagnosis: Primary Deep venous thrombosis Acute renal failure Respiratory failure Oral ulcers Septic shock Secondary Discharge Condition: stable Discharge Instructions: You were admitted with altered mental status and low blood pressures. You were treated with medications to bring up your blood pressure. You were treated for a severe cellulitis of your leg and a fungal infection of your blood. Additionally, your respiratory status required that you receive ventilatory support. A tracheostomy and percutaneous endoscopic gastrostomy tube were placed during your stay to support your respiration and nutrition. Plastic surgery and wound care were consulted to help take care of your wounds. There wound care recommendation will be followed at the rehabilitation facility. Followup Instructions: Provider: [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1047**] Date/Time:[**2117-8-16**] 12:00 Provider: [**Name10 (NameIs) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2117-8-17**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2117-9-14**] 11:30 Please follow up with [**Last Name (LF) 5059**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 2-4 weeks. His office can be reached at ([**Telephone/Fax (1) 9000**]. Completed by:[**2118-6-23**]

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icd9cm

[ [ [] ] ]

[ "96.72", "97.23", "39.95", "31.1", "38.91", "38.95", "86.11", "33.21", "86.05", "96.04", "96.6", "43.11", "33.23", "38.93" ]

icd9pcs

[ [ [] ] ]

15427, 15495

6651, 12788

351, 476

15646, 15655

2826, 6628

16311, 17042

1989, 2003

13074, 15404

15516, 15625

12814, 13051

15679, 16288

2018, 2807

276, 313

504, 1686

1708, 1816

1832, 1973

17,639

142,533

44948

Discharge summary

report

Admission Date: [**2168-8-9**] Discharge Date: [**2168-8-15**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Ms. [**Known lastname 96131**] is an 81 yo WF with adenocarcinoma of the lung, metastatic to the brain and liver on Tarceva, now presenting from her nursing home with sepsis. At [**Hospital 100**] Rehab, was noted to have decreased appetite for the last 2 days, then was found to be acutely SOB with SpO2 of 78% on RA. On 5L NC O2, her SpO2 increased to 93%. Paramedics reported a BP of 90/palp and administered a 200 cc bolus with a subsequent BP of 110/88 following fluid bolus. She was transferred to [**Hospital1 18**] for further management. . In [**Name (NI) **] pt produced large watery BM. Her initial ABG on arrival was 7.22/37/149, Initial VS were 101.8, HR 135, BP 90/palp, RR 24, SpO2 of 76% on RA, and CVP 8. The sepsis protocol was initiated and she was transfused 1u PRBC and given 10L NS and 1L LR. In addition levo/flagyl/vanc initiated. In addition a RIJ line was placed with development of hematoma. . Code status was confirmed to be DNI/DNshock by patient and husband. She agreed to central line, abx, and blood products. Past Medical History: 1. Lung Cancer - Original diagnosis made in [**2161**], T2N0 s/p right lower lobectomy by Dr. [**Last Name (STitle) 175**]. In early [**2162**], she developed a single frontal lobe metastatic lesion that was resected and treated with radiation therapy. Following her radiation therapy over the next number of months, she never truly recovered and was felt to have a significant post-radiation encephalopathy. She had been in the [**Hospital 100**] Rehab since that time, but over the latter part of [**2166**] and the early part of [**2167**], she deteriorated clinically, becoming less alert, with poor appetite, weight loss, and somewhat less interactive. She was found to have lesions in the liver and was started on tarceva for palliation. 2. Asthma 3. GERD 4. Hiatal hernia 5. Osteoperosis 6. Upper GIB 7. Fibroids s/p TAH/BSO 8. Pulmonary emboli s/p IVC filter placement [**2162**] 9. Depression Social History: Permanent resident of [**Hospital 100**] Rehab. She receives assistance with all ADLs. She walks with assistance with a walker. Prior tobacco use. Family History: Non-contributory Physical Exam: Gen: Awake, lying in bed, min responsive HEENT: R neck hematoma, at RIJ site CV: tachy rr, no mrg Lungs: ant xm, coarse bs Abd: +BS, diffuse tender, soft, no RT, guaiac + per ED note Ext: no c/c Neuro: awake, alert Pertinent Results: Abdomen CT 1. Multiple loops of edematous small bowel as well as the splenic flexure and descending colon consistent with enterocolitis. No superior mesenteric or portal venous gas identified. Findings are more likely consistent with infectious etiology. 2. Posterior right hepatic irregular hypodense lesion corresponds to large hepatic metastasis seen on ultrasound [**Month (only) **] [**2167**]. The possibility of superinfection cannot be excluded. 3. Multiple small hypodense lesions of the spleen may represent metastatic involvement or infectious foci. 4. Moderate hiatal hernia appears similar to [**2162-7-8**]. 5. Small bilateral pleural effusions. 6. Ascites. Brief Hospital Course: Mrs. [**Known lastname 96131**] is an 81 YO WF with a history of metastatic NSCLC p/w sepsis. 1.) ICU Course: Upon arrival to the ICU, a hematoma was noted at her CVL site, and the line was subsequently pulled. Hydration was continued, tailored to urine output and MAP. An abdominal CT was obtained, remarkable for diffuse bowel wall thickening consistent with colitis. Blood cultures 1/4 bottles returned positive for GPC in clusters, and urine grew GBS. She was started on Vancomycin, Levofloxacin and Flagyl. Given the presence of edematous small bowel on CT scan, her stool was screened for c. diff toxin, and she was continued on Flagyl empiricially. Her I/O for length of stay are +16 liters. Given her poor prognosis, and after discussion with the family, it was understood that she would be DNR/DNI, no pressors, no CVL, but family wished to continue antibiotics and steroids. At this time, she was transferred to the medicine service for further care. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] was consulted to provide palliative care counseling and support for the family. . 1) SEPSIS - Included in the differential for the source of her sepsis are infectious colitis vs. urosepsis vs. other unknown source. Given her clinical history of watery diarrhea, abdominal pain, and edematous bowel on abdominal CT, colitis was considered to be the most likely source. Ms. [**Known lastname 96131**] was treated with Levofloxacin, and Flagyl for 7 days prior to discharge for presumed sepsis secondary to enterocolitis. She received 72 hours of empiric therapy with Vancomycin on admission, but Vancomycin was then discontinued after lack of microbial growth to support its necessity. At the time it was discontinued, surveillance blood and urine cultures were performed. Her surveillance urine culture returned without growth; however, her blood cultures revealed 1 out of 4 coagulase-negative staphylococcus, likely secondary to contamination. At time of discharge, the plan was to complete a [**11-19**] day course of IV levofloxacin and metronidazole. Over the hospital course, her WBC trended down from the mid-twenties into the normal range, although this picture may have been confounded by IV steroid use. Of note, she had no positive result for c. diff toxin in her stool. . 2) Adrenal Insufficiency - A baseline cortisol was elevated at 41.5, without a rise following cosyntropin (although timing of blood test questionable). She was started on IV hydrocortisone and fludrocortisone for presumed adrenal insufficiency. She had been gradually weaned off of both at time of discharge. . 3) NSTEMI - During her ICU course her cardiac biomarkers without notable EKG changes. Findings were considered to be consistent with NSTEMI; however, intervention was deferred given her overall poor prognosis. . 4) Metastatic lung cancer - The plan for Mrs.[**Known lastname 96132**] care was considered extensively in the setting of her terminal illness with very poor prognosis. Her Tarceva was discontinued during this hospitalization given her inability to take oral medications and the unlikelihood of any benefit from any further chemotherapeutic options. . 5) Disposition: Ms. [**Known lastname 96131**] will return to [**Hospital3 **] with hospice services. Her prognosis was discussed at length with husband [**Name (NI) **] and with her children who were present at bedside. At time of discharge, she was responsive to stimuli and minimally interactive. Her pain was palliated throughout hospitalization with IV morphine and carefully titrated to match her needs. At discharge, palliative care was decided to be the primary goal, although her family still desired ongoing treatment of her infection with IV antibiotics. . 6) Prophylaxis: SC Heparin for DVT prophylaxis and Protonix for GI prophylaxis. . 7) FEN: Patient is unable to tolerate PO medications or nutrition. Supplemental nutrition was deferred. D51/2NS was continued at 30 cc/hour. . 8) Code Status: DNI/DNR, no pressors or central line. Abx and IVF's only. Medications on Admission: MOM 30 daily prn Tarceva 150 mg daily, Celexa 40 mg daily Robitussin 100mg qshift prn Nexium 20 mg daily Tylenol 650mg q8 prn Ritalin 2.5 mg every other day Clotrimazole 1% to rash on buttocks and under breasts Erythromycin op ointment Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*qs qs* Refills:*2* 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 4. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 4 days. Disp:*qs qs* Refills:*0* 5. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 4 days. Disp:*qs qs* Refills:*0* 6. Morphine Concentrate 20 mg/mL Solution Sig: [**2-8**] PO Q1-2H () as needed. Disp:*qs qs* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: 1) Sepsis 2) Metastatic lung cancer 3) NSTEMI 4) Adrenal insufficiency Discharge Condition: Poor Discharge Instructions: 1) Please administer medications as prescribed. 2) A PICC line has been placed for antibiotic use. She will need to continue the antibiotics for 4 days following discharge to complete the planned 10 day course (at time of discharge, she is Levaquin Day 7 and Metronidazole Day 7). The PICC line may be removed after the antibiotics are discontinued. Followup Instructions: Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]

[ "038.9", "V66.7", "197.7", "009.0", "255.4", "V15.82", "V10.11", "E879.2", "995.92", "553.3", "348.39", "785.52", "410.71", "998.12", "530.81", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "99.21", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8492, 8557

3410, 7496

227, 249

8672, 8679

2713, 3387

9081, 9202

2439, 2457

7783, 8469

8578, 8651

7522, 7760

8703, 9058

2472, 2694

180, 189

277, 1328

1350, 2257

2273, 2423

31,246

145,543

33719

Discharge summary

report

Admission Date: [**2107-6-27**] Discharge Date: [**2107-7-5**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Suprarenal aneurysm extending up to the diaphragm found on surveillance CT Major Surgical or Invasive Procedure: Repair of thoracoabdominal aortic aneurysm with beveled anastomosis and left renal artery bypass using a partial right heart bypass, left colectomy [**2107-6-27**] History of Present Illness: This is an elderly gentleman with a previous infrarenal abdominal aortic aneurysm who presented with a suprarenal aneurysm extending up to the diaphragm. He also had prior mesenteric ischemia necessitating bowel resection with mucous fistula and end-ileostomy. He subsequently underwent mesenteric stenting, although there is a suboptimal result from this, and his entire mesenteric supply essentially emanates from a meandering mesenteric artery which is intimately associated with this mucous fistula. He also has 2 tumors within the residual left colon. Past Medical History: 1. CAD, dilated cardiomyopathy, s/p pacemaker [**2084**]; last cath [**9-25**] demonstrated circumflex 80% stenosis, LAD mild/mod disease (no focal stenoses), RCA mild diffuse disease, LVEF 25% 2. ischemic colitis s/p R colectomy with end ileostomy & mucous fistula [**7-28**] 3. L colon adenoca polyps x 2 s/p colonoscopy/excision [**12-28**] 4. HTN 5. GERD 6. diverticulitis 7. mesenteric ischemia s/p SMA & celiac angioplasty & stents [**9-27**] 8. L brachial pseudoaneurysm s/p suture repair [**12-28**] 9. emphysematous cholecystitis s/p percutaneous cholecystostomy tube [**4-28**] 10. COPD 11. TB in [**2043**] 12. arthritis in spine/shoulder 13. bursitis s/p shoulder surgery [**12**]. s/p AAA repair [**2090**] 15. s/p hernia repair 16. PUD s/p GI bleed x 2 [**2048**] Social History: Pt was born and raised in [**State 5887**]. He has 4 children (age 42-59) all living in the area, and 5 grandkids. Pt lives with his wife. They spent much of their time traveling, but are unable to do so now d/t his medical problems. Pt also owns an apartment building, and still does some work with upkeep on it. Was in the army for about 35 months, with combat experience in WWII (denies any PTSD symptoms). No alcohol. Occasional tobacco. Lives in [**Location 1456**]. Daughter [**Name (NI) **] can be reached at [**Telephone/Fax (1) 78014**] (home phone). Family History: Denies for CAD. Brother has an aortic aneurysm s/p repair. Father died in his 60s from lung disease r/t being [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] minor. Mother died at age 86 after a fractured hip. Physical Exam: VS T 98.2 P 59 BP 110/47 RR 16 O2 sat 97% RA Gen: AAOx3, NAD HENT: wnl Lungs:CTA b/l Heart: RRR, no murmur Abd: [**Last Name (un) 37450**] drain on RUQ, colostomy on RUQ, L thoracotomy-> anterior abdomen incision with staples intact, soft, nontender. Positive bowel sounds. Pulses: Fem DP PT Rt 2+ 2+ 2+ Lt 2+ 2+ mono Pertinent Results: [**2107-7-3**] 05:00AM BLOOD WBC-4.8 RBC-3.05* Hgb-9.3* Hct-27.0* MCV-89 MCH-30.3 MCHC-34.3 RDW-14.9 Plt Ct-112* [**2107-7-2**] 02:02PM BLOOD WBC-7.0 RBC-3.37* Hgb-9.9* Hct-30.5* MCV-90 MCH-29.2 MCHC-32.3 RDW-14.7 Plt Ct-119* [**2107-7-1**] 03:08AM BLOOD WBC-7.2 RBC-3.18* Hgb-9.5* Hct-27.8* MCV-87 MCH-29.9 MCHC-34.3 RDW-15.0 Plt Ct-95* [**2107-6-30**] 04:26AM BLOOD WBC-9.9 RBC-3.27* Hgb-9.8* Hct-29.0* MCV-89 MCH-29.9 MCHC-33.7 RDW-15.1 Plt Ct-100* [**2107-6-29**] 02:56AM BLOOD WBC-15.6* RBC-3.39* Hgb-10.2* Hct-29.6* MCV-87 MCH-30.2 MCHC-34.6 RDW-15.3 Plt Ct-116* [**2107-6-28**] 03:33AM BLOOD WBC-12.8* RBC-3.34* Hgb-10.2* Hct-29.1* MCV-87 MCH-30.5 MCHC-35.1* RDW-15.0 Plt Ct-141* [**2107-6-27**] 09:55PM BLOOD WBC-12.6* RBC-3.37*# Hgb-10.2*# Hct-29.5*# MCV-88 MCH-30.2 MCHC-34.4 RDW-14.7 Plt Ct-144* [**2107-6-27**] 05:21PM BLOOD WBC-11.5* RBC-2.48* Hgb-7.6* Hct-22.4* MCV-90 MCH-30.6 MCHC-34.0 RDW-14.4 Plt Ct-99*# [**2107-6-27**] 03:14PM BLOOD WBC-9.5# RBC-2.26*# Hgb-7.0*# Hct-20.6*# MCV-91 MCH-31.0 MCHC-34.0 RDW-14.1 Plt Ct-45*# [**2107-7-3**] 05:00AM BLOOD Plt Ct-112* [**2107-7-2**] 02:02PM BLOOD PT-17.2* PTT-36.3* INR(PT)-1.6* [**2107-6-30**] 04:26AM BLOOD Plt Ct-100* [**2107-6-29**] 02:56AM BLOOD Plt Ct-116* [**2107-6-28**] 03:33AM BLOOD Plt Ct-141* [**2107-6-28**] 03:33AM BLOOD PTT-39.3* [**2107-6-27**] 09:55PM BLOOD Plt Ct-144* [**2107-6-27**] 05:21PM BLOOD Plt Ct-99*# [**2107-6-27**] 05:21PM BLOOD PT-19.6* PTT-100.3* INR(PT)-1.8* [**2107-7-3**] 05:00AM BLOOD Glucose-122* UreaN-25* Creat-1.0 Na-132* K-3.9 Cl-101 HCO3-27 AnGap-8 [**2107-7-2**] 05:06AM BLOOD Glucose-105 UreaN-30* Creat-1.1 Na-135 K-3.6 Cl-103 HCO3-26 AnGap-10 [**2107-6-30**] 10:49AM BLOOD K-4.3 [**2107-6-30**] 04:26AM BLOOD UreaN-37* Creat-1.2 Na-140 Cl-107 HCO3-28 [**2107-6-29**] 02:56AM BLOOD UreaN-35* Creat-1.6* Na-139 Cl-107 HCO3-25 [**2107-6-28**] 03:33AM BLOOD Glucose-71 UreaN-25* Creat-1.3* Na-137 K-4.5 Cl-108 HCO3-24 AnGap-10 [**2107-6-27**] 05:21PM BLOOD Glucose-127* UreaN-21* Creat-1.2 Na-140 K-3.9 Cl-109* HCO3-22 AnGap-13 [**2107-7-3**] 05:00AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0 [**2107-7-2**] 05:06AM BLOOD Calcium-8.1* Phos-1.7* Mg-1.8 [**2107-7-1**] 03:08AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.9 ECG Study Date of [**2107-6-27**] 4:51:48 PM Atrial fibrillation with ventricular paced rhythm Since previous tracing of [**2107-6-7**], no significant change CHEST (PORTABLE AP) [**2107-6-30**] Clip # [**Clip Number (Radiology) 78015**] Final Report HISTORY: Status post removal of left chest tube, to evaluate for pneumothorax. FINDINGS: In comparison with the study of [**6-29**], the Swan-Ganz catheter and nasogastric tube have been removed. Specifically, there is no evidence of pneumothorax. Little change in the appearance of the heart and lungs. Brief Hospital Course: This is an elderly gentleman with a previous infrarenal abdominal aortic aneurysm who presented with a suprarenal aneurysm extending up to the diaphragm. He also had prior mesenteric ischemia necessitating bowel resection with mucous fistula and end-ileostomy. He subsequently underwent mesenteric stenting, although there is a suboptimal result from this, and his entire mesenteric supply essentially emanates from a meandering mesenteric artery which is intimately associated with this mucous fistula. He also has 2 tumors within the residual left colon. Patient was admitted to undergo repair of his suprarenal aneurysm in conjunction with general surgery for resection of transverse and descending colon with takedown of splenic flexure. [**2107-6-27**] Patient was taken to OR by Dr. [**Last Name (STitle) **] [**Name (STitle) 78016**] Dr. [**Last Name (STitle) 914**]/Dr. [**Last Name (STitle) **] for 1.Colectomy with takedown of colostomy. 2. Repair of suprarenal abdominal aortic aneurysm with a Vascutek Gelweave 22-mm Dacron tube graft with an 8-mm prefabricated side limb using partial right heart bypass. Catalog number [**Numeric Identifier 78017**], lot number [**Serial Number 78018**], serial number [**Serial Number 78019**]. 3. Left renal artery bypass using the prefabricated 8-mm side branch from the tube graft. Intra-op patient received multiple blood transfusions and cystalloids. Patient tolerated procedure well, transferred to CVICU for recovery. [**2107-6-28**] Patient in CVICU intubated, sedate, did not tolerate vent wean, VSS.Continued to require fluid reuscitation, given crystalloids and blood products. Chest tube no bleeding. [**2107-6-29**] CVICUD2 Patient remains intubated, sedated on Propofol, Fentany boluses for pain control, isulin gtt for glycemic control, Nitro gtt for BP control. Marginal urine output. Extaubated, off sedation, hemodynamically stable, PA line, and A-line d/c'd. Chest tube place to water seal. [**2107-6-30**] CVICUD3 No acute events, started on Dilaudid PCA for pain control, started on sips, colostomy started putting out. [**Doctor Last Name 406**] drain still in, minimal chest tube output. NGT d/c'd. [**2107-7-1**] CVICUD4 patient continued to progress, chest tube d/c'd, continued on PCA Dilaudid, started pre-op meds (ASA/statin/betablocker), colostomy putting large amounts of stool-started on Lomotil, diet advanced, out of bed to chair. Transferred to [**Wardname 10876**] VICU. [**2107-7-2**] Farr5VICUD1 Patient is mostly pain free with PCA Dialaudid, progressed to regular diet, VSS, continue to get out of bed. Chest tube site draining large amounts of serrous drainage. [**Doctor Last Name 406**] drain still draining. [**2107-7-3**] No acute events, VSS, ambulating, colostomy working. Planned for rehab screen on Monday. [**Doctor Last Name 406**] drain still in. [**2107-7-4**] No acute events, VSS. Rehab screened. [**Doctor Last Name 406**] drain still in. [**2107-7-5**] Discharged to Rehab in good condition, re-start Coumadin when [**Doctor Last Name 406**] drain is out. Medications on Admission: Zantac 150 mg qd terazosin 5 mg qd fosinopril 10 mg qd ASA 81 mg qd Coumadin 2.5 mg qhs (stopped 6 days PTA) Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Insulin Regular Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Glucose Insulin Dose 0-50 mg/dL 4 oz. Juice 4 oz. Juice 51-150 <-150mg/dL 0 Units 0 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital 5682**] Rehab & Skilled Nursing Center Discharge Diagnosis: AAA s/p repair COPD CAD (last cath [**4-28**]: no flow-limiting CAD, patent Cx stents, elevated filling pressures, LVEF 37%) arthritis in spine/shoulder HTN GERD h/o dilated cardiomyopathy diverticulitis CRI Discharge Condition: Good 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 [**5-29**] 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 [**1-23**] 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 Followup Instructions: Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 2625**] Date:[**2107-7-14**] 2:45 Provider: [**Name10 (NameIs) 78020**],[**First Name8 (NamePattern2) **] [**Doctor First Name **] Phone: [**Telephone/Fax (1) 78021**] Date/Time: [**2107-7-26**] 10:30 AM Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:([**Telephone/Fax (1) 1483**] call to make an appointment when [**Doctor Last Name 406**] drain is draining less than 30cc per 24 hours x 2 days. Completed by:[**2107-7-5**]

[ "996.74", "441.4", "V45.01", "E879.8", "530.81", "557.1", "V45.82", "440.1", "568.0", "153.2", "425.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.75", "38.93", "54.59", "39.24", "96.6", "39.61", "38.44", "88.72" ]

icd9pcs

[ [ [] ] ]

10000, 10077

5868, 8960

335, 501

10329, 10336

3067, 5844

13076, 13625

2487, 2713

9119, 9977

10098, 10308

8986, 9096

10360, 12623

12649, 13053

2728, 3048

221, 297

529, 1088

1110, 1889

1905, 2471

20,279

156,922

50088+50089+59221

Discharge summary

report+report+addendum

Admission Date: [**2125-10-26**] Discharge Date: [**2125-11-5**] Date of Birth: [**2077-6-28**] Sex: M Service: [**Location (un) 259**]/MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old male with HIV/AIDS, end stage renal disease on hemodialysis who presented with rectal bleeding. The patient had recently been discharged from [**Hospital1 69**] on [**10-17**] when he left against medical advise. During that admission he had been treated for a gout flare sacral decubitus wound debridement and had a negative workup for abdominal pain and diarrhea. At this time the patient had three to four days of bright red blood per rectum. He denies abdominal pain. Denies nausea or vomiting. He also denies fever or chills. The bleeding had been brisk for three to four days since it began and then subsided on the day prior to admission, however, on the day of admission he had increased amounts of bright red blood per rectum and was passing clots. In the Emergency Department the patient was found to be tachycardic and had a hematocrit of 17, which is down from a baseline of approximately 30. PAST MEDICAL HISTORY: 1. VRE. 2. HIV/AIDS. 3. End stage renal disease on hemodialysis. 4. Hepatitis B and C positive. 5. Hypertension. 6. Gout. 7. Peripheral neuropathy. 8. Status post multiple gunshot wounds. 9. Sacral decubitus ulcers. 10. Status post colectomy. 11. Status post colostomy now reversed. 12. Status post AV fistula. MEDICATIONS: The patient was actually not taking any medications during the time of discharge as he had been discharged against medical advise. The patient at baseline reportedly takes ________ 1500 q day, Lopressor 50 t.i.d., aspirin 325 mg q day, Clonidine .1 t.i.d., Allopurinol 100 q day, calcium acetate 667 t.i.d., zinc sulfate 220 q day, vitamin C 500 q day, folate one q day, Phos-Lo 1600 t.i.d., Protonix 40 q day. Percocet prn. ALLERGIES: Sulfa and Captopril. SOCIAL HISTORY: The patient is homeless. He has a history of significant drug use including heroine. Also history of prison stays. Positive tobacco currently. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 120. Blood pressure 115/79. Respiratory rate 22. Sating 100% on room air. The patient was awake, alert and oriented times three, very thin and cachectic ill appearing male with a right Quinton in place. Cardiovascular was tachycardic. Regular rhythm. Normal S1 and S2. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended. He had approximately 3 cm sacral decubitus with granulation tissue. He had a right heel ulcer healing. Endoscopy at the time of admission revealed no acute bleed. LABORATORY VALUES ON ADMISSION: White blood cell count of 23, hematocrit 17, platelets 353. Chem 7 significant for BUN of 108, creatinine 11.6, INR 2, PT 17.2, PTT 150. Electrocardiogram revealed sinus tachycardia, normal axis. HOSPITAL COURSE: 1. Lower gastrointestinal bleed: The patient underwent an angiogram on [**10-27**], which showed an active bleed from the left rectal artery status post an embolization of the superior hemorrhoidal artery. Good hemostasis was achieved. The patient was stabilized eventually requiring 7 units of packed red blood cells and 1 unit of fresh frozen platelets. Hematocrits were followed q day and remained stable approximately 28. The patient declined repeat flexible sigmoidoscopy for further evaluation. 2. End stage renal disease: Patient on hemodialysis. The patient missed one week of hemodialysis prior to admission. However, at the time of admission he was restarted on his Renagel, Nephrocaps and required significant calcium repletion. The patient underwent dialysis three times a week. On [**11-2**] his dialysis line was removed secondary to bacteremia. Please see further discharge summary for further details of the patient's hemodialysis. 3. Bacteremia: The patient was four out of four bottles showing Methicillin resistant staph aureus. The patient received Vancomycin dose at hemodialysis and dosed by level. The patient's dialysis catheter was pulled on [**11-2**]. Prior to that the patient's temporary femoral line had been pulled as well as his arterial line. The patient remained afebrile during the remainder of his hospital course and dosed with Vancomycin appropriately. The patient was scheduled for an echocardiogram to evaluate for vegetations at the time of the discharge summary. This will be further detailed in a subsequent discharge summary. 4. Mental status: The patient's Neurontin was not continued at the time of this admission given question of altered mental status. Further details to be on next discharge summary. 5. Respiratory: The patient was intubated on [**10-27**] for the embolization procedure. The patient was extubated on [**10-30**] without difficulty. The patient required intubation for this period of time only because of increased sedation on medications, however, had good oxygen saturations and had no problems with extubation. 6. HIV/AIDS: The patient was continued on ____________ prophylaxis. The patient is not on HAART due to medication noncompliance. The patient's CD4 count was 46 on [**10-28**]. 7. Hypertension: The patient had originally been admitted with elevated blood pressures requiring significant intravenous medications. He was restarted on Clonidine and Lopressor, however, after the initiation of hemodialysis this was not needed provided the patient continues to undergo regular hemodialysis. He will likely require no further antihypertensive medications. 8. Psychiatric: Patient with issues with acceptance of medical care. The patient frequently declined procedures including flexible sigmoidoscopy, sometimes refusing dialysis. Upon further conversation the patient had agreed to dialysis and line placement. This again will be further monitored and followed up in a subsequent discharge summary. Please see subsequent discharge summary for continuation of hospital course as well as discharge medications and follow up plans. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**] Dictated By:[**Doctor Last Name 32868**] MEDQUIST36 D: [**2125-11-5**] 10:19 T: [**2125-11-5**] 10:37 JOB#: [**Job Number 104580**] Admission Date: [**2125-10-26**] Discharge Date: [**2125-11-23**] Date of Birth: [**2077-7-8**] Sex: M Service: Anticipated placement for tunneled catheterization on [**2124-11-23**] for hemodialysis. On date of procedure, patient was consented. Declined to sign consent for general anesthesia. At time of scheduled procedure, patient eloped from floor for four hours. On return, patient claimed to have not wanted the procedure that day. Spoke at great length with clinical adviser, nursing adviser, attending physician, [**Name10 (NameIs) **] patient regarding patient's continual elopements from floor, which compromise his clinical care as well as procedures for permanent hemodialysis catheter placement. Patient reassured team that he would remain compliant and would remain on floor for tunneled catheter placement on [**2125-11-26**]. Later that evening on [**2125-11-24**], patient eloped again from floor with numerous times to find patient. He was gone for seven hours. House officer and attending made aware, instructed to wrap up patient's belongings. If patient returns, to return to the Emergency Room for readmission. Patient returned to floor at 7:30 a.m. the following day claiming he was sleeping in the lobby, although numerous searches including the presumed place where he was to have been were negative. Patient is dependent on hemodialysis and has no outpatient followup for hemodialysis. Patient instructed to return to the Emergency Room, which he refused stating he would return on Monday for his tunneled catheter placement. Discussed with IR and General Anesthesia that this patient is no longer inpatient, would lose scheduled slot for Monday morning. Patient eloped, signed against medical advice, and was escorted to a cab. Discussed with Dr. [**First Name (STitle) 4702**] and is made aware. Patient received no prescriptions for his linezolid declining any medical advisement on elopement. Patient is discharged on [**2124-11-24**]. Patient is against medical advice on discharge, no medication or prescriptions given. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 49859**] Dictated By:[**Last Name (NamePattern1) 972**] MEDQUIST36 D: [**2125-11-24**] 09:30 T: [**2125-11-24**] 09:28 JOB#: [**Job Number 104581**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16955**] Admission Date: [**2125-10-26**] Discharge Date: [**2125-11-20**] Date of Birth: [**2077-7-8**] Sex: M Service: ADDENDUM: HOSPITAL COURSE: Starting at [**2125-11-5**]: The patient had a negative transthoracic echocardiogram and initially refused a transesophageal echocardiogram to rule out bacterial endocarditis. The patient got a temporal hemodialysis catheter for hemodialysis planning for permanent tunnel catheter within the next few days. The patient had several negative surveillance blood cultures. It was decided to wait for five additional days from the day of the catheter tip was positive for Methicillin resistant Staphylococcus aureus until placement of the permanent tunneled catheter. The patient's Vancomycin was dosed at dialysis, however, the patient continued refusing dialysis frequently and never completing recommended four hour dialysis run. The patient got a permacath placed on [**2125-11-8**], and underwent hemodialysis through that, however, his course was complicated by bleeding from permacath site. The patient received DDAVP, intravenous and p.o. Vitamin K and a total of two units of packed red blood cells. The patient had a hematocrit drop to 22.0. The patient stated that he did not want a catheter pressure dressing continued and the bleed stabilized. However, the patient refused further hematocrit checks and further blood product replacement. The patient continued exhibiting a lot of behavioral issues such as ripping out an intravenous while blood products were running and having blood spill all over the floor, smoking in his room, being absent from the hospital for hours at a time, all of which were appropriately addressed with the patient. SWAT team were called to aid with behavioral issues and to help in management of this patient. The patient finally agreed to have another set of surveillance cultures done on [**2125-11-12**]. The cultures came back positive with VRE necessitating removal of the tunneled catheter placement. The catheter was removed and the patient was started on Linezolid which the patient has been compliant with. His surveillance cultures have been so far negative and since the patient has been off dialysis for seven days, temporal femoral hemodialysis line was successfully placed on [**2125-11-20**], and the patient was successfully dialyzed. It is planned for the patient to undergo an interventional radiology placement over the permanent tunneled catheter under general anesthesia on Friday. After that time, the patient will likely be discharged to [**Hospital1 1238**] for further treatment and management. The patient also had a transesophageal echocardiogram on [**2125-11-19**], which was read as cannot exclude vegetations on aortic and mitral valves and therefore consistent with endocarditis necessitating six weeks therapy with Linezolid. Infectious disease consultation is going to be called today on [**2125-11-20**], prior to placement of another permanent catheter in the setting of VRE. End stage renal disease - Hemodialysis - The patient had multiple hemodialysis lines and tunneled catheters as above. The patient was never adequately dialyzed due to patient noncompliance. The patient did not exhibit any symptoms of uremia or severe fluid overload. The patient had permanent hemodialysis catheter placed and then discontinued due to development of VRE infection. The patient now has a temporal hemodialysis line and is planned for permacath placement within the next few days. Gastrointestinal bleed - The patient had a flexible sigmoidoscopy done on [**2125-11-5**], which showed two rectal ulcers, no bleed. A biopsy, however, did not confirm that these were ulcers. The patient did not have any more episodes of bleeding per rectum and it is recommended to repeat a flexible sigmoidoscopy within the next four to eight weeks. HIV/AIDS - The patient continued on Atovaquone prophylaxis for toxo and PCP . Lower extremity pain - The patient complained of bilateral feet tenderness. The patient has a history of gout and the patient was treated with Colchicine 0.6 mg p.o. once daily. Due to end stage renal disease, higher doses of Colchicine could not be given to the patient. The patient experienced some relief, however, pain still persisted. The patient is not compliant with trying to get a film of the ankle to clearly establish diagnosis. Since the patient also started complaining of bilateral wrist pain, it is unlikely that this is gout. For further diagnosis, a x-ray of either his wrists or his ankle needs to be done whenever the patient is compliant with this recommendation. Steroids will not be started at this time in the setting of ongoing VRE infection. Behavioral issues - The patient has been noncompliant with many of his recommended therapies such as hemodialysis, daily laboratory draws, medication administration. The patient was found to be smoking in the room at one point. The patient has been absent from the hospital for hours at a time. On [**2125-11-19**], the patient was absent from the hospital for six hours and almost lost his hospital bed but he came back to the floor. He was found to have his toxicology screen positive of Cocaine in his urine. The patient's attending was notified of this and a discussion is planned with case managers and social workers about how to address this behavioral issue. The patient was also seen by the psychiatry service during the hospitalization and was deemed competent in making his decisions. [**Name6 (MD) **] [**Last Name (NamePattern4) 10795**], M.D. [**MD Number(1) 16964**] Dictated By:[**Name8 (MD) 4104**] MEDQUIST36 D: [**2125-11-20**] 18:54 T: [**2125-11-20**] 20:34 JOB#: [**Job Number 16965**]

[ "285.1", "403.91", "305.60", "070.51", "042", "707.0", "996.62", "790.7", "569.3" ]

icd9cm

[ [ [] ] ]

[ "38.95", "48.24", "88.72", "99.04", "99.07", "99.29", "39.95", "88.47" ]

icd9pcs

[ [ [] ] ]

9001, 14624

195, 1138

2738, 2936

4564, 8983

1160, 1960

1977, 2145

49,641

127,304

41036

Discharge summary

report

Admission Date: [**2141-2-26**] Discharge Date: [**2141-2-26**] Date of Birth: [**2063-9-19**] Sex: F Service: SURGERY Allergies: Codeine / Penicillins / Ether Attending:[**First Name3 (LF) 1234**] Chief Complaint: impending AAA rupture Major Surgical or Invasive Procedure: thoracoabdominal aneurysm repair History of Present Illness: 77F history of PUD, CAD, AAA (unknown size) and chronic abdominal pain presents with abdominal pain. Patient states this is severe abdominal pain for 2d. Patient states pain started 3mo ago when she was found to have ulcers and a AAA. Patient states this pain had been stable since discharge, but became more severe 2d ago. +nausea no vomiting. Denies fevers, dysuria, diarrhea. Denies CP, SOB, cough, skin changes. She has generalized abd tenderness. mild distension w/ guaiac+ brown stool. Bedside ultrasound was performed in the ED without evidence of free fluid, unable to visualize aorta due to body habitus. Past Medical History: PMH: PUD PSH: cholecystectomy, vaginal partial hysterectomy Social History: lives in homeless shelter. No contacts given Family History: n/a Physical Exam: PE: 98.5 120 106/71 18 99% ra Gen: Alert and oriented CV: RRR Resp: Clear to auscultation Abd: Distended, non-peritoneal, diffusely tender Pulses: All palpable Pertinent Results: [**2141-2-26**] 01:24PM LACTATE-8.6* K+-3.0* [**2141-2-26**] 01:24PM O2 SAT-96 [**2141-2-26**] 12:39PM TYPE-MIX PH-7.19* [**2141-2-26**] 11:30AM TYPE-MIX COMMENTS-GREEN TOP [**2141-2-26**] 11:24AM TYPE-ART PO2-208* PCO2-53* PH-7.24* TOTAL CO2-24 BASE XS--5 [**2141-2-26**] 10:15AM HGB-8.9* calcHCT-27 [**2141-2-26**] 01:24PM TYPE-ART PO2-103 PCO2-45 PH-7.26* TOTAL CO2-21 BASE XS--6 [**2141-2-26**] 12:51PM HCT-30.0*# Brief Hospital Course: Pt was admitted to the vascular surgical service. After informed consent was obtained and carefully informing her of all the potential risks of the procedure, she still decided to proceed with the operation. Accordingly, she was taken emergently to the operating room with the cardiac surgical team. She underwent a 1) Repair of contained rupture of thoracoabdominal aneurysm with 30-mm Gelweave graft. Cold circulatory arrest. Atrial femoral bypass 2) Graft from distal to the left subclavian artery at the proximal anastomosis, distal anastomosis beveled include all the visceral vessels on [**2141-2-26**]. Intraoperative fluids included 6L crystalloid, 3700ml of pRBC, 2300 ml of FFP, 600ml platelets, 670ml cryoprecipitate. The chest was closed and abdomen was packed opened due to her critical state. Please refer to operative note for more details. Postoperatively, she was transferred to the CVICU for monitoring. She needed aggressive resuscitation. Chest tube output was with 1L of sanguinous drainage after 1.5 hours. She develped extensive subcutaneous emphysema to her chest bilaterally. There was trouble attempting to ventilate the patient. Chest X-ray showing completely opacified left lung. Despite chest tube with high output, it was still clotted off and required frequent stripping. The decision was to place another tube to decompress the chest, subcutaneous air and facilitate drainage. While attempting to place the chest tube, massive clot exsanguinated from the chest. There was copious amounts and profuse drainage. Patient's pressure began to drop and she was coded for approximately 3 minutes. Level I transfusion protocol was initiated. Pt's was still critically unstable and hypotensive. The decision by all members of staff - vascular surgery, cardiac surgery and ICU team was to withdraw measures given already high morbidity. She was pronounced dead at 218pm. Medical examiner declined autopsy. Medications on Admission: [**Last Name (un) 1724**]: Proventil HFA 90 mcg/actuation Aerosol Inhaler Inhalation 1 HFA Aerosol Inhaler(s) Every 4-6 hrs cyclobenzaprine 10 mg Tab Oral 1 Tablet(s) Once Daily, as needed omeprazole 20 mg Cap, Delayed Release Oral 1 Capsule, Delayed Release(E.C.)(s) simethicone 80 mg Chewable Tab Oral 1 Tablet, Chewable(s) Every 6-8 hrs, as needed Mapap (acetaminophen) 325 mg Tab Oral 2 Tablet(s) Three times daily tramadol 50 mg Tab Oral 1 Tablet(s) Every 6-8 hrs O docusate sodium 100 mg Cap Oral 1 Capsule(s) Once Daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: ruptured thoracoabdominal aneurysm bleeding asystole deceased Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a

[ "441.6", "998.11", "533.90", "V60.0", "458.9", "493.90", "414.01", "429.89", "278.00", "998.81", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.44", "99.60", "38.45" ]

icd9pcs

[ [ [] ] ]

4364, 4373

1814, 3751

312, 347

4478, 4484

1356, 1791

4536, 4543

1155, 1160

4336, 4341

4394, 4457

3777, 4313

4508, 4513

1175, 1337

250, 274

375, 992

1014, 1077

1093, 1139

2,069

186,948

20681

Discharge summary

report

Admission Date: [**2178-6-30**] Discharge Date: [**2178-7-22**] Date of Birth: [**2112-10-6**] Sex: M Service: [**Last Name (un) 7081**] ADMISSION DIAGNOSES: Esophageal adenocarcinoma. Alcoholism. History of pancreatitis. History of melena. DISCHARGE DIAGNOSES: Esophageal adenocarcinoma - status post esophagogastrectomy. Status post feeding jejunostomy. Status post percutaneous tracheostomy. Status post esophagoscopy. Status post insertion of chest tubes. Left pneumothorax. Respiratory failure. Urinary tract infection. ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 65 year old man who was seen in the Thoracic [**Hospital **] Clinic for evaluation of his esophageal adenocarcinoma which was found after he had initially presented in late [**2177-11-15**] with emesis and pancreatitis which were thought to be related to alcohol abuse. At the time, he underwent an EGD which showed Grade 4 ulcerative esophagitis with severe dysplasia. He was managed conservatively with medication but follow-up EGDs showed Barrett's type changes which eventually were found to have a small focus of adenocarcinoma at 30 cm. Otherwise, there was no note of invasion into the muscular wall. Given the extent of his disease, in the clinic it was felt that he would be a good candidate for esophagogastrectomy without need for adjuvant therapy. On his initial examination, he was in no acute distress. His weight was 142.8 lb. He was 5 feet 6 inches tall. He was otherwise afebrile with a pulse of 78, blood pressure of 140/88 and O2 saturation of 98 percent on room air. His pupils were round, equal and reactive. He had no scleral icterus. He had no cervical adenopathy. There were no supraclavicular or thyroid masses. Thoracic examination was unremarkable with clear breath sounds bilaterally. Heart was regular without rub or murmur. The abdomen was soft and flat. There was no hepatosplenomegaly or ascites. The extremities had no edema or clubbing and he had no axillary or groin adenopathy. Neurologically, his exam was unremarkable. When he initially presented, his white count was 6 with a hematocrit of 45. Platelets were 422. His BUN and creatinine were 23 and 1.1. LFTs were otherwise unremarkable. His CEA was 2.0 and PSA was 2.4. His PET-CT scan demonstrated a small focus of FDG uptake in the mid esophagus without any evidence of distant metastasis. HOSPITAL COURSE: The patient was admitted on [**2178-6-30**] for preoperative preparation for his surgery which took place on [**2178-7-1**]. There was no note of intraoperative complication or excessive blood loss and the patient underwent a total esophagectomy which was thoracoscopically and laparoscopically assisted with an esophagoscopy and jejunostomy placement by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] and by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]. The patient tolerated the procedure well without note of excessive blood loss or intraoperative complication. From a neurologic point of view, the patient's main issue was his history of significant alcoholism for which there is significant concern for experiencing delirium tremens. Therefore, postoperatively, he was managed aggressively with intravenous benzodiazepine (Ativan) for prophylaxis against delirium tremens. This regiment worked out well for him and the patient never really seemed to suffer any adverse symptoms of alcohol withdrawal. Otherwise, his pain was initially managed with an epidural catheter and subsequently he was switched over to IV narcotics. From a respiratory standpoint, postoperatively the patient was extubated on postoperative day 2 but failed extubation and required reintubation subsequently. Essentially, he failed extubation three times requiring placement of a percutaneous tracheostomy on [**2178-7-14**] which the patient was discharged with. The reasons for failure of extubation seemed to be related to some mild laryngeal edema of which the etiology is unclear but the patient was breathing well without need for supplemental oxygenation. At the time of discharged, he had saturations in the high 90 percent. Otherwise, the patient had no other respiratory problems. From a cardiac standpoint, the patient did well. His rate and blood pressures were controlled with low doses of Lopressor. He otherwise had no cardiac medications although occasionally he was seen to go into first degree heart block. At the time he was evaluated, cardiac enzymes were sent but these were negative and therefore it was felt that he could safely continue his low dose Lopressor. From a GI perspective, the patient was felt to do well in the initial postoperative period but during the first postoperative week, he developed a fever and there was a concern that there may be a small esophageal leak. This was managed conservatively with broad spectrum antibiotics and the patient actually did undergo an esophagoscopy which did not evidence any visible leak and the anastomosis looked good during the esophagoscopy. Otherwise, he was maintained on lansoprazole. From a nutritional standpoint, the patient was given tube feeds for nutritional supplementation through his jejunostomy given the fact that his oral intake was limited, but by postoperative day 19, the patient had passed a swallow evaluation allowing him to eat soft solids which he tolerated well and was continued on a diet of full liquids for the first week which was advanced to soft solids after the second week in conjunction with his tube feeds which would be adjusted during his follow-up visit. It is to be noted he should not be taking thin liquids. The swallow evaluation showed that he can take thick liquids and solids and soft solids. From a renal standpoint, the patient did well. His BUN and creatinine remained stable and he had excellent urine output throughout his hospitalization. From a hematological standpoint, the patient's hematocrit was otherwise stable. He was given heparin subcu along with Venodyne boots for DVT prophylaxis. From an Infectious Disease standpoint, there was concern for an esophageal leak one week after the patient's surgery, given the fact that he had spiked temperatures to 102 degrees along with a rising white count which had been as high as 26. The patient was pancultured including blood, urine, sputum and JP fluid. The wound was thoroughly inspected and no focus of infection could ever be found. He was empirically started on vancomycin, levofloxacin and Flagyl, pending return of culture data but these all were negative. Eventually, search for an infectious source led to CT scan of the neck, chest and abdomen which again showed no evidence of abscess or any sort of fluid collection. There was a question of trace gallbladder wall thickening but the patient's LFTs were checked and these were all normal and he otherwise had no subjective complaints and no findings of pain on physical examination. Therefore, this was not felt to likely be the source, but during the patient's second and third postoperative week, he remained essentially afebrile although he did still have moderate leukocytosis with a white count of 20 and 0 bands. At the time of discharge, it is felt that there was no source of infection and he had adequately been treated and therefore his antibiotics were stopped. Otherwise, his only infectious complication postoperatively was a urinary tract infection which was covered with the vancomycin and levofloxacin. By the time of discharge, the patient's white count was 20.1 with a hematocrit of 38.3 and a platelet count of 867. His urine was otherwise unremarkable and did not evidence any sort of infection. In terms of his electrolytes, his BUN and creatinine were 22 and 0.9 prior to discharge. It was felt that by postoperative day 21 that as the patient had adequate pain control with PO medications, was otherwise stable from a respiratory perspective, had no cardiac issues and was otherwise obtaining adequate caloric nutrition with his tube feeds and was beginning to take PO's and otherwise had been afebrile, that he could be discharged to a rehab facility in fair condition with follow-up in two weeks. DISCHARGE MEDICATIONS: He was sent with a fluticasone aerosol inhaler 110 mcg two puffs [**Hospital1 **], albuterol inhaler one to two puffs q6h as needed, lansoprazole 30 mg po qd, Tylenol 325 mg one to two tablets every 4-6 hours as needed for pain, albuterol nebulizer treatments, Colace prn, Lopressor 12.5 mg po bid, Reglan 10 mg po qid ac hs, Zofran prn, Ativan 2 mg po q4h as needed. FOLLOW UP: He would follow-up with Dr. [**Last Name (STitle) 952**] in two weeks. [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2178-7-22**] 09:29:48 T: [**2178-7-22**] 11:20:00 Job#: [**Job Number 55229**]

[ "V15.82", "599.0", "518.5", "V10.82", "V11.3", "150.5" ]

icd9cm

[ [ [] ] ]

[ "42.42", "40.3", "31.1", "96.6", "46.39", "86.74" ]

icd9pcs

[ [ [] ] ]

289, 2407

8252, 8622

2425, 8228

8634, 8970

180, 267

61,201

185,272

25911

Discharge summary

report

Admission Date: [**2194-8-8**] Discharge Date: [**2194-8-11**] Date of Birth: [**2112-8-6**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4691**] Chief Complaint: Trauma: fall Bilateral SAHs Right ulnar fracture ? C5 fracture Major Surgical or Invasive Procedure: none History of Present Illness: Chief Complaint: UNWITNESSED FALL/R ARM PAIN Note: 0655 Pt required pain rx after ortho manip. She then awoke again and in agitated state went into af with RVR at 150-160. Re-sedation and diltiazem with good rate control and reversion to NSR; ECG w/o new [**Last Name (un) **] changes. At 0700 pt had good gag, maintained oxygenation, and was arousable. Await [**Doctor First Name **] dispo re ICU accept. Past Medical History: COPD, followed by Dr. [**Last Name (STitle) **], on 2L O2 with activity and at night Cervical Spondylosis HCV HTN GERD Hypothyroidism Osteoporosis s/p bilateral hip replacement CKD, baseline Cr 1.1 h/o GIB Diverticulosis Urinary incontinence and retention Substance abuse on methadone h/o gallstones Anxiety/Depression Chronic axial lumbosacral pain and degenerative scoliosis Dysphagia s/p TAH BSO Moderate to severe spinal stenosis as seen on MRI [**6-/2194**] Social History: Widowed. Lives alone. Son is involved in her care. She smokes [**2-16**] ppd currently (approx 30 pack year history). Denies ETOH. She has a prior history of IVDU (last use>40 years ago) and is on methadone. Previously worked as a buyer for [**Doctor Last Name 64441**]in [**State 531**]. Uses walker. Family History: Father had emphysema Physical Exam: PHYSICAL EXAMINATION: upon admission Temp: 98.2 HR: 128 to 100 BP: 137/100 Resp: 18 O(2)Sat: 98 Normal HEENT: R forehead hematoma Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2194-8-8**] 10:10PM BLOOD WBC-8.8 RBC-3.62* Hgb-11.4* Hct-34.4* MCV-95 MCH-31.5 MCHC-33.2 RDW-14.3 Plt Ct-147* [**2194-8-8**] 02:57PM BLOOD Hct-30.8* [**2194-8-8**] 03:05AM BLOOD Neuts-82.1* Lymphs-11.9* Monos-4.8 Eos-0.7 Baso-0.4 [**2194-8-8**] 10:10PM BLOOD Plt Ct-147* [**2194-8-8**] 03:05AM BLOOD PT-12.9 PTT-25.3 INR(PT)-1.1 [**2194-8-8**] 10:10PM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-132* K-4.8 Cl-98 HCO3-29 AnGap-10 [**2194-8-8**] 02:57PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-132* K-4.5 Cl-98 HCO3-28 AnGap-11 [**2194-8-8**] 10:10PM BLOOD cTropnT-0.08* [**2194-8-8**] 02:57PM BLOOD cTropnT-0.15* [**2194-8-8**] 08:35AM BLOOD cTropnT-0.17* [**2194-8-8**] 10:10PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0 [**2194-8-8**] 02:57PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 [**2194-8-8**] 09:18AM BLOOD freeCa-1.25 [**2194-8-8**]: EKG: Sinus tachycardia with an atrial premature beat. Since the previous tracing of [**2194-7-16**] the rate is faster. ST segment abnormalities are now present. [**2194-8-8**]: EKG: Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing there is no definite change. [**2194-8-8**]: cat scan of the head: IMPRESSION: 1. Bilateral foci of subarachnoid hemorrhage. 2. No subfalcine herniation. 3. No fracture. 4. Right subgaleal frontal hematoma. [**2194-8-8**]: cat scan of c-spine: IMPRESSION: Moderate-to-severe degenerative changes in the cervical spine gives suboptimal evaluation of the spine. Lucent line through the left C5 transverse foramen could be a fracture line; correlate with point tenderness. If clinically concerning, consider CTA neck to exclude vessel injury. [**2194-8-8**]: X-ray of right forearm: RIGHT WRIST: Degenerative changes are seen at the first and second carpometacarpal joints and triscaphe joint. No evidence of fracture or dislocation at the wrist. There is some widening of the scapholunate interval. RIGHT FOREARM: There is a fracture at the distal ulna, minimally impacted and with medial displacement of the distal fracture fragment of 6 mm. No radiopaque foreign body is seen. [**2194-8-8**]: chest x-ray: 1. Mild cardiac decompensation. 2. There is no displaced rib fracture [**2194-8-8**]: cat scan of the head: IMPRESSION: Unchanged appearance of bilateral subarachnoid hemorrhage and right frontal subgaleal hematoma. No new hemorrhage, large vascular territorial infarct, or mass effect. Brief Hospital Course: Admitted to the acute care service after falling. Upon admission, she was made NPO, given intravenous fluids, and underwent imaging of the head, neck, and right arm. She was reported to have sustained bilateral subarachnoid hemorrhages. Her initial lab work did indicate a bump in her troponin levels, they have currently normalized. She was evaluated by Neurosurgery who made recommendations for a follow-up cat scan upon discharge. No immediate neuro-surgical interventions were warrented at this time unless there was a change in her status. She was also evaluated by Orthopedic/Spine/Trauma. She was placed in a cervical collar upon admission, but it was clinically cleared for removal. An x-ray of her right upper extremity did show a fracture at the distal ulna, minimally impacted and with medial displacement of the distal fracture fragment. No surgical intervention was needed. Occupational therapy placed a ulnar-gutter splint to her right arm. During her hospitalization, she was found to have a urinary tract infection and started on an antibiotic. She was also evaluated by the Geriatric service because of occasional episodes of agitation. Upon there evaluation, she was found not to exhibit any signs of delirium. Her vital signs are stable and she is afebrile. She is tolerating a regular diet and voiding without difficulty. She has been evaluated by the Social Worker. She is preparing for discharge to an extended care facility for further evaluation and continued care. She has been cleared by neuro-surgery to resume aspirin. Of note: she will need physical therapy evaluation prior to discharge home Medications on Admission: MED: Protonix 40 mg daily, MVI, advair 500/50mcg [**Hospital1 **], Lexapro 20 mg daily, Spiriva, Vitamin D3, methadone 10mg/5mL Oral Soln daily, Calcium, Acetaminophen, albuterol, lisinopril 20mg [**Hospital1 **], Docusate, levothyroxine 125mcg daily, Estrace 0.01% Vaginal Cream, Loratadine 10 mg daily, Iron Discharge Medications: 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days: started [**8-11**]. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for wheezing. 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: hold for increased sedation, resp. rate <10. Disp:*15 Tablet(s)* Refills:*0* 13. methadone 10 mg Tablet Sig: Five (5) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day. 15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Trauma: fall Bilateral SAHs Right ulnar fracture ? C5 fracture UTI 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 you fell at home. You hit your head and sustained a small bleed. You also sustained a fracture of the right arm for which a splint was applied. You are now preparing for discharge to a rehabilitation facility with the following instructions: Please follow up in the emergency room if you experience: *severe headache *difficulty speaking *weakness one side of your body *drooping face *visual changes *nausea/vomitting associated with headache Please report: *numbness/tingling fingers right hand *increased pain, swellling fingers right hand Followup Instructions: Please follow up in the neurosurgical clinic in [**5-21**] weeks with a non-contrast head CT with Dr. [**First Name (STitle) **]. This can be arranged by calling [**Telephone/Fax (1) 1669**]. Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Orthopedic nurse practitioner in 2 weeks. You can schedule your appointment by calling # [**Telephone/Fax (1) 1228**] Completed by:[**2194-8-11**]

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41710

Discharge summary

report

Admission Date: [**2181-10-28**] Discharge Date: [**2181-11-2**] Date of Birth: [**2104-5-12**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5018**] Chief Complaint: Headache and speech difficulties Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo old right handed man who was transferred by [**Location (un) **] from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital after having an increasing headache while at home and finding an ICH on CT scan. Mr. [**Known lastname **] states that he was talking with a friend and the friend was asking for money to borrow when he felt the gradual onset of a left frontal squeezing headache. The headache increased in intensity over the next few minutes until it was unbearable. He took his blood pressure at home and the systolic was 225. He had not noticed any associated symptoms at that time, no weakness, no difficulty speaking or understanding. He drove himself (around 10 miles) to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. While in the ED he was documented as having difficulty understanding commands and was repeating questions such as "just tell me what you want me to do". He was taken to CT which noted a L temporo-parietal intraparenchymal hemorrhage and he was started on a Cardene drip and medflighted to [**Hospital1 18**]. His son and daughter-in-law arrived and said they thought he was initially dysarthric, but this has since improved. He has had a mild non-productive cough over the past few days. No fevers. He has had no recent changes in medications. On neuro ROS, the pt had a headache, denies vertigo, tinnitus or hearing difficulty. Has had difficulties producing and comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. + cough, no shortness of breath. Some chest tightness no palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Hypertension Atrial Fibrillation - not on coumadin (unclear reason - attributes to possible R eye detached retina) CABG - [**2170**] Bilateral hearing loss Social History: Lives in [**Location **] by himself. Full ADLs and IDLs. Worked in autobody work. Non-smoker. No EtOH Family History: Mother - GI cancer Father - smoker - unknown cause of death Son - healthy Physical Exam: Admission assessment Vitals: 98.3 83 142/72 16 SpO2 98% ra General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: slight crackles at bases, good air entry Cardiac: sternal scar, soft heart sounds, II/VI SEM Abdomen: soft, nontender, nondistended Extremities: mild edema of LE to ankle, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to [**Hospital1 18**] w/ prompting, unable to get date, knew [**2180**]. Able to relate history with some tangentiality. Could do DOW forward, not back.. Language is nonfluent with frequent pausing, intact repetition to "today was a sunny day in [**Location (un) 3844**]" and comprehension "touch left hand to right ear". Normal prosody. There were no paraphasic errors. Pt. was unable to name any objects on the stroke card. Alexia without agraphia, able to write "we came in a helicopter", but could not read a sentence. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**12-25**] at 5 minutes. There was possibly apraxia with the right hand (more clumsy when asked to wave/salute). Significant R visual field necglect versus hemianopia. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Significant R visual field hemianopia v. neglect. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, increased tone in legs. No pronator drift bilaterally. Mild intention tremor greater on the L hand noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to graphesthesia on the R hand or L. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. Extinction on the R to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was upgoing on the right and flexor on the left. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: unable to test Discharge exam: Alert and oriented x2. Anomic. Full strength throughout. Sensation intact to light touch, pinprick, vibratory sense, and proprioception. Pertinent Results: Admission labs: [**2181-10-28**] 07:45PM BLOOD WBC-10.4 RBC-5.35 Hgb-16.3 Hct-47.1 MCV-88 MCH-30.5 MCHC-34.7 RDW-13.0 Plt Ct-167 [**2181-10-28**] 07:45PM BLOOD PT-13.1 PTT-26.1 INR(PT)-1.1 [**2181-10-28**] 07:45PM BLOOD Fibrino-368 [**2181-10-28**] 07:45PM BLOOD UreaN-12 Creat-0.7 . Other pertinent labs: [**2181-10-29**] 04:18AM BLOOD CK(CPK)-96 [**2181-10-28**] 07:45PM BLOOD Lipase-25 [**2181-10-29**] 04:18AM BLOOD CK-MB-4 cTropnT-<0.01 [**2181-10-29**] 04:18AM BLOOD %HbA1c-5.6 eAG-114 [**2181-10-29**] 04:18AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7 Cholest-132 [**2181-10-29**] 04:18AM BLOOD Triglyc-89 HDL-40 CHOL/HD-3.3 LDLcalc-74 [**2181-10-28**] 07:45PM BLOOD Digoxin-0.5* [**2181-10-28**] 07:50PM BLOOD Glucose-102 Lactate-2.2* Na-139 K-4.0 Cl-101 [**2181-10-28**] 07:50PM BLOOD freeCa-1.11* [**2181-10-28**] 07:50PM BLOOD pO2-65* pCO2-41 pH-7.38 calTCO2-25 Base XS-0 Comment-GREEN TOP . . Urine: [**2181-10-28**] 08:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2181-10-28**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2181-10-28**] 08:00PM URINE Hours-RANDOM . . Microbiology: [**2181-10-29**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2181-10-28**] URINE URINE CULTURE-PENDING . . CHEST (PA & LAT) Study Date of [**2181-10-28**] 10:22 PM PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median sternotomy and CABG. The heart size is mildly enlarged and the aorta is tortuous. Diffuse aortic calcifications are noted. Pulmonary vascularity is normal, and the hilar contours are unremarkable. There is minimal atelectasis at the lung bases. No focal consolidation, pleural effusion or pneumothorax is identified. No acute osseous abnormalities are visualized. IMPRESSION: Minimal bibasilar atelectasis. . CTA HEAD/NECK W&W/OC & RECONS Study Date of [**2181-10-28**] 10:40 PM CT: No significant interval change in left parietal/occipital lobe intraparenchymal hemorrhage, measuring up to 3.2 x 5.5 cm in the axial plane. New intraventricular hemorrhagic extension with minimal blood products layering in both occipital horns of the lateral ventricles. No midline shift or central herniation. No acute large vascular territorial infarction. CTA head/neck: No evidence of large vessel occlusion, flow limiting stenosis, or aneurysm greater than 2mm involving the cervical or intracranial anterior or posterior arterial circulations. No arteriovenous malformation identified. Dominant left vertebral artery with hypoplastic right vertebral artery. . CT HEAD W/O CONTRAST Study Date of [**2181-10-30**] FINDINGS: There is a large parenchymal hematoma involving the left posterior temporal, parietal and occipital lobes, which is not significantly changed in size. Mild surrounding edema is unchanged in extent. There is slightly more blood in the occipital horns and atria of the lateral ventricles. The left occipital [**Doctor Last Name 534**] is compressed, as before. Overall, the ventricles are stable in size. There is no shift of normally midline structures. Multiple foci of low density are again seen in the subcortical, deep, and periventricular white matter, most suggestive of sequela of chronic small vessel ischemic disease in a patient of this age. Intracranial arterial calcifications are again noted. The imaged portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Stable large left temporal/occipital/parietal parenchymal hematoma with slightly increased intraventricular extension. Stable mass effect. . MRI/MRV HEAD W/O CONTRAST Study Date of [**2181-10-29**] 11:18 AM FINDINGS: Again seen is a 5.2 (AP) x 2.8 cm (TRV) intraparenchymal hemorrhage within the left temporoparietal regions. The overall size of the lesion appears unchanged from the prior exam. Given the lobar distribution of the hemorrhage this is likely related to amyloid angiopathy. However, seen within the center of the lesion are multiple foci of enhancement with the largest measuring 0.7 x 0.6 cm (102b:42). Although these are located centrally, it could be suggestive of active extravasation or enhancement of an underlying lesion such as a malignancy or AVM. Given that the surrounding FLAIR hyperintensity does not involve the adjacent [**Doctor Last Name 352**] matter, an infarction would be less likely. Evaluation of the MRV reveals no evidence for venous thrombosis. There is a hypoplastic left venous system, which, although not well visualized on the time-of-flight sequence, does opacify with contrast on the MP-RAGE sequence. Blood is again seen within the occipital horns of the lateral ventricles but with no evidence for hydrocephalus. An incidental developmental venous anomaly is seen within the right parietal lobe. There is no shift of the normally midline structures seen and, other than the previously described lesion, there are no additional areas of abnormal enhancement or diffusion. The lenses and globes are normal. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. No evidence for venous thrombosis. 2. Large left temporo-occipital intraparenchymal hemorrhage with central enhancing foci. Again, this is suggestive of either active extravasation or enhancing underlying lesion. However, given the lobar distribution this appears to be sequela to amyloid angiopathy. Followup is recommended. . . Cardiology: Portable TTE (Complete) Done [**2181-10-29**] at 10:08:02 AM Conclusions The left atrium and right atrium are moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography).There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets appear structurally normal. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Pulmonary artery hypertension. Dilated thoracic aorta. [**2181-11-1**] Cerebral Angiography: No AVM or dural fistula noted. Brief Hospital Course: 77 year old right handed man with HTN, AF not anticoagulated, CAD with previous CABG ([**2170**]) who presented with an acute headache w/ significant hypertension, found to have a L temporo-parietal IPH on CT at an OSH. On initial exam, he had significant aphasia, alexia w/out agraphia, complete anomia, with retained ability to follow commands and fluent but frequently halting speech. He had no agraphesthesia, sensory loss, and full motor strength throughout. On visual field exam, he was noted to have a right upper quadrantanopia, which was consistent with the location of his brain lesion. His blood pressures were significantly elevated on admission to neuro ICU [**2181-10-28**] so he was started on IV nicardipine infusion. At this time, CT showed no significant interval change in the ICH, which measured 3.2 x 5.5 cm in the axial plane with new intraventricular extension and dominant left vertebral artery with hypoplastic right vertebral artery. MRI/MRV showed some contrast enhancemenet in the area of the bleed and MRV showed no venous sinus thrombosis. Echo showed mild symmetric LVH with EF>55% and mild-moderate MR, evidence of pulmonary HTN, a dilated 4cm thoracic aorta, and no evidence of atrial mass or thrombus. As he was stable, he was transferred to the stepdown unit on [**10-29**]. He arrived on the floor in stable condition and converted to home meds. Aspirin and s/c heparin were initially held given the risk of hemorrhagic expansion. Soon after conversion to home meds, his blood pressure became difficult to control, requiring uptitration of his home mediations (lisinopril and metoprolol) and the addition of 5mg of amlodipine. This regimen was able to keep his SBP between 120-140. He also spiked a temperature of 100.9, prompting infectious workup involving blood cultures, urine cultures, and CXR all of which were unrevealing. On [**10-30**], he continued to have a low grade fever and appeared more somnolent, prompting a repeat CT which showed a stable hematoma with slight increase in intraventricular expansion. On [**11-1**] he developed a right eye conjunctivitis, which was promptly treated with ciprofloxacin ophth soln with rapid improvement. This was thought to be the origin of his low grade fevers. Otherwise, his infectious workup was unrevealing-- CXR x2 were negative, urine and blood cultures had no growth. He had a mild leukocytosis. He received at formal angiogram on [**11-1**] which did not show any evidence of AVM or dural fistula or aneurysm. His IPH was thought to be the result of amyloid angiopathy. IT is possible that it is the result of hypertension. Clinically, over the course of hospital stay, his speech improved but he persisted in having marked expressive aphasia and anomia. He was evaluated by Speech/swallow and was found to tolerate regular foods. PT and OT also evaluated him and found him to be ataxic and therefore recommended rehabilitation. On discharge to rehab, Mr. [**Known lastname **] was in good condition and seemed to be in high spirits. His son, however, notes that his father has poor insight into his condition and reports a history of steady decline marked by a significant loss of physical ability. As Mr. [**Known lastname **] currently lives alone, his son is currently consider [**Hospital3 **] and other options after rehabilitation. = = = = = = = = = = = = = = = = = = = ================================================================ Transitional issues: 1. Intraparenchymal bleed: thought [**1-24**] amyloid angiopathy. He was started on low dose aspirin given his stable condition. He he was to worsen clinically, further imaging should be performed to rule out further bleeding. HE will have Neurology follow up at [**Hospital1 18**]. 2. HTN: he had difficult to control BP post- stroke requiring uptitration of his BP meds and addition of amlodipine. He might require further titration of these meds (either up or down) in the near future. 3. Intermittent low grade temperature/ mild leukocytosis: He had conjuctivitis which was treated with ciprofloxacin drops. He had no clear source of infection with negative blood cultures/negative urine cultures/negative CXR. If he continues to be afebrile, he will require further workup for infectious etiologies. Medications on Admission: Metoprolol 25 mg [**Hospital1 **] Pravastatin 10 mg daily Digoxin 0.125 mg daily Aspirin 81 mg daily Lisinopril 10 mg daily Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: [**12-24**] Capsules PO BID (2 times a day). 5. insulin regular human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 7. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. ciprofloxacin 0.3 % Drops Sig: Two (2) Drop Ophthalmic Q4H (every 4 hours): please continue for 5 more days until [**2181-11-6**]. 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Left parieto-occipital intraparenchymal hemorrhage likely secondary to amyloid angiopathy Discharge Condition: Alert Unable to ambulate without assistance Unchanged aphasia Discharge Instructions: Take all of your medications as directed. Do not stop or change any of your medications without first speaking to your doctor. If you experience any severe headaches, fevers, chills, or any other concerning symptoms seek medical attention immediately. Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2181-12-4**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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Discharge summary

report

Admission Date: [**2106-11-27**] Discharge Date: [**2106-12-7**] Date of Birth: [**2029-7-6**] Sex: M Service: MEDICINE Allergies: Aspirin / Lasix / Monosodium Glutamate / Cucumber (Cucumis Sativus) / lisinopril Attending:[**First Name3 (LF) 4327**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: [**2106-11-27**] - Synchronized electrical cardioversion [**2106-11-29**] - AVNRT ablation History of Present Illness: The patient is a 77 year old male with medical history that includes non-ischemic cardiomyopathy thought to be secondary to velcade/rituxan (now with normalized left ventricular function), paroxysmal atrial fibrillation on coumadin, supraventricular tachycardia, severe tricuspid regurgitation, ESRD secondary to waldenstroms macroglobulinemia, and metastatic prostate cancer who is transferred from [**Hospital **] Hospital with hypotension and supraventricular tachycardia. For the past couple weeks he reports worsening dyspnea. At baseline his functional status is limited as he becomes dyspniec with ambulation of 10-20feet. Lately, however he becomes short of breath just with transitioning from sitting to standing or any ambulation. He also endorses episodes of waking up at night feeling very short of breath. He also endorses worsening lower extremity edema but is not clear if his weight has changed. He denies chest pain, fever, chills. He reports stable bone pain related to his metastatic prostate cancer. At dialysis this past week, he was felt to be volume overloaded and underwent extra ultrafiltration with removal of 6.5kg Tuesday, 2.5kg Wednesday, and 1kg Thursday with some improvement in his breathing and lower extremity edema. Per notes, he usually tolerates a blood pressure in the 80s during dialysis. . He is followed by Dr. [**First Name (STitle) 437**] for cardiomyopathy and was referred to Dr. [**Last Name (STitle) **] in [**Month (only) **] for evaluation of supraventricular tachycardia. In [**5-/2106**], he underwent successful DCCV for atrial fibrillation. During the procedure, he went into supraventricular tachycardia that did not respond to vagal maneuvers but broke with adenosine. Since that time he has been noted during dialysis session to be in SVT, limiting fluid removal. He underwent Holter monotoring where he was predominantly in an ectopic atrial rhythm with episodes up to 14hrs in duration of atrial tachycardia. He was seen by Dr. [**Last Name (STitle) **] in [**Month (only) **] and was started on amiodarone after declining invasive procedures to further characterize/treat his rhythm. . He presented to [**Hospital **] hospital on [**2106-11-26**] complaining of generalized weakness and fatigue where initial vitals were 98.2 82/53, HR 129, and 98%RA. EKG revealed regular narrow complex tachycardia. He was felt to be volume overloaded on exam. He underwent hemodialysis on Saturday with removal of 1kg of fluid. Cardiology recommended starting dobutamine for hypotension. He was transferred to [**Hospital1 18**] on 5 of dobutamine with 2PIV. . On arrival to CCU, blood pressure was 71/40, HR 140s regular narrow complex tachycardia, respiratory rate of 20 with O2 sat mid 90s on room air. EKG showed narrow complex tachycardia with rate of 148 with long R-P interval. He was given adesonine 6mg and then 12mg without significant change in rate (130s) or rhythm. Bedside TTE showed hyperdynamic LV and dilated RV with adequate wall motion and moderate/severe TR. He was then given 2 mg versed and underwent DCCV 200J after which he transiently went into an atrial ectopic rhythm with rate in 80s and then atrial fibrillation with rates in 80s-90s. His blood pressure improved to 88/50 and then later to 90s/50s. 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Non-ischemic cardiomyopathy attributed to Velcade and Rituxin (with improved LVEF following discontinuation) 2. Waldenstrom's macroglobulinemia s/p Velcade and Rituxan (last Rx in [**8-/2103**]) 3. Metastatic prostate cancer - Lupron every 3 months 4. ESRD due to Waldenstrom's macroglobulinemia - HD Tues, Thurs and Sat 5. Hypertension 6. Hypercholesterolemia 7. s/p RV perforation and surgery with complication from RV biopsy to rule out amyloidosis Social History: Retired photographer who lives with his wife, [**Name (NI) 1494**] [**Name (NI) 76298**] (she is also is HCP). Quit smoking since [**2056**]. Denies current alcohol use; none since [**2101**]. Family History: Father died of throat cancer at age 58 (prior smoker) and mother died in her 90's - ? brain tumor. Physical Exam: ON ADMISSION: . VS: 97.8 71/44 147 22 95%RA GENERAL: Oriented x 3. Affect appropriate, speak full sentences. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP elevated to 10 cm, prominent V waves. CARDIAC: PMI located in 5th intercostal space, midclavicular line. normal S1, S2.III/VI systolic murmur heard at LLSB worsened by inspiration, regular rhythm, increased rate LUNGS: Tachypnic, no accessory muscle use. Decreased BS at bases ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No cyanosis or clubbing with 2+ peripheral edema to the level of the mid-thighs bilaterally. 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: [**2106-11-28**] 06:19AM BLOOD WBC-3.5* RBC-3.24* Hgb-9.4* Hct-31.1* MCV-96 MCH-29.1 MCHC-30.3* RDW-23.8* Plt Ct-157 . [**2106-11-27**] 09:50PM BLOOD Neuts-79.5* Lymphs-15.9* Monos-3.0 Eos-1.0 Baso-0.5 . [**2106-11-27**] 09:50PM BLOOD PT-54.3* PTT-56.9* INR(PT)-5.4* . [**2106-11-27**] 09:50PM BLOOD Glucose-121* UreaN-23* Creat-3.1* Na-140 K-4.2 Cl-96 HCO3-30 AnGap-18 . [**2106-11-27**] 09:50PM BLOOD ALT-19 AST-52* LD(LDH)-399* CK(CPK)-53 AlkPhos-662* TotBili-1.8* . [**2106-11-27**] 09:50PM BLOOD CK-MB-2 cTropnT-0.13* proBNP-[**Numeric Identifier 76342**]* . [**2106-11-27**] 09:50PM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.1 Mg-2.0 . MICROBIOLOGIC DATA: [**2106-11-27**] Blood culture - pending [**2106-11-27**] MRSA screen - negative [**2106-11-28**] Blood culture - pending . IMAGING STUDIES: [**2106-11-27**] 2D-ECHO - There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Normal LV function. Dilated and hypertrophied RV with pressure and volume overload. Severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the findings of the prior study (images reviewed) of [**2106-5-9**], there are now signs of worsening RV pressure and volume overload. . [**2106-11-27**] CHEST (PORTABLE AP) - Bilateral effusions slighly increased since [**11-9**]. Old displaced anterior third rib fracture. Intact sternal wires. Left subclavian stent. Brief Hospital Course: 77M with medical history that includes non-ischemic cardiomyopathy thought to be secondary to velcade/rituxan (now with normalized left ventricular function), history of paroxysmal atrial fibrillation on coumadin, supraventricular tachycardia, severe tricuspid regurgitation, ESRD secondary to Waldenstrom??????s macroglobulinemia, and metastatic prostate cancer who [**Hospital 76343**] transferred from [**Hospital **] Hospital with hemodynamically unstable supraventricular tachycardia with improvement in blood pressure following electrical cardioversion. . # SUPRAVENTRICULAR, NARROW-COMPLEX TACHYCARDIA - The patient presented with a regular, narrow complex tachycardia with predominantly no P (or P in QRS). Adenosine did not terminate (as typically occurs in AVNRT; he received 6 mg IV push followed by 12 mg IV push without resolve) his rhythm or bring out P waves (as typically occurs in atrial tachycardia). In the past he was not interested in formal EP studies and potential ablation but this was re-addressed this admission. Following electrical cardioversion, his rhythm converted to atrial fibrillation with a HR in the 80-90 bpm range; he reverted back to an atypical tachyarrhythmia with a rate of 130-140 bpm within 1-2 hours following cardioversion. He was prepared for an electrophysiology study on [**2106-11-29**] given his persistent rhythm issues. He was started on Amiodarone 100 mg IV loading followed by a 0.5 mcg/min continuous infusion with improvement in his HR to the 100-120s with improvement in his BP to the 80/60s range. We initially held his AV-nodal blocking agents. His TSH on admission was 6.4. We also initially held his anticoagulation (indication being atrial fibrillation) on admission, given that his INR was 5.4 - and he received 3 mg Vitamin K PO x 1 given his supratherapeutic INR and the need for an EP study. On [**2106-11-29**] he went to the Electrophysiology lab and underwent an AVNRT ablation with successful ablation of his re-entry pathway; although the passage of the wire was difficult given his wide-open tricuspid regurgitation. He was also transitioned to Amiodarone 200 mg PO daily following the procedure, however, he developed thrombocytopenia which was thought to be related to the IV amiodarone load he received, and this was briefly discontinued. After the procedure, he remained predominantly in NSR with frequent PACs but had some episodes of AFib. Prior to discharge, he had reverted back into Afib and will be restarted on amiodarone in an attempt to maintain NSR. The thrombocytopenia was thought to be related to the IV amiodarone as he had previously tolerated IV amio with no observed drop in platelets. . # HYPOTENSION - The patient presented with hypotension in the setting of a supra-ventricular tachyarrhythmia, improved following electrical cardioversion initially, but then he spontaneously reverted to an atypical tachyarrhythmia with a blood pressure in the 70/50 mmHg range. While he met SIRS criteria on admission, there was no clear source of infection at that time. Culture data was obtained on admission, which was unrevealing, and we held off on empiric antibiotics. His admission CXR showed bilateral pleural effusions with no evidence of consolidation. His hypotension did improved with cardioversion and with initiation of anti-arrhythmic medication. He notably has blood pressures in the 80/60 mmHg range while at dialysis, per his records; without notable symptoms. . # DECOMPENSATED HEART FAILURE WITH PRESERVED EJECTION FRACTION - The patient has a history of non-ischemic cardiomyopathy with a previous ejection fraction of 50-55% on most recent echocardiogram (prior LVEF was 20% while on chemotherapy agents). He has stage III/IV NYHA heart failure and appeared to be volume overloaded on exam when admitted (lower extremity edema, JVD in setting of moderate-severe TR). His labs (elevated BNP) and imaging studies (pleural effusions, mild pulmonary edema) supported these findings. He appeared to have moderate pulmonary artery hypertension with a dilated right ventricle and severe (4+) tricuspid regurgitation with overall worsened right ventricular function compared to his prior exam; with abnormal septal motion/position consistent with right ventricular pressure/volume overload (LVEF 55%). The development of his tachyarrhythmia likely contributed to this acute decompensation. He has not been on ACEI/[**Last Name (un) **] therapy (creatinine 3.1 on hemodialysis). We initially held beta-blocker therapy given his hypotension; his home dose being Metoprolol succinate 250 mg PO daily. This was restarted fir rate control when he returned to Afib. Nephrology was consulted given the concern for volume overload and the need for ultrafiltration. We were only able to remove fluid by ultrafiltration and his volume status slowly improved during admission, he will continue to have fluid removed by ultrafiltration at HD after discharge. . # THROMBOCYTOPENIA: During this admission, his platelets trended down from 100-150 at admission to 15 on HD5. The patient did not have any bleeding. HIT antibody was negative, and the patient has been receiving heparin at dialysis routinely, making HIT unlikely. No evidence of DIC on labs. Hematology was consulted, and he was treated with prednisone 50mg which was quickly tapered down and the patient's platetets improved. The etiology of his thrombocytopenia was thought to be antibody-mediated amiodarone toxicity from the IV amiodarone load he received at admission. Hematology recommended avoiding PO amiodarone if possible, although this will be necessary to control his rate. At admission, he had been on PO amiodarone and had maintained his platelet count. . # ESRD ON HEMODIALYSIS - Thought to be secondary to light chain cast nephropathy from Waldenstrom's macroglobulinemia, on hemodialysis since [**2102**]. He presented with volume overload, but without significant metabolic derangements warranting urgent dialysis. Nephrology was consulted and he continued to receive HD on a TuThSa this admission. He was maintained on Nephrocaps 1 tablet PO daily and all medications were renally dosed. . # PROSTATE CANCER - The patient is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for castrate-resistant metastatic prostate cancer that has been refractory to Docetaxel with a rising PSA (most recently 1883 in [**2106-10-19**]) on Zytiga and prednisone at home. He has also received radiation to his right hip in the past for metastatic disease. We continued his home Oxycodone medication (as needed) for pain control given his bone metastasis. . # ANEMIA/LEUKOPENIA - His anemia and leukopenia are stable compared to prior recent labs and are thought to be due to bone marrow involvement of his prostate cancer; less likely due to Waldenstrom's. His counts were serially trended on this admission. . # CODE STATUS - FULL CODE (discussed with patient) . # TRANSITION OF CARE ISSUES: 1. Will need INR monitored - was therapeutic at discharge and he will be continued on home dose of 1 mg daily 2. Currently on Tuesday, Thursday, Saturday hemodialysis schedule 3. [**Month (only) 116**] need uptitration of his Metoprolol dose if tachycardia persists. We decreased from 250 to 100 mg daily because of hypotension. 4. Should have platelets monitored after discharge to ensure that he is not thrombocytopenic; given that he is going home on Amiodarone. Medications on Admission: -amiodarone 200mg daily (started [**10/2106**]) -metoprolol succinate 100 mg daily -nephrocaps 1 capsule po daily -Lanthanum 1000 mg tablet po TID with meals -prednisone 5 mg po daily -coumadin 1 mg po daily -oxycodone 5mg Q4 hours PRN pain -vitamin E 400-800 mg po qd -hydroxyzine 25-50mg po BID prn -prochlorperazine maleate 10 mg po q8 hrs prn nausea -leuprolide 7.5 mg injected q 12 weeks Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take this medication with food. Disp:*30 Tablet(s)* Refills:*0* 2. abiraterone 250 mg Tablet Sig: Four (4) Tablet PO Daily (): Take 1-2 hours before prednisone. 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for itching. 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 7. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day: Hold SBP < 100, HR < 55. 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day: Hold SBP< 100, HR < 55. 12. leuprolide 7.5 mg Syringe Kit Sig: One (1) injection Intramuscular every 12 weeks. Discharge Disposition: Extended Care Facility: [**Hospital 5682**] Rehabilitation and Skilled Nursing Center - [**Hospital1 **] Discharge Diagnosis: Primary diagnosis: . AV node re-entrant tachycardia s/p ablation procedure Hypotension Paroxysmal atrial fibrillation . Secondary diagnoses: . End stage renal disease Waldenstrom's macroglobulinemia Metastatic prostate cancer Chronic diastolic heart failure Severe tricuspid regurgitation Thrombocytopenia of unclear etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 76298**], It was a pleasure taking care of you during your admission at [**Hospital1 18**]. You were admitted to the Cardiac Care Unit because your heart was beating very fast and your blood pressure was low. We treated you with an antiarrhythmic drug called amiodarone and performed an ablation procedure in an attempt to prevent this event from happening again. You tolerated the procedure well. You also continued to receive dialysis during your admission to remove extra fluid that was causing swelling in your arms and legs. Your platelet count dropped and have now increased again. You did not have any signs that you were bleeding. You will follow up with Dr. [**Last Name (STitle) **] next week and will need to get your platelet count followed regularly. . The following changes were made to your medications: 1. Change metoprolol to tartrate and increase the dose to 50 mg three times a day to lower your heart rate 2. START Amiodarone to slow your heart rate and keep you in a normal rhythm. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2106-12-14**] 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 Department: CARDIAC SERVICES When: WEDNESDAY [**2106-12-15**] at 11:00 AM With: ECHOCARDIOGRAM [**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 [**2106-12-15**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2107-1-13**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2120-11-11**] Discharge Date: [**2120-12-5**] Date of Birth: [**2092-11-10**] Sex: F Service: CARDIOTHORACIC Allergies: Milk Attending:[**First Name3 (LF) 922**] Chief Complaint: transfer from OSH with tamponade Major Surgical or Invasive Procedure: [**11-11**] right heart cath with pericardiocentesis [**11-13**] pericardial window [**11-20**] pericardiectomy History of Present Illness: 28F with PMH of sarcoidosis s/p recent transbronchial lung biopsy 2-3 weeks ago in [**State 2690**], who presented to [**Hospital3 **] Sunday [**11-10**] with chest pain. Per her family, she was well for approximately 1 week following the lung biopsy. Subsequently, however, she began to complain of persistent CP, as well as subjective fevers and night sweats. Her pain was sharp and substernal, and lasted on the order of minutes. It was positional, and was worse [**Doctor First Name **] trying to lie flat. Because of this she began sleeping with 4 pillows to stay upright at night. No SOB/PND at that time. Additionally, she complained of nausea and vomited on several occasions. She was weak and complaining of fatigue and malaise. She present to her Air Force Base in [**Location (un) 75174**] this past Friday evening with persistent CP and fevers. An echo was reportedly performed at that time which showed a pericardial effusion, and she was given the diagnosis of pericarditis. Given her recent fevers, it was presumed to be post-viral in etiology, and she was prescribed NSAIDS and Percocet for pain control. She then flew to [**Location (un) 86**] with her husband for vacation. . On Sunday morning she called her mother complaining of severe chest pain, this time associated with shortness of breath, a new complaint for her. She went to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On presentation to [**Hospital1 **], she was noted to have evidence of pericarditis on EKG and labs (ESR elevation), and was begun on prednisone and indomethacin. Troponins were 0.02, 0.05, 0.05. At 7AM this morning [**11-11**] she was complaining of nausea and CP, then became lethargic and unresponsive, and was not following commands. Although not hypotensive, her extremities were cool and clammy. Her urine output was noted to be zero overnight. . She had a stat CT head which was negative. She was urgently intubated. Stat EKG showed diffuse 1-2mm ST elevations, and bedside echo showed concentric LVH, large pericardial effusion with early signs of tamponade with diastolic collapse of RA, also ?mass outside pericardium. Stat labs showed K 6.5 (treated), Creatinine 4.0 from 0.9, ALT 6600, WBC 28 (12.2 day prior). HCT 37 (33). Got 100mg solumedrol, given levoquin 500mg x 1 and was urgently transferred to [**Hospital1 18**]. . Upon arrival at [**Hospital1 18**] a stat bedside echo confirmed a large pericardial effusion with L atrial diastolic collapse and extrinic R ventricular compression. She was immediately taken to the interventional suites for a R heart cath and pericardiocentesis to be performed. The pericardial pressure and RA pressure were noted to be identical at 33mmHg. Approximately 300cc of green purulent fluid was drained from the pericardial space and sent from gram stain and culture. There was subsequent separation of the pericardial and RA pressures. . Cardiac review of systems is notable for chest pain and 4-pillow orthopnea to prevent CP. No paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: Sarcoidosis s/p recent lung biopsy in [**State 2690**] "Borderline" diabetes diagnosed 1.5 years ago, diet controlled Remote asthma history, has not used inhaler in >2 years . Cardiac Risk Factors: "borderline" diabetes . Cardiac History: no history of CABG, PCI, MI, or ICD . Social History: Social history is significant for the absence of current or former tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T , BP , pulsus measured at 14mmHg, HR , RR , O2 % on Gen: intubated and sedated young AAF HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: EKG demonstrated diffuse 2mm ST elevations . 2D-ECHOCARDIOGRAM performed on [**11-11**] demonstrated: Moderate circumferential pericardial effusion with small right ventricular cavity size and evidence of increased pericardial pressure. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . R HEART CATH performed on [**11-11**] demonstrated: 1. Right heart catheterization revealed equalization of pressures between RA, RVEDP and PAD. Mean RA as well as the pericardial pressure were 30 mmHg. Initial PA saturation was 43%. 2. Close to 400 ccs of purulent yellow-green fluid was withdrawn from the pericardial space with separation of the mean RA and the pericardial pressure. At the end of the case mean RA was 20 mmHg, mean PCWP was 26 mmHg, PA saturation improved to 64%, pericardial pressure was 4 mmHg. FINAL DIAGNOSIS: 1. Cardiac tamponade. 2. Successful pericardiocenthesis. . HEMODYNAMICS: HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.18 m2 FICK **PRESSURES RIGHT ATRIUM {a/v/m} 34/33/33 RIGHT VENTRICLE {s/ed} 47/33 PULMONARY ARTERY {s/d/m} 47/34/40 PULMONARY WEDGE {a/v/m} 33/34/32 PERICARDIUM {m} 33 **CARDIAC OUTPUT HEART RATE {beats/min} 105 RHYTHM SINUS **% SATURATION DATA (NL) PA MAIN 43 . [**11-11**] Pericardial aspirate(Blood cult bottles) 4+ polys, Prevotella, veillonella, peptostreptococcus, strep milleri [**11-11**] Pericardial aspirate as above [**11-12**] Urine Yeast [**11-13**] Pleural fluid negative [**11-13**] Pericardial tissue Strep milleri, veillonella [**11-14**] Pleural fluid negative [**11-15**] Sputum negative 10/5 Blood cult negative [**11-15**] Urien yeast [**2120-12-4**] 10:25AM BLOOD WBC-9.3 RBC-3.29* Hgb-9.9* Hct-28.9* MCV-88 MCH-29.9 MCHC-34.1 RDW-14.9 Plt Ct-694* [**2120-12-4**] 10:25AM BLOOD Plt Ct-694* [**2120-12-4**] 10:25AM BLOOD Glucose-108* UreaN-33* Creat-3.4*# Na-142 K-4.2 Cl-105 HCO3-26 AnGap-15 [**2120-12-2**] 06:00AM BLOOD ALT-23 AST-20 LD(LDH)-265* AlkPhos-79 Amylase-82 TotBili-1.2 [**2120-11-12**] 03:36AM BLOOD %HbA1c-5.9 [**2120-11-25**] 09:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2120-12-3**] 06:10AM BLOOD Vanco-16.6 [**2120-11-25**] 09:10AM BLOOD HCV Ab-NEGATIVE [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75175**] (Complete) Done [**2120-11-18**] at 12:22:19 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Cardiac Services [**Location (un) 830**], [**Hospital Ward Name 23**] 7 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2092-11-10**] Age (years): 28 F Hgt (in): 68 BP (mm Hg): 161/80 Wgt (lb): 220 HR (bpm): 85 BSA (m2): 2.13 m2 Indication: Endocarditis. Pericardial effusion. ICD-9 Codes: 424.90 Test Information Date/Time: [**2120-11-18**] at 12:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2007W00-0:0 Machine: Vivid i-4 Echocardiographic Measurements Results Measurements Normal Range Pericardium - Effusion Size: 0.5 cm Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A prominent Chiari network is present (normal variant). Normal interatrial septum. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Overall normal LVEF (>55%). AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **] mass or vegetation on mitral valve. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. Effusion circumferential. Effusion echo dense, c/w blood, inflammation or other cellular elements. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. There is a small (0.5 cm) circumferential echo-dense pericardial effusion. The aorta is free of plaque 5 cm above the aortic valve and distal to 25 cm. The aorch and proximal descending aorta were poorly visualized due to poor esophageal contact. There is a prominent Eustachian valve vs. Chiari network (normal variant). IMPRESSION: No echocardiographic evidence of endocarditis. Small circumferential pericardial effusion. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting physician ?????? [**2116**] Brief Hospital Course: The patient was admitted [**11-11**] with an infective pericarditis with tamponade physiology, Cr 3.9 and oliguria, and Acute Hepatitis with coagulopathy, likely "shock liver". Renal ultrasound was negative for obstruction. She received an emergent pericardiocentesis on [**2120-11-11**] with removal of 400cc purulent green fluid and the tamponade physiology subsequently resolved. She was started on empiric antibiotic treatment with vanc/zosyn. She had a left VATS pericardial window on [**2120-11-13**] for persistent purulent drainage. On [**11-14**], started CVVH due to volume overload. She also had a bronchoscopy and transbronchial biopsy for further evaluation of her mediastinal lymphadenopathy. She continued to have a WBC to ~40s and her antibiotic coverage was broadened to include flagyl for empiric anaerobic coverage and fluconazole for yeast in urine cx. On [**11-18**] she had a TEE which revealed a persistent pericardial effusion. Due to persistent WBC and low grade fevers and evidence of persistent pericardial effusion with purulent drainage, she underwent a pericardiectomy and lymph node biopsy on [**11-20**]. She underwent therapeutic bronchoscopy and BAL on [**11-21**]. She remained intubated and was started on tube feeds. She was switched from CVVHD to HD. She was extubated on POD #6. She was transferred to the floor on POD #8. Creatinine and urine output improved and dialysis was discontinued. Her antibiotics for pericarditis were completed. She was cdiff positive and continued treatment with flagyl. She was cleared for discharge on [**12-5**] to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] hotel where she will be for 2 weeks completing oral vanco therapy, and then will return home to [**State 2690**]. Pt is to follow up with her primary care as soon as she returns to [**State 2690**], and have a nephrology consult immediately upon her return. Medications on Admission: indomethacin solumedrol levoquin 500mg x 1 dose Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 caps* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 6. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): through [**12-17**]. Disp:*52 Capsule(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: tamponade, acute renal failure, shock liver, purulent pericarditis sarcoidosis s/p transbronch lung bx (TX), DM, mild asthma Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No lifting more than 10 pounds for 10 wweks. No driving for one month until follow up with surgeon or while taking narcotic pain medicine Shower, no baths, and pat incisions dry. Followup Instructions: Dr. [**Last Name (STitle) 10543**] 2 weeks Dr. [**Last Name (STitle) 914**] 4 weeks [**Telephone/Fax (1) 170**] See Primary Care as soon as you return to [**State 2690**] Make an appt. with a nephrologist as soon as possible after return to [**State 2690**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2120-12-10**] 8:30 Completed by:[**2120-12-5**]

[ "423.3", "135", "420.99", "276.2", "570", "008.45", "584.9", "785.51" ]

icd9cm

[ [ [] ] ]

[ "40.11", "39.95", "37.31", "34.21", "33.27", "37.0", "34.91", "37.12", "37.21", "33.23", "96.6", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

13435, 13454

10685, 12600

305, 419

13623, 13631

4864, 5734

13975, 14428

3988, 4070

12699, 13412

13475, 13602

12626, 12676

5751, 10662

13655, 13952

4085, 4845

233, 267

447, 3536

3558, 3837

3853, 3972

22,316

183,801

26728

Discharge summary

report

Admission Date: [**2193-3-1**] Discharge Date: [**2193-3-22**] Date of Birth: [**2134-1-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4219**] Chief Complaint: Transferred from OSH for sepsis and resp failure Major Surgical or Invasive Procedure: - central venous access - arterial line - incision & drainage of R elbow in OR - closure of R elbow wound - extubation - PICC line placement History of Present Illness: Per OSH summary: 59 yo M who was admitted on [**2193-2-27**] with muscle aches, nausea and vomiting for a few days. Pt had some trauma to his right elbow against a rusted gas tank. Tetanus up to date. ED course notable for hypotension, tachycardia and diaphoresis, with fever to 101.7. CXR negative for infiltrate. Elbow x-ray with soft tissue swelling. Joint tap revealed group A beta strep, PCN sensitive. Initial labs with WBC 16.2, 80 % P, 13 % bands. Vanc was started for ? of MRSA, unasyn and clindamycin added. CE with CK 314, MB 5.2, trop I <0.03. . WBC increased to 17.9, 97% P, 36 % bands. Pt noted to have resp acidosis on [**2-28**] (ABG 7.2/81) for which he was intubated. HR in the 180's, pt pale and diaphroetic. D-dimer elevated, V/Q scan normal. . On day of transfer pt taken to OR by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65850**] prior to transfer. Wide debridement with irrigation with 4 L saline/abx; wound was left open and packed with kerlex; no necrotizing fascitis noted. Cultures taken, gram stain pending and will be ready [**3-2**]. . Enroute, [**Location (un) 7622**] crew stated that his HR post procedure was elevated to 180's in AF. Sedation was manipulated from propofol to fentanyl/versed (recieved 450 mg fentanyl, 450 mg versed). Received 2 L NS enroute. . Transferred to [**Hospital1 18**] for further mgmt. On arrival, pt intubated and sedated. Past Medical History: 1. HTN 2. Elevated cholesterol Social History: nonsmoker, quit several years ago, married, fisherman Family History: non-contributory Physical Exam: 97.8 103/50 (0.1 levophed) CVP 7 120 (AF) AC, 600x21, 50% Fio2, PIP 30, I/O:3.5 L + on transfer intubated, sedated PEERLA, anicteric thick neck, right IJ in place CTA bilaterally RRR nl s1/s2 no m/r/g obese soft NT/D +BS warm ext., no edema small petichial rash on leg and chest wall, blanching right arm wrapped in bandage Pertinent Results: Labs on admission: WBC 17.9, HCT 34.5, MCV 87, RDW 14.0, PLT 160 (DIFF: NEUTS-81* BANDS-5 LYMPHS-3* MONOS-9 METAS-2*) PT 13.9*, PTT 29.6, INR(PT) 1.2* Na 136, K 4.3, Cl 102, HCO3 24, BUN 57, Cr 3.2, Glu 195 ALT(SGPT) 34, AST(SGOT) 53*, LD(LDH) 247, AMYLASE 24, TBILI 0.8, LIP 21 CALCIUM 7.2*, PHOSPHATE 2.7, MAGNESIUM 1.4* CORTISOL 106.6* Lactate 2.3 [**2193-3-1**] 11:42PM ABG: 7.24/26/103 on AC 600, PEEP 5, FiO2 50% . Labs on discharge: WBC 8.8, Hct 27.1, MCV 90, plts 212 Na 139, K 3.8, Cl 105, HCO3 28, BUN 14, Cr 1.4, Glu 112 Ca 7.7, Mg 1.7, P 3.2 ALT 18, AST 28, Alk Phos 64, Tbili 0.2 INR 1.1 Urine eos negative . MICRO: OSH data: [**2-27**] wound asp = grp A strep OSH data: [**3-1**] wound cx = enterococcus D (vanc sensitive), MRSA [**3-1**] - blood cx no growth [**3-2**] - urine cx no growth [**3-2**] - blood cx no growth [**3-2**] - sputum cx [**10-9**] polys, <10 epis; no orgs; resp cx OP flora absent, sparse growth yeast [**3-3**] - blood cx no growth [**3-5**] - swab cx gram stain no polys, no orgs; wound cx no growth, anaerobes no growth [**3-6**] - urine no growth [**3-6**] - blood cx NGTD [**3-6**] - sputum cx >25 PMNs, <10 epithelial cells/100X field. 1+ (<1 per 1000X field) BUDDING YEAST. Resp cx: OP flora absent, sparse growth of yeast [**3-10**] - stool cx C diff neg [**3-12**] - tissue cx gram stain = no polys, no orgs; cx (broth only) + CNS; no anaerobes isolated [**3-12**] - stool cx fecal, campylobacter, yersinia, vibrio, Ecoli neg [**3-13**] - stool cx C diff neg [**3-13**] - blood cx NGTD [**3-13**] - urine cx <10,000 org [**3-16**] - stool cx C diff neg [**3-17**] - C diff toxin B PENDING . IMAGING: ECHO [**3-2**] - The left ventricular cavity size is normal. Left ventricular systolic function appears grossly preserved/vigorous but views are technically suboptimal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular free wall motion appears grossly preserved in suboptimal views. The valves are not well visualized. No significant mitral regurgitation is detected in suboptimal views. There is a trivial/physiologic pericardial effusion. . CXR [**3-2**] - A single semierect AP view at 1100 hrs is compared to a supine film earlier from the same day. The positions of the right IJ and endotracheal tubes are unchanged. The distal tip of the NG tube cannot be appreciated due to underpenetration of the film. There is no evidence of pneumothorax. . CXR [**3-6**] - Mild failure and left lower lobe pneumonia. . CXR [**3-7**] - PICC overlies the right atrium and should be pulled back 2-3 cm into the distal SVC. Findings discussed by telephone with IV therapy in the morning of [**2193-3-7**]. . CXR [**3-8**] - The heart size is normal. The mediastinal and hilar contours are normal. There is a heterogeneous worsening opacity in the left lower lobe indicative of pneumonia. The dense opacity in the right lower lobe is likely due to overlying soft tissue and unlikely due to pneumonia. Note that the left costophrenic sulcus and lower lung is not included in the film. . CXR [**3-9**] - Improving aeration in both lung bases. . CXR [**3-13**] - Opacity in the right lower lobe, atelectasis vs. consolidation. Small layering right pleural effusion. . ABD XR [**3-13**] - Normal gas pattern seen within the large bowel. No evidence of megacolon. . ABD XR [**3-14**] - No abnormally dilated loops of small bowel are seen. Normal gas pattern is seen within the large bowel. No evidence of megacolon. . CT a/p [**3-14**] - 1. Atelectasis at the right lung base. 2. Small amount of ascites surrounding the liver. 3. Cholelithiasis without cholecystitis. 4. Mesenteric stranding and small pockets of mesenteric fluid in the region of the distal small bowel with possible mild small bowel wall thickening. In the clinical setting of the patient, this is most likely due to an ischemic or infectious etiology. Much less likely but included in the differential diagnosis would be atypical Crohn's disease or lymphoma. The colon appears unremarkable. . ECHO [**3-15**] - There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2193-3-2**], probably no major change. . CXR [**3-17**] - Previous right pleural effusion has resolved. There is no pulmonary edema or pneumonia. Aside from a band of atelectasis in the right lower lobe, the lungs are clear. Heart size is normal and the cardiomediastinal and hilar silhouettes are unremarkable. Biapical pleural thickening is symmetric and unchanged. Brief Hospital Course: Mr. [**Known lastname 65851**] is a 59 yo M with HTN and hyperlipidemia who presents to [**Hospital1 18**] with group A strep toxic shock syndrome from an injury to his R elbow from a rusted gas tank. . # TOXIC SHOCK SYNDROME: Mr. [**Known lastname 65851**] was transferred from OSH with a R elbow bursitis from grp A strep who was admitted s/p debridement in OR with subsequent septic shock, respiratory failure, and worsening renal failure. He was admitted to the ICU and was intubated for respiratory distress. On arrival to the MICU, the patient was without central venous access and required vasopressors for hypotension. A TLC central line was placed under U/S guidance. The patient was continued on penicillin G and clindamycin (for 5 day course) was added per ID recommendations. Mr. [**Known lastname 65851**] went to the OR on [**3-1**] and [**3-2**] for incision and debridement of his right elbow with open posterior and anterior wounds. The patient was started on vancomycin on [**3-4**] as wound fluid from the OSH grew enteroccus (sensitive to vancomycin) and MRSA. On [**2193-3-5**], the patient underwent incision, debridement, and closure of the anterior elbow and a vacuum dressing was placed to posterior elbow. He was then gradually weaned off pressors. He was extubated on [**3-7**] without complications. The patient's renal failure improved (admission Cr was 3.2) thoroughout his stay in the MICU, likely from the administration of aggressive IVF. On [**2193-3-9**], Mr. [**Known lastname 65851**] was able to be transferred to the general medicine [**Hospital1 **]. His hospital course was subsequently significant for clinical evidence of volume overload for which he was diuresed with IV lasix. His tachypnea was noted to improve with diuresis. Hemodynamically, he remained stable and had no further signs of septic shock. His arm wound was closed on [**2193-3-12**]. He was continued on penicillin and vancomycin until [**2193-3-20**]. Vancomycin troughs were drawn regularly in response to his improving creatinine and its dosing was adjusted appropriately. Mr. [**Known lastname 65851**] had several sets of surveillance cultures drawn and all were negative. He had cultures taken from his R elbow in the OR on [**3-12**] and coagulase negative staph was the only bacteria that grew in the culture broth. . # TACHYCARDIA: Mr. [**Known lastname 65851**] was found to be in afib with RVR on admission to the MICU. Upon transfer to the floor, he was placed on telemetry for his GI bleeding and he was found to have episodic bursts of tachycardia, though he always defended his BP. EKG and tele strips were consistent with several types of tachycardia, including sinus tach, afib, and possibly AVNRT. He was started on a beta-blocker and the dose was titrated up until it suppressed these episodes. Cardiology was curbsided about the need for an anti-arrhythmic vs. increasing his beta-blockade and recommended trying to increase his beta-blockade first before committing the patient to a course of an anti-arrhythmic as it was felt that his arrhythmia was likely related to his current illness and may resolve over time. He was switched to oral beta-blockers and did well. An ECHO was performed to evaluate for atrial clot but no clot was seen. He was found to be hyperdynamic, but did not have any focal wall motion abnormalities. We attempted to scan his abdomen by MRA to look for a mesenteric clot perhaps causing an ischemic colitis, but due to his size and his bandaged arm, he was not able to fit appropriately in the MRI scanner. He was discharged on metoprolol 37.5mg PO TID. It was recommended that he follow-up with his PCP upon discharge from rehab to have a repeat EKG and colonoscopy. If the colonoscopy is negative for any bleed and he is persistently in afib, he may need anticoagulation. . # HTN: He has HTN as an outpatient, for which he was on atenolol. His beta-blocker was restarted upon his recovery from the ICU. He was put on metoprolol because of its shorter half-life and he tolerated this without any difficulty. His dose was uptitrated to 37.5mg PO TID. His goal SBP was 120-140s in order to adequately perfuse his bowel. . # RESPIRATORY FAILURE: Mr. [**Known lastname 65851**] was noted to be in respiratory failure at the time of arrival to the hospital. He was felt to be volume overloaded by exam and was diuresed with 20mg IV lasix. He was intubated and received at least 8L of IVF over the course of his ICU stay. Once he was hemodynamically stable, the the focus switched to diuresis and the team attempted to keep him 1L negative daily until his dry weight was achieved. On the floor, we attempted diuresis with frequent doses of lasix 20mg IV, continually monitoring his Cr so as not to worsen his renal failure. The pt was maintained on incentive spirometry and nebulizers. His CXR showed interval improvement of a patchy density in the left lower lobe concerning for pneumonia. The CXR was also significant for prominent pulmonary vasculature, consistent with mild congestive heart failure, which improved over time. By time of discharge, he was breathing at a RR of 18 and his room air sats were 96%. . # GUAIAC POSITIVE STOOL: Mr. [**Known lastname 65851**] began to have guaiac positive stools upon transfer to the floor. The differential diagnosis at the time included abx related diarrhea vs. C diff vs. ischemic colitis. NG lavage was negative for blood. His stools were liquid brown/yellow and were strongly heme positive. A CT of his abdomen was performed and revealed ischemic vs. infectious colitis at the distal small bowel. He was kept NPO, Hct were monitored regularly and protonix was changed to IV BID. His adbomen appeared distended at the time, but he did not have any pain. Lactate was normal. GI and general surgery were consulted and both advocated watchful waiting. Radiology confirmed that the patient had dilated loops of colon, but not toxic megacolon. He was started empirically on flagyl. He continued to have guaiac positive stools throughout the remainder of his hospital course. He required 1u pRBC transfusion, after which his Hct remained stable at 28. C diff was negative x3, but C diff toxin B was pending upon discharge. His diet was advanced and his abdominal distension improved. The most likely diagnosis was ischemic colitis either from his hypotension in the ICU or from a clot due to his afib. The frequency of his stools decreased prior to discharge and the plan was to perform an outpatient colonoscopy approximately 6 weeks after discharge. He will continue on flagyl for a total of 6 additional days, to complete a course of empiric treatment for C. diff. . # ARF: The pt was noted to have an elevated BUN/Cr on admission in the setting of sepsis. The pt's renal failure gradually resolved with treatment and was noted to be 1.4 on discharge. This was felt to be his new baseline. The pt was also noted to have positive urine eosinophils at the start of his antibiotic treatment, so all potentially nephrotoxic agents were avoided and his medications were renally dosed. Repeat checks of his urine eosinophils were negative x2. . # HYPERGLYCEMIA: Mr. [**Known lastname 65851**] was noted to be hyperglycemic on admission in the setting of sepsis. He was maintained on an insulin drip in the ICU but insulin was discontinued once the patient was transferred to the floor because of stable blood glucose levels for 4 days. . # DELIRIUM: The pt was noted to have ICU delirium for which he was treated with Haldol as needed. The pt was noted to have improvement of his mental status after being transferred to the [**Hospital1 **]. He had another brief episode of delirium while on the floor, but did not require any medication for his symptoms. His mental status improved on its own. He had no focal neuro deficits at the time so no imaging was performed. . # ANEMIA: Mr. [**Known lastname 65851**] was anemic on admission, but he continued to have guaiac positive stools throughout the second half of his hospital stay. His Hct remained stable around 28 and serial Hcts were monitored. It had originally been thought that the drop from 34.5 to 28.3 was likely secondary to his ongoing infection and a small amount of ongoing blood loss via VAC dressing. However, it continued to drift downwards to 26 and he was having frequent episodes of frankly bloody stool. He was given 1u pRBC for a Hct of 26 and he tolerated this transfusion well. His Hct then remained stable at 28 despite continued, though less frequent, liquid guaiac positive stool. Further workup of his anemia was not pursued as he had been given a transfusion. . # AXILLARY RASHES: Treated with miconazole powder. . # FEN: His PO intake was poor while in the ICU. Once transferred to the floor, his diet was advanced until he began having bloody bowel movements, at which point he was made NPO with IVF only. Once his hematocrit stabilized, his diet was advanced to clears and then to regular. He was tolerating POs well prior to discharge. He did not receive much IVF once on the floor. Instead, we diuresed him as he was grossly volume overloaded and hypoxic as a result. His electrolytes were checked regularly and repleted as needed. . # PPx: Heparin sc, PPI. He had originally been on a bowel regimen, but it was no longer needed upon discharge given his loose stools. . # CODE: Full . # COMM: Was with his wife, [**Name (NI) 2127**] . # ACCESS: Had triple lumen central line while in the ICU. On the floor, he had a PICC line in his L arm and peripheral IV on L hand. . # DISPO: To acute rehab. Medications on Admission: Meds at home: ASA 81 mg qd atenolol 25 mg qd triameterene/HCTZ 25 mg qd lipitor 10 mg qd . Meds in MICU: Hydromorphone 1-4 mg IV Q2-3H:PRN for pain Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Sliding Scale Ipratropium Bromide Neb 1 NEB IH Q6H Bisacodyl 10 mg PO/PR DAILY:PRN Lansoprazole 15 mg NG DAILY Chloral Hydrate 500 mg PO QHS:PRN insomnia Metoprolol 12.5 mg PO BID DiphenhydrAMINE HCl 25 mg IV Q6H:PRN Docusate Sodium 100 mg PO BID Penicillin G Potassium 3 MU IV Q4H Haloperidol 2-5 mg IV TID:PRN Heparin 5000 UNIT TID Vancomycin HCl 1000 mg IV Q 12H Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. 6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): To axillas bilaterally. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin rash: To groin rash . 8. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital Subacute Unit Discharge Diagnosis: Primary diagnosis: Grp A strep infection in R elbow Toxic shock syndrome Acute renal failure Paroxysmal atrial fibrillation/flutter ICU delirium . Secondary diagnosis: HTN Hypercholesterolemia Discharge Condition: Good, afebrile, BP 118/68, HR 86, sats 95% on RA. Walking with assistance, eating and drinking well. Discharge Instructions: Please call your PCP or go to the nearest ER if you develop any of the following symptoms: fever, chills, headaches, chest pain, palpitations, lightheadedness, dizziness, shortness of breath, leg swelling, arm pain, arm swelling, persistent diarrhea, bloody stools, or any other worrisome symptoms. . Please take all your medications as prescribed. Please continue taking flagyl, an antibiotic for your loose stools, for an additional 6 days. . Please keep all your follow-up appointments. Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge from rehab. Your PCP will need to recheck an EKG to see if you are still in atrial fibrillation and, if so, will decide whether or not to start anticoagulation. . Please follow-up with your orthopedist, Dr. [**Last Name (STitle) 1005**], on [**4-9**] at 10:30am. Please call his office at [**Telephone/Fax (1) 1228**] if you have any questions or need to reschedule. . Please follow-up with a gastroenterologist for a repeat colonoscopy. You can have your PCP refer you to one in your area or you can return to [**Hospital1 18**]. The number for the GI department at [**Hospital1 18**] is [**Telephone/Fax (1) 463**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

[ "584.9", "E917.9", "E849.3", "428.0", "711.02", "038.0", "041.01", "518.81", "V09.0", "427.31", "785.52", "726.33", "881.11", "578.1", "881.21", "293.0", "041.11", "995.92", "557.0", "682.3", "518.0", "040.82", "009.0" ]

icd9cm

[ [ [] ] ]

[ "93.59", "80.82", "86.59", "86.22", "38.91", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

18478, 18593

7426, 17005

363, 505

18830, 18933

2465, 2470

19471, 20265

2087, 2105

17613, 18455

18614, 18614

17031, 17590

18957, 19448

2120, 2446

275, 325

2905, 7403

533, 1945

18782, 18809

18633, 18761

2484, 2886

1967, 2000

2016, 2071

10,807

146,457

27567

Discharge summary

report

Admission Date: [**2169-4-20**] Discharge Date: [**2169-4-25**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2169-4-20**] CABG x 3 (LIMA to LAD, vein grafts to OM and PDA) History of Present Illness: This is an 83 year old male who was admitted to [**Hospital3 35813**] Center with chest pain and NSTEMI. Outside cardiac catheterization was significant for left main disease and severe three vessel disease. He was urgently transferred to [**Hospital1 18**] for surgical revascularization surgery. Past Medical History: Coronary artery disease, Congestive heart failure, Hypertension, Hypertension, Peripheral Vascular Disease - occluded right iliac artery, Carotid Disease, Diabetes mellitus type II, GERD, BPH Social History: Quit tobacco 25 years ago. Denies excessive ETOH. He is a retired State policeman. Lives in [**Doctor Last Name 792**]with his wife. Family History: Brother with CAD. Physical Exam: Vitals: BP 102/50, HR 60, RR 20 General: elderly male in no acute distress HEENT: oropharynx benign, PERRL, sclera anicteric Neck: supple, no JVD, bilateral carotid bruits noted Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: alert and oriented, nonfocal Pertinent Results: [**2169-4-20**] 12:45PM BLOOD WBC-8.6 RBC-4.58* Hgb-13.9* Hct-38.4* MCV-84 MCH-30.4 MCHC-36.3* RDW-15.0 Plt Ct-213 [**2169-4-22**] 02:30AM BLOOD WBC-13.4* RBC-3.22* Hgb-9.7* Hct-27.6* MCV-86 MCH-30.1 MCHC-35.2* RDW-16.0* Plt Ct-122* [**2169-4-24**] 08:50AM BLOOD Hct-27.6* [**2169-4-20**] 12:45PM BLOOD Glucose-129* UreaN-30* Creat-1.3* Na-139 K-3.3 Cl-101 HCO3-26 AnGap-15 [**2169-4-23**] 05:10AM BLOOD Glucose-106* UreaN-34* Creat-1.1 Na-134 K-4.1 Cl-100 HCO3-23 AnGap-15 [**2169-4-20**] 12:45PM BLOOD ALT-36 AST-25 LD(LDH)-213 AlkPhos-78 TotBili-1.2 [**2169-4-24**] CXR - Slight improvement in right lower lobe opacity which may reflect resolving atelectasis or improving pneumonia. Small bilateral pleural effusions. [**2169-4-24**] Carotid Ultrasound - 1. Occlusion of the left internal carotid artery. 2. Close to 70% stenosis of the right internal carotid artery. The plaque begins in the distal common carotid artery and extends into the internal carotid artery on the right. Brief Hospital Course: Mr. [**Known lastname 67379**] arrived to [**Hospital1 18**] in stable condition. He was pain free on intravenous Heparin and Nitroglycerin. Later that day, he was taken to the operating room where Dr. [**Last Name (STitle) **] performed three vessel coronary artery bypass grafting. The operation was uneventful. For surgical details, please see seperate dictated operative note. After the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He experienced bouts of paroxsymal atrial fibrillation for which Amiodarone therapy was initiated. He otherwise maintained stable hemodynamics and weaned from inotropic support without difficulty. On postoperative day two, he transferred to the SDU. He eventually converted back to a normal sinus rhythm on postoperative day three. No further bouts of atrial fibrillation were noted for the rest of his hospital stay. He tolerated and was maintained on low dose beta blockade and Amiodarone. He otherwise continued to maintain good hemodynamics and continued to make steady improvements with diuresis. He worked daily with physical therapy to improve strength and mobility. Medical therapy was optimized and he was medically cleared for discharge to rehab on postoperative day five. Prior to discharge, a carotid ultrasound was obtained to further evaluate his carotid disease and findings of bilateral carotid bruits. Ultrasound revealed an occlusion of the left internal carotid artery, and close to a 70% stenosis of the right internal carotid artery. Based on these findings, Mr. [**Known lastname 67379**] should follow up with a vascular surgeon at the [**Hospital1 18**] or in [**State 792**]for surgical evaluation. Medications on Admission: Flomax 0.4 qd, Glyburide 2.5 qd, Protonix 40 qd, Aspirin 325 qd, Lopressor 25 tid, Lasix 20 tid, IV Heparin, IV TNG Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg (2 tabs) daily x 1 week, then 200 mg (1 tab) daily until stopped by cardiologist. Disp:*60 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: Coronary artery disease - s/p CABG, Postop AF, Congestive heart failure, Hypertension, Hypertension, Peripheral Vascular Disease - occluded right iliac artery, Carotid Disease - bilateral, Diabetes mellitus type II, GERD, BPH Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five ine one week. No heavy lifting (more than 10 pounds) or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. Followup Instructions: Cardiac Surgery Dr. [**Last Name (STitle) **] 4 weeks Call [**Doctor First Name **] at [**Telephone/Fax (1) 67380**] to make appointment. Vascular Surgeon Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2625**]) or Vascular Surgeon in RI for Carotid Disease. Call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67381**] for appt - please see in [**12-23**] weeks. Call Cardiologist Dr. [**Last Name (STitle) 61691**] for appt - please see in [**12-23**] weeks. Completed by:[**2169-4-25**]

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icd9cm

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Discharge summary

report

Admission Date: [**2101-8-7**] Discharge Date: [**2101-9-16**] Date of Birth: [**2051-7-25**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 30**] Chief Complaint: Low Back Pain Major Surgical or Invasive Procedure: L4/L5 vertebra and disc biopsy. History of Present Illness: This is a 50 y/o male with a history of IV drug abuse, cirrhosis, ETOH abuse, DM and HTN who is transfered from [**Hospital6 **] after being diagnosed with L4-L5 osteomyelitis and epidural inflamation. . Patient presents with a history of 12 weeks of lower back pain, after lifting a steel door. Initially, he felt that it was not bothering him much, but the pain became progressively worse, and over the prior 4 days his pain was [**11-15**]. He states that it was difficult for him to move his left leg. Walking of sitting up was very difficult. He also refers pain and needles sensation down his left leg. Denied bowel incontinence, althouh refers constipation. No urinary incontinence. No fevers, chills, nausea or vomiting. He has been tolerating po's well. . He refers history of IV drug use, and last time was [**2101-7-25**] using clean needles. On that date, he did miss [**First Name (Titles) **] [**Last Name (Titles) 5703**] and re-injected without cleaning the needle. He developed a large cellulitis/furunculosis per the patient which he lanced and subsequently it healed on its own. He was initially taking percocet for the pain but given that it was not working, he was started on methadone that seems to improve his pain control. He was also drinking vodka over the last 3 days to help with the pain. . He went to see his PCP Dr [**First Name (STitle) 10378**] who decided to sent a Lumbar MRI. Lumbar MRI [**2101-8-6**] showed discovertebral osteomyelitis at L4-L5 level with significant epidural inflammation. Also marked spinal stenosis. He was admitted to [**Hospital3 **] today. VS: T 99, BP 125/73 Hr 75 RR 16. Labs WBc 9.4, HCt 39.7 Plat 174. Na 130, k 4.6, Cl 94, HCO3 19.7 glucose 98. bun 13, Creati 0.6 and Calcium 8.8. . Given the question of possible vertebraectomy and his other comorbdities, patient was transfered for Neurosurgical evaluation. . In the [**Hospital1 **] ED: T 99.5 HR 75 BP 124/80 RR 16 Sats 99% RA. Evaluated by neurosurgery who would not intervene at this point but recomended obtaining biopsy from IR to identify the type of infection prior to starting antibiotics. They also recomended blood cx, CRP and ESR. At 19:30, he spiked to 101 and patient was given antibiotics in the Ed Unasyn, Vancomycin and Flagyl. He was also given dilaudid and methadone for pain. . On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied 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: Hepatitis C Cirrhosis - apparently dx about a year ago. IV drug used (last used 1 month PTA) Alcohol abuse - He used to drink about half gallon vodka a day. Diabetes Hypertension Social History: Patient lives at home with his long-term girlfriend. currently not working. He used to drink about half a gallon of vodka a day, until diagnosed with cirrhosis and incarcerated for buying heroin. He has a 1.5 ppd X 30 years smoking, quit while in jail, but re-started recently. Now smoking [**4-9**] cigarettes/day. 12 year history of significant IV heroin use, off while incarcerated. Used IV heroin last on [**7-25**] (birthday). No history of withdrawal from etoh/dts, or heroin withdrawal. Family History: Mother history of abdominal cancer. Physical Exam: T 100.7, P78, R 20, BP 140/80, O2 sat 98% RA Gen: uncomfortable white male, track marks on both arms, minimal motion, complaining of pain HEENT: no icterus, PERRL, OP clear Neck: supple, nontender, no lymphadenopathy Car: RRR no murmur Resp: CTAB Abd: soft, nontender, normal bowel sounds, liver edge 3 cm below costal margin, ventral hernia, umbilical hernia Ext: track marks on bilateral arms, no lower extremity edema Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 4+(pain)5 5 5 5 L 5 5 5 5 5 4+(pain) 5 5 5 5 Sensation: Decreased to from left thigh to top of left foot but is able to discrimate from pinprick and light touch. Propioception intact bilaterally Reflexes: B T Br Pa Ac Right 1+ 1+ 0 0 Left 1+ 1+ 0 0 Toes downgoing bilaterally Pertinent Results: [**2101-8-7**] 08:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2101-8-7**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5 LEUK-NEG [**2101-8-7**] 07:30PM WBC-7.9 RBC-4.10* HGB-12.7* HCT-35.9* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.0 [**2101-8-7**] 07:30PM SED RATE-117* [**2101-8-7**] 05:05PM CRP-58.5* [**2101-8-7**] 04:58PM LACTATE-2.3* [**2101-8-24**] 05:41AM BLOOD WBC-2.9* RBC-2.79* Hgb-8.9* Hct-25.1* MCV-90 MCH-31.8 MCHC-35.3* RDW-16.5* Plt Ct-20* [**2101-8-15**] 06:05AM BLOOD ALT-25 AST-51* AlkPhos-327* Amylase-54 TotBili-5.1* DirBili-3.7* IndBili-1.4 [**2101-8-8**] 06:00AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [**2101-8-19**] 05:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2101-8-11**] 05:05PM BLOOD CRP-59.4* . Microbiology: Blood cultures: [**8-7**], [**8-8**], [**8-9**] with no growth Blood cultures: [**8-12**]: no growth [**8-11**] Disc culture/swab:[**Female First Name (un) **] ALBICANS. SPARSE GROWTH. [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. 2ND TYPE. [**8-12**] Bone biopsy L4: no growth [**8-17**] Ucx and Bcx no growth . MRI with gad: Comparison is made to outside MR [**First Name (Titles) 767**] [**Hospital1 34585**] dated [**2101-8-6**]. . There has been no significant change since the prior study. . There is destruction of the L4/5 disc as well as the inferior endplate of L4 and the superior endplate of L5. There is diffuse enhancement of the vertebral bodies of L4 and L5 as well as diffuse enhancement of the surrounding paraspinal soft tissues extending into the psoas muscles bilaterally. There is also extension of soft tissue enhancement into the epidural space at the L4/5 level. This is causing moderate compression of the thecal sac. These findings are consistent with discitis, osteomyelitis, with paraspinal and epidural phlegmon, the latter causing moderate thecal sac compression. No discrete fluid collections identifying an abscess cavity are seen. The involved vertebrae and disc are T2 hyperintense, consistent with inflammatory edema. . The conus medullaris normally ends at the level of L1 and no signal abnormalities of the visualized spinal cord are seen. . IMPRESSION: No significant change since [**2101-8-6**], with L4 and L5 with osteomyelitis and discitis, with paraspinal and epidural phlegmon, the latter causing moderate compression of the thecal sac. Above findings were discussed with directly with Dr. [**Last Name (STitle) 10351**], the requesting physician, [**Name10 (NameIs) **] an emergent neurosurgical consult was recommended and obtained. . TTE ([**8-8**]): IMPRESSION: Normal study. No valvular pathology or pathologic flow identified . TEE ([**8-19**]): IMPRESSION: No valvular pathology or abscess identified. . Chest X-ray: IMPRESSION: 1. No acute cardiopulmonary abnormality. 2. Questionable nodular opacity at left lung apex, finding that could indicate a superimposition of vascular and osseous structures, although dedicated PA and lateral chest radiograph is recommended for further assessment. . Scrotal U/S: IMPRESSION: Hypoechoic, nonvascular right testicular lesion concerning for possible neoplasm. A focal orchitis is felt to be less likely given the lack of vascular flow. . MRI w/ and w/o contrast ([**9-1**]): No significant change since [**2101-8-8**] with spondylytic discitis involving the L4 and L5 vertebral bodies with paraspinal and epidural phlegmon formation causing moderate compression of the thecal sac. Brief Hospital Course: 50 y/o M with h/o IV drug abuse, cirrhosis, ETOH, hep C, and DM who presents with L4/L5 osteomyelitis. S/p CT-guided bx of L4/L5 disc on [**8-11**]-Yeast grown from disc cx found to be [**Female First Name (un) **] albicans. Complicated by thrombocytopenia, ARF, and hypotension. . 1. L4-L5 osteomyelitis w/ phlegmonous extension: An initial evaluation by neurosurgery was performed. However, neurosurgery did not feel that the pt was a candidate for surgery. A medical approach was taken with various antibiotics over the course of the [**Hospital 228**] hospital stay. An initial blood cx at [**Hospital3 **] grew [**2-9**] coag-neg staph. No further blood or urine cultures were positive. So it was thought to be a contaminant although this could not be ruled out. For this reason, the pt was stared on Vancomycin which was discontinued later during the hospital course b/o suspected bone marrow suppression thought to cause significant thrombocytopenia, leukopenia and anemia. A disc cx from [**8-11**] grew sparse [**Female First Name (un) **] albicans and beta-glucan lab test was positive making [**Female First Name (un) **] albicans osteomyelitis most likely despite a bone cx from [**8-12**] showing no growth. The pt was started on Amphotericin after the positive cx results. At that time he was still treated with both Vancomycin and Amphotericin. However, the pt developed ATN which was attributed to Amphotericin. So both Vancomycin and Amphotericin have been D/C'd over the course of his stay b/o ATN and thrombocytopenia/leukopenia, and treatment with Caspofungin has been started on [**8-17**] (initially with 35 mg IV q24h, later increased to 50 mg IV q24h) and continued throughout the remainder of his stay. The patient was moved to the ICU when developing recurrent hypotension and worsening renal failure, but recovered soon thereafter. The patient improved significantly towards the end of his hospital stay and his symptoms were well controlled at discharge. He was afebrile and able to ambulate. A lumbar brace has been placed. CRP was trending down from 58.6 [**2101-8-7**] to 11.8 [**2101-9-13**]. Further recovery is expected at an extended care facility. Followup appointments have been scheduled with ID and neurosurgery. An outpatient MRI of the L-spine has been scheduled as well. The patient should also get weekly CBC, LFTs and BUN/Crea while on Caspofungin. Results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. . 2. Acute Renal Failure. Baseline creatinine was 0.7-0.9 (0.9 on [**8-15**]). Crea was 2.4 on [**8-16**].8 on [**8-17**].0 on [**8-19**]. He was anuric from [**Date range (1) 67404**] with uremic symptoms (nausea/vomiting). His Crea was 5.7 on [**8-22**] after starting CVV hemodialysis on [**8-20**]. After having been in the ICU b/o ARF and recurrent hypotension, the patient recovered quickly on the floor and his kidneys proceded to the polyuric phase. Crea 1.6 on [**8-28**]. Crea came down to 1.3 towards the end of his stay. After the polyuric phase, the kidney function returned to [**Location 213**] output. The patient was asymptomatic at discharge. . 3. Thrombocytopenia. Plts 152 on admission, Plts 69 on [**8-13**] on [**8-20**]. Anti-platelet4 (HIT) antibody was positive and the patient was initially thought to have HIT. All heparin products were D/C'ed. However, on [**8-26**] Serotonin Release Ab came back negative. Since HIT Ab not very specific and SRA test negative, the diagnosis of HIT was questioned at this point. Treatment with Vancomycin correlated with the worsening thrombocytopenia and was thought to be a likely cause. After having D/C'ed Vancomycin, the CBC improved consistently. The pt did not bleed significantly except for mild R conjunctival bleeding observed [**8-22**]. Platelet transfusions were given on [**8-24**] in order to raise plts temporarily for line removals. Platelets came up from 20 to 31 o/n. Platelets came up considerably towards the end of his stay (Platelets 77 on [**8-31**]). The patient was discharged without any signs of active bleeding and hemodynamically stable. . 4. Anemia: Hct 35.9 on [**8-7**].5 on [**8-24**], Pt received 2U PRBC on [**8-25**] raising Hct up to 26.3 and stable thereafter. Following course of renal dysfunction, perhaps due to low erythropoeitin levels. Iron studies consistent w/ ACD. Also occult bleeding was considered since pt was also thrombocytopenic, cirrhotic, and uremic. Stools were guaiaced. Improvement was noted when Vancomycin was D/C'ed. Vancomycin was likely cause of suppression of all three lines in the bone marrow although multiple factors were certainly involved. Patient's Hct came up again towards the end of his stay. Hct was 29.6 [**2101-9-13**]. Pt was asymptomatic at discharge. . 5. Leukopenia: WBC dropped down to 2.9 on [**8-24**], but after that continuously rising. WBC 4.0 on [**8-28**] and stable thereafter (previous baseline [**6-13**]). Possible causes were immunosuppression b/o fungal osteo or medications, especially Vancomycin which causes bone marrow suppression. Vanco had been D/C'ed. WBC stable. Patient did not develop any opportunistic infections and his osteomyelitis stayed stable despite the transient leukopenia. Pt was asymptomatic at discharge. . 6. Pain: Low back pain with radiation to both legs (R>L) was managed throughout the [**Hospital 228**] hospital stay with a variety of pain medications including a Fentanyl patch, Methadone at increasing doses, Morphine, Dilaudid IV and PO, Oxycontin and Oxycodone. The patient became hypotensive on some of these medications. The fentanyl patch was D/C'ed b/o that although multiple factors were likely responsible for his hypotensive episodes. Methadone was tapered during his hospitalization by 20 mg/day with MSContin increased by 30 mg/day throughout the taper. His pain regimen on discharge is as follows: MSContin 430 mg [**Hospital1 **], Neurontin 900 mg tid, Tylenol 500 mg qid, Dilaudid 30 mg q4-6h prn, Tramadol 50 mg q4-6h prn. . 7. Thigh pain: New left lateral thigh pain on [**8-25**] and right lateral thigh pain on [**8-28**]. No bruise or bulge at either thigh. DVT on L leg ruled out with LENIS. Pain seems to be muscular and most likely due to recent use of LE muscles after extended periods of immobility. The pain was managed with the same medications as stated above. The new quality of pain subsided soon after having been mobile for longer periods and was thought to be different from his radiating back pain [**3-10**] osteomyelitis. . 8. Acute scrotal pain: Pt developed acute left scrotal pain radiating up his groin and flank on [**8-17**]. Pt received 500 cc IV NS bolus, 4 mg Dilaudid, scrotal and renal u/s were unremarkable except for an incidentally found R testicular lesion. Urology was consulted. DD included testicular torsion, orchitis, acute kidney stone, inguinal hernia. Doppler U/S of kidneys negative for [**Month/Year (2) 5703**] thrombosis on [**8-17**]. The pain subsided soon after having been treated with Dilaudid. The exact cause of this episode remains unclear. A followup appointment has been scheduled with urology in order to work up the R testicular cystic lesion as outpt. . 9. DM: Pt was formerly on Glyburide. Last HbA1c normal. Pt was rather hypoglycemic at beginning of his hospital stay and was treated as needed. For the majority of his stay, FS were stable. Pt was started on metformin 500 mg qam one week prior to discharge. Pt was asymptomatic throughout his stay. . 10. Cirrhosis/Hep C: no history of GI bleeding, encephalopathy or any other complications in the past. Pt developed transiently cholestatic labs during stay, likely due to infectious process and mulitple medications. Pt was briefly icteric, but returned quickly to normal state. Labs remained at baseline elevation for the remainder of his stay. Pt received Hepatitis A vaccination. The outpatient medication Spironolactone has been discontinued during the hospital stay because the patient developed acute renal failure. It was not restarted upon discharge. It is recommended to discuss the restarting of spironolactone with his liver team during follow up as an outpatient. . 11. Hyponatremia: Initially progressed to sodium of 124, but later wnl. Pt was euvolemic throughout his hospital stay. No rx was necessary and sodium was stable at discharge. . 12. Pos UCx: The patient had GNR growing from a UCx on [**8-30**] after having spiked a fever once the day before. The UA was repeatedly negative and the patient remained afebrile thereafter. A CXR was also negative and a repeat MRI of the L-spine did not show any significant change to previous MRIs. The patient completed a seven-day course of ciprofloxacin and remained asymptomatic. . 13. HTN: Pt was normotensive with an episode of hypotension as described above. BP medications were held and BP was monitored throughout his stay. It is recommended that his medications are started as an outpatient after monitoring his BP for hypotension and reevaluating his hypertension. . 14. H/o alcohol abuse: Pt was monitored on CIWA, with prn Ativan. . 15. FEN: cardiac/diabetic diet. . 16. Prophylaxis: Initially SC heparin, pneumoboots when off heparin. Ambulatory towards the end of his stay. Bowel regimen, PPI. . 17. Access: PICC placed on [**8-15**] and kept on discharge for outpatient treatment. IJ and HD catheter were removed [**8-24**] after 2x platelet transfusions plus 1x FFP b/o low ptls and chronically high INR [**3-10**] cirrhosis. . 18. Code Status: Full Medications on Admission: methadone 20 mg po qd, atenolol 50 mg po qd, Zestril 20 mg Po qd, Aldactone 25 mg po qd, glyburide stopped over the last month because BS below 100 in the am Discharge Medications: 1. Caspofungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): per sliding scale. 5. Outpatient Lab Work Please obtain weekly CBC, BUN/Crea and LFTs and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. Hydromorphone 4 mg Tablet Sig: 7.5 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed: Titrate to 3 bm/day. 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. Morphine 200 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO every twelve (12) hours. 14. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every twelve (12) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: L4-L5 osteomyelitis L4-L5 discitis Epidural and Paraspinal phlegmon IVDA Alcoholism Hepatitis C Cirrhosis Hypertension Diabetes mellitus Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Discharge Instructions: Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, severe back pain, increasing pain radiating down your legs, urinary or bowel incontinence, or any other concerning symptoms. Please take all your medications as directed. Please keep you follow up appointments as below. . Please keep lumbar half of TSLO brace on while out of bed until follow-up in [**Hospital 4695**] clinic. Followup Instructions: Please follow up with your Primary Doctor ([**Last Name (LF) 67405**],[**Known firstname 177**] J. [**Telephone/Fax (1) 53045**]) with the next 1-2 weeks after your extended care facility stay. . Please follow up with a urologist regarding the lesion found in your right testicle within the next 1-2 weeks after your extended care facility stay. Please call [**Telephone/Fax (1) 61400**] in order to schedule an appointment at the [**Hospital 159**] clinic. . Please have an appointment scheduled at the Infectious [**Hospital 2228**] clinic in [**7-13**] wks from now ([**Telephone/Fax (1) 457**]). Please have weekly lab values (CBC, BUN/Crea, LFTs) drawn while on intravenous treatment with Caspofungin as an outpatient. Results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. . Please have an MRI of your L-spine with and without contrast scheduled shortly prior to your outpatient clinic appointment with Infectious Diseases. Please call [**Telephone/Fax (1) 67406**] for scheduling. Depending on the result, the Infectious Disease specialist might switch you to an oral medication for treatment of your fungal osteomyelitis. . Please follow up with L-spine MRI w/&w/o contrast in [**Hospital 4695**] Clinic (Dr. [**Last Name (STitle) 739**] in 10 weeks or 2 weeks after completion of antibiotic course. Phone: [**Telephone/Fax (1) 1669**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

19728, 19801

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286, 320

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20514, 21941

3809, 3847

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20056, 20491

3862, 4291

233, 248

348, 3075

4306, 4870

3097, 3278

3294, 3793

41,532

106,323

31303

Discharge summary

report

Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-15**] Service: MEDICINE Allergies: morphine Attending:[**Doctor First Name 3298**] Chief Complaint: transfer from OSH for ERCP for bile leak Major Surgical or Invasive Procedure: ERCP with stent placement History of Present Illness: This is an 86 yo F with CAD s/p CABG, HTN, dyslipidemia, GERD, history of CVA, and tracheobronchomalacia and eosinophilic bronchitis who presented on transfer from [**Hospital3 60338**] for ERCP for a biliary leak. Patient initially presented to OSH on [**10-5**] with RUQ abdominal pain and nausea without vomiting. Her labs were significant for WBC 11.6, Tbili 0.5, Dbili 0.2, amylase 97, lipase 26, ALT 22, AST 22, alk phos 121, UA positive. Patient had a RUQ ultrasound which showed interval development of mild to moderate biliary dilatation (CBD 9mm at level of ampulla). Also with 9 mm gallstone in the fundus of the gallbladder. She underwent a laparoscopic cholecystectomy [**10-6**] which was a difficult procedure and JP drain was left in place. Due to persistently high output and suspicion of bile leak ERCP was attempted [**2199-10-8**] to assess for cystic duct leak however unable to cannulate common bile duct. Decision made to transfer patient to [**Hospital1 18**] for ERCP with biliary stent if there is a cystic duct leak. On presentation here patient reported [**7-24**] RUQ pain, described as sharp. Pain steadily worsening. She denied nausea, vomiting, diarrhea, cp, sob or lightheadedness/dizziness. No fever or chills. No po intake since ERCP. Patient did have a significant amount of epigastric abdominal pain after ERCP on day prior to arrival but that resolved after procedure. She denied hematochezia or melena. Last BM prior to admission. ROS as per HPI otherwise 10 pt ROS negative Past Medical History: CAD s/p CABG in [**2190**] S/p PPM Aortic regurg HTN Dyslipidemia Nephrolithiasis Chronic back pain GERD Hx of CVA with left eye blindness Tracheomalacia Eosinophilic bronchitis Social History: Lives with husband in [**Name (NI) 6691**]; 2 children and 2 grandchildren. Retired from paper company. No history of tobacco, no etoh or illicits. Family History: Mother deceased from CHF Father deceased from unclear causes Physical Exam: ON ADMISSION: VS: 98.1 136/67 76 20 99% 2L NC Appearance: alert, NAD, thin Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 [**2-17**] diastolic murmur at LUSB, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, + RUQ ttp, slight distension, +bs, incisions with small amount of serosanginuous drainage; no rebound/guarding, JP drain with dark bile output Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] ON DISCHARGE: VS: T 98 (afebrile >24 hrs), BP 126/68, P 83, RR 20, O2 Sat 99% on RA Gen: Thin elderly female in NAD HEENT: anicteric, MMM CV: regular rate and rhythm, no periperhal edema, JVP not elevated (at clavicle with patient at 20 degrees) Pulm: Mild crackles at bases resolved with cough and taking deep breaths, good air movement bilaterally, no wheezing or rhonchi Abd: Soft, mildly hypoactive BS, slight tenderness to palpation in right upper quadrant w/o guarding or rebound, JP drain in place with small amount of bilious fluid, no organomegaly or masses appreciated Extrem: W and WP with no clubbing, cyanosis, or edema Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-12.0* RBC-3.43* Hgb-10.8* Hct-30.8* MCV-90 RDW-13.5 Plt Ct-332 --Neuts-78.8* Lymphs-12.1* Monos-4.3 Eos-4.5* Baso-0.4 PT-15.8* PTT-30.5 INR(PT)-1.4* Glucose-67* UreaN-14 Creat-0.7 Na-141 K-4.1 Cl-108 HCO3-24 ALT-52* AST-30 LD(LDH)-170 AlkPhos-86 Amylase-90 TotBili-0.9 Lipase-34 Calcium-8.8 Phos-2.6* Mg-1.6 On Discharge: WBC-10.1 RBC-3.47* Hgb-10.6* Hct-30.8* MCV-89 RDW-14.4 Plt Ct-431 Glucose-95 UreaN-9 Creat-0.7 Na-140 K-4.2 Cl-105 HCO3-29 AnGap-10 ALT-29 AST-27 AlkPhos-76 TotBili-0.6 Other Important Labs [**2199-10-10**] 07:25AM BLOOD CK-MB-5 cTropnT-0.05* [**2199-10-10**] 04:53PM BLOOD CK-MB-9 cTropnT-0.06* [**2199-10-11**] 04:29AM BLOOD CK-MB-6 cTropnT-0.07* ============== MICROBIOLOGY ============== Blood Cultures *2 [**2199-10-9**]: No growth- FINAL Bile Culture [**2199-10-9**]: GRAM STAIN (Final [**2199-10-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2199-10-12**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2199-10-15**]): NO GROWTH. C diff toxin assay [**2199-10-12**]: Negative ============== OTHER RESULTS ============== ECG Study Date of [**2199-10-10**] Atrial fibrillation with ventricular premature beats. Left axis deviation. Diffuse ST-T wave abnormalities. No previous tracing available for comparison. PORTABLE ABDOMEN Study Date of [**2199-10-10**] IMPRESSION: No evidence of obstruction. The evaluation of free air is limited on this supine radiograph. Suggest upright films to better assess for free air. CHEST (PORTABLE AP) Study Date of [**2199-10-10**] IMPRESSION: Free intraperitoneal air. Please see comments above regarding documentation of communication of this finding. CT ABD & PELVIS WITH CONTRAST Study Date of [**2199-10-10**] IMPRESSION: 1. Inflammatory changes and free air but no drainable collection. Free air of uncertain significance in the setting of recent surgery although bowel perforation cannot be excluded. 2. Small focal fluid collection adjacent to the pancreas. 4. Distended fluid-filled loops of bowel suggest an ileus. 5. Bibasilar atelectasis and effusions. 6. Biliary stent and pneumobilia consistent with recent ERCP. Abdominal drain with tip in the surgical bed. ERCP [**2199-10-10**]: Impression: -The major papilla was gaping, but did have the appearance of a fish mouth papilla. -Extravasation was noted at the right intrahepatic duct c/w with a duct of Luschka leak. -Otherwise normal biliary tree. -A sphincterotomy was performed. -A biliary stent was placed. -Otherwise normal ercp to third part of the duodenum Portable TTE (Complete) Done [**2199-10-11**] Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 86 yo F with CAD, s/p PM, HTN, dyslipidemia, GERD, hx of CVA, tacheomalacia and eosinophilic bronchitis who initially presented to OSH on [**2199-10-5**] with cholecystitis now s/p lap chole with complicated surgery requiring JP drain presented in transfer with concern for bile leak. 1) Cholecystitis s/p lap chole: On admission, patient with abdominal pain and increased JP drain output concerning for bile leak. Pt was initially admitted to Medicine, and the ERCP team was consulted. She underwent successful ERCP with placement of a plastic stent, which relieved the biliary leak. Following the procedure, pt developed acute respiratory distress and hypoxia. CXR was concerning for acute pulmonary edema. She was treated with lasix for diuresis and she was transferred to the ICU for further care. In the ICU, patient was noted to have free air under the diaphragm and was evaluated by surgery for urgent OR. However, given stable abdominal exam with no evidence of acute abdomen, and temporal relationship to lap chole, air was attributed to recent surgery and no intervention was necessary. Her breathing rapidly stabilized (see below). Abdominal exam improved with tenderness around JP drain resolving steadily after ERCP and at discharge had only slight tenderness around drain with movement. Surgery consult recommended JP drain removal be performed as an outpatient by her primary surgeon. She was initially treated with vanc/zosyn, though this was changed to cipro/flagyl as exam remained stable. Her diet was gradually advanced, which she tolerated well. She was discharged with plan to complete two more day of ciprofloxacin/metronidazole for a total course of 7 days after biliary stent placement. 2) Acute on chronic diastolic congestive heart failure: Patient was transferred to ICU on [**10-10**] after developing sudden respiratory distress on the floor in the setting of elevated BP (presumed catecholamine surge). Pt was diuresed with lasix IV boluses with significant improvement in her respiratory status. She was weaned off the facemask and maintained her saturation on nasal canula. Home blood pressure medications were restarted and she was euvolemic on transfer out of the ICU. Echocardiogram showed normal EF, mild AS. Furosemide was stopped and she was weaned off supplemental oxygen with no further respiratory distress. 3) Atrial fibrillation: Pt has history of previous AF and was on coumadin but stopped some time prior to admission in the context of severe GI bleed. After discussion with PCP and cardiologist pt is usually in sinus and during hospitalization had a brief episode of well rate controlled AF that converted back to sinus. Given history of severe bleeding coumadin will be discussed further as an outpatient but held for now. This was decided in discussion with PCP and stroke risk was discussed with patient and husband. Aspirin and diltiazem were continued. 4) Diarrhea: Patient had diarrhea after being transferred out of the MICU but this was low volume and not associated with fever, leukocytosis or other symptoms. C diff was negative and this began to improve after solid food was restarted. Likely due to functional hypermotility and liquid diet. 5) GERD: She was continued on her her home PPI 6) Eosinophilic bronchitis: She was continued on her home fluticasone-salmeterol inhaler and albuterol PRN 7) CAD s/p CABG: She never had signs or symptoms of ACS. She was continued on her home ASA and diltiazem. Simvastatin was held at admission then restarted at discharge. 8) HTN, benign: She was hypertensive post procedure but then blood pressures were well controlled on home regimen of diltiazem and amlodipine. 9) History of cerebrovascular disease: Blood pressure control was continued with dilt and amlodipine. Her aspirin was similarly continued. 10) Glaucoma: She was continued on her home cyclosporin drops. The patient tolerated a full diet prior to discharge. She received heparin SC for DVT prophylaxis. She was full code. Transitional Issues: - She will be discharged to acute rehab given deconditioning and poor exercise tolerance for PT - She will follow up with Dr. [**Last Name (STitle) 73823**], her surgeon, regarding removal of her JP drain - She should have an MRCP as an outpatient to evaluate a possible pancreatic cyst seen on in house CT scan - She will follow up with Dr. [**Last Name (STitle) 64453**], her cardiologist, for further management of her diastolic heart failure and CAD - She will follow up with Dr. [**Last Name (STitle) **] in 6 wks for repeat ERCP and evaluation of need for more stents vs stent removal - Doctors [**Name5 (PTitle) 73824**] and [**Name5 (PTitle) 64453**] [**Name5 (PTitle) **] continue to manage patient's atrial fibrillation and discuss/ weigh risks and benefits of anticoagulation with the family Medications on Admission: Outpatient Medications: Diltiazem ER 360mg daily Protonix 20mg [**Hospital1 **] Advair 250/50 [**Hospital1 **] Norvasc 2.5mg daily ASA 81 Vit D3 [**2187**] IU daily MVI Vit C 500mg daily Simvastatin 40mg daily Gelnique Sachets 10% gel q evening Restasis 1 gtt ea eye [**Hospital1 **] Tylenol prn . Transfer Meds: per discharge summary, no doses listed Norvasc Vitamin C ASA Cyclosporin Cardizem Fluticasone Hydrocodone with acetaminophen MVI Protonix Kcl Zocor Genteal to eyes Vit D3 Discharge Medications: 1. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 2. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. multivitamin Capsule Sig: One (1) Capsule PO once a day. 8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Gelnique 10 % (100 mg /gram) Gel in Packet Sig: One (1) packet Transdermal at bedtime. 11. cyclosporine 0.05 % Dropperette Sig: One (1) drop each eye Ophthalmic [**Hospital1 **] (2 times a day). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: last day [**10-17**]. Tablet(s) 16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days: last day [**10-17**]. Discharge Disposition: Extended Care Facility: Mt. Greylock ECF Discharge Diagnosis: # Bile leak s/p cholecystectomy # Cholecystitis # Hypoxic respiratory distress/acute diastolic heart failure # Atrial fibrillation 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 in transfer from [**Hospital6 6689**] for complicated cholecystitis and cholecystectomy complicated by bile leakage. You underwent ERCP with stent placement, and the leak stopped. Your hospitalization was complicated by a period of heart failure, but this improved with treatment. Due to weakness you are being discharged to a rehabilitation facility who will help manage your medications. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73823**] [**Hospital1 **] Surgical Associates Friday, [**10-25**] at 1:30 PM [**Apartment Address(1) 73825**] [**Location (un) 6691**], MA Phone: [**Telephone/Fax (1) 73826**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64453**]- Cardiology Monday, [**11-4**] 9:15 am [**Street Address(2) 73827**], [**Apartment Address(1) 36475**] [**Location (un) 6691**], MA Phone [**Telephone/Fax (1) 73828**] Dr. [**First Name (STitle) **] [**Name (STitle) **] Thursday, [**11-21**] Arrive at 7 am for 8 am repeat ERCP [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES Phone [**Telephone/Fax (1) 13246**] (you should not eat on the morning of the procedure)

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icd9cm

[ [ [] ] ]

[ "51.85", "51.87" ]

icd9pcs

[ [ [] ] ]

14077, 14120

7238, 11257

259, 287

14295, 14295

3599, 3658

14913, 15738

2230, 2292

12617, 14054

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28,202

195,079

34055

Discharge summary

report

Admission Date: [**2115-4-15**] Discharge Date: [**2115-4-25**] Date of Birth: [**2051-4-20**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Iodine Attending:[**First Name3 (LF) 4679**] Chief Complaint: MSSA epidural abscess Major Surgical or Invasive Procedure: Thoracentesis [**2115-4-16**] Laminectomy T9,T10,T11/Resection of epidural abscess [**2115-4-17**] History of Present Illness: HPI: 64 y/o M with PMHx as below initially admitted to [**Hospital 28941**] Hosp on [**4-4**] with lower back pain & fever and found to have MSSA bacteremia complicated by T9 epidural abscess and vertebral osteomyelitis/discitis. . OUTSIDE HOSPITAL COURSE: Due to his PCN allergy, was initially placed on vanco/rifampin and transitioned to Levaquin 750mg IV qD. Was evaluated by neurosurgery who recommended conservative therapy and no surgical options. A TTE was performed which was negative for endocarditis or vegetations (no documented TEE). Pt was continued on Abx although blood cultures continued to return positive as below. . On arrival, pt endorses persistent back pain. He denies F/chills, SOB, odynophagia, HA, double/blurry vision, numbness/tingling or weakness, N/V/abd pain. He does note 1 loose stool yesterday. He denies any b/b incontinence. He denies any CP, palpiations, PND, or orthopnea. Past Medical History: 1) Bipolar D/o 2) Hypothyroidism 3) DMII 4) Hyperlipidemia 5) Asthma 6) Depression Social History: Tob: Remote 30 pkyr hx; quit 20 yrs ago. No etoh. +Marijuana use. No IVDU or other IV injection use. Retired; former electrician. Lives with son, daughter-in-law and grandson. Family History: Father DM2 Mother CAD Physical Exam: VS: T95.6 BP 100/70 HR80 RR 22 92%RA Gen: Slightly disheveled elderly male in NAD. Non-toxic appearing. Able to speak in complete sentences. HEENT: Anicteric sclera. No conj hemorrhages noted. O/P clear with poor dentitition. No abscess seen. Uvula midline. Neck: No LAD. No JVD Lungs: Decreased BS at right base with dullness to percussion and decreased egophony c/w consolidation. No wheezes, rales or rhonchi heard. right chest tube to pneumostat. Heart: RRR. Nml s1,s2. No diastolic or systolic murmur appreciated although heart sounds slightly muffled. Abd: Soft, NTND. +BS. No HSM. Extrem: No edema. Pulses 2+ SKIN: ------------------ NEURO: CN II-XII intact. UE/LE Strength 5/5. Sensation intact to LT. Pertinent Results: [**2115-4-19**] 2:30 pm TISSUE PLEURAL RIGHT. GRAM STAIN (Final [**2115-4-19**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2115-4-23**]): STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 78597**] ([**2115-4-19**]). ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2115-4-17**] 7:59 pm TISSUE EPIDURAL ABSCESS. GRAM STAIN (Final [**2115-4-17**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] @ 1040PM ON [**2115-4-17**]. TISSUE (Final [**2115-4-21**]): STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [**2115-4-21**]): NO ANAEROBES ISOLATED. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2115-4-18**]): NO FUNGAL ELEMENTS SEEN. ACID FAST SMEAR (Final [**2115-4-18**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. Brief Hospital Course: A/P: 64 y/o M with HTN, DM2 who was admitted to OSH with fever and LBP and found to have a discitis and epidural abscess at T9; transferred here for further care. . 1) Epidural Abscess/Discitis/Vertebral Osteomyelitis: Unclear source at present time, although is having persistent bacteremia that suggests an endocarditis. No evidence of peripheral splinters or lesions to suggest embolic phenomenon. Has +blood cxs as major criteria, and fever as minority Duke criteria. His embolic complications include the abscess/discitis/osteomyelitis as above. Unfortunately has PCN allergy as above that prevented first line therapy with Nafcillin or Ancef. He was restarted on Vancomycin IV 1g [**Hospital1 **] for coverage of his MSSA given his ? PCN allergy. He had a repeat Thoracic MRI that again demonstrated the T9-T10 epidural abscess. He was seen by the ortho spine service who took him to the OR on [**2115-4-17**] who performed a laminectomy and epidural abscess drainage. Fluid was sent to the lab for cx and a JP drain was left in place until POD#5. Pt was taken to ICU for PCN desensitization w/o complication. Per ID the pt will require at the very least a 6 week course of naficillin and will be re-imaged at that time w/ neck MRI and Chest CT to determine if and how long additional nafcillin will be required. a Picc line was placed under fluro on [**2115-4-24**]. 2) Empyema On admission, he was found to have greatly diminished breath sounds and a CXR demonstrated a loculated anterior pleural effusion. The IP service was consulted who performed a thoracentesis which demonstrated an empyema with GPC growing from the fluid. The thoracics service was consulted who placed a chest tube in place for drainage of the collection. He was taken to the OR on [**4-19**] for a VATS/decortication. Fluid and pus were removed from the pleural space and again sent to the lab for culture. 2 chest tubes were left in place. Post-op he developed worsening stridor and SOB and he was re-intubated in the PACU. He was transferred to the SICU x 3days anfd thought to have lost hypoxic drive secondary to incrased O2 and worsening COPD/resp acidosis. He was bronch'd on ICU day 3 and found to have tracheobronchitis w/ copious secretions. His resp and metabolic disturbances were corrected and he had aggressive pul tiolet and was extubated successfully on ICU day #4. 2) DM2 His Januvia was continued for coverage of his FS. He was initially started on short-acting Insulin, but given his high insulin requirement, long acting Lantus was started and titrated up for goal FS < 200. 3) Psych Continued his home dose of Abilify 40mg and Lexapro 30mg. 4) Hyperlipidemia Continued statin and Tricor 5) Asthma Continued Albuterol/Atrovent nebs, Flovent [**Hospital1 **] # FEN: [**Last Name (un) 1815**] reg diet # PPx: Hep SC, PPI # Code: Full Code # Dispo: LTAC for emypema tube management and rehab. Medications on Admission: Janumet 50/1000 [**Hospital1 **], Abilify 40mg, Lexapro 30, Synthroid 137, Lipitor 40, Diclofenac 50, Tricor 145, Piroxicam 20 prn, Albuterol, Flovent 220 [**Hospital1 **] Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Ten (10) ML Miscellaneous Q2H (every 2 hours) as needed. 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**] Puffs Inhalation Q6H (every 6 hours) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gms Intravenous Q4H (every 4 hours) for 4 weeks: after 4 weeks- ABX course may be lengthened. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/headaches. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 19. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. regular insulin sliding scale regular insulin per fingerstick Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: DM, htn, ^lipids, asthma, bipolar disease, depression, hypothyroidism, inguinal LN bx SH: 1ppd x 40yrs smoker, + MJ, no ETOH, no IVDU Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your incision site. If your chest tube sutures break, please call the office and have them replaced. If the chest tube falls out, place an occlusive dressing on the site and call the office immediately to have it replaced. Followup Instructions: You have a follow up appointment with Dr. [**First Name (STitle) **] on the [**Hospital Ward Name **] clinical center [**Location (un) **] on [**2115-5-7**] 10:30. Please arrive 45 minutes prior to your appointment and report to the [**Location (un) **] radiology for a chest xray. You have a follow up appointment with Dr. [**Last Name (STitle) 1007**] on [**2115-5-8**] at 1:30pm [**Telephone/Fax (1) 3736**] on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]. You will have an MRI cervical spine and chest CT scan in 6 weeks. Provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD infectious disease clinic [**Hospital Ward Name **] [**Hospital **] medical building [**Doctor First Name **] - basement Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2115-6-19**] 11:30 Completed by:[**2115-4-26**]

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icd9cm

[ [ [] ] ]

[ "34.04", "34.91", "34.52", "96.72", "33.24", "38.93", "03.4", "88.72" ]

icd9pcs

[ [ [] ] ]

9535, 9582

4396, 7308

309, 410

9760, 9776

2439, 2805

10199, 11056

1668, 1692

7530, 9512

9603, 9739

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248, 271

438, 678

2841, 4089

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28,982

167,554

7368

Discharge summary

report

Admission Date: [**2124-9-25**] Discharge Date: [**2124-10-10**] Service: MEDICINE Allergies: Unasyn Attending:[**First Name3 (LF) 25876**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: from family and chart; patient unable to give history) Mr. [**Known lastname 27137**] is an 83-year-old man with history of metastatic melanoma, s/p bilateral neck dissections, most recent L neck dissection on [**2124-8-21**], who presents with altered mental status for 6 days. The patient was in his usual state of health, being very functional at home, when on [**2124-9-19**], he started becoming confused and was initially aware of his confusion. He gradually became agitated, unable to recognize his family members. [**Name (NI) **] loss of consciousness. No fevers, chills. No localized weakness per family. The patient also had poor PO intake. He vomited a few times in the past several days. He was taken to a local hospital in [**Location (un) 27138**] where labs were reportedly normal, with KUB and head CT reportedly negative. The patient's symptoms worsened and the family brought him to [**Hospital1 18**]. On arrival in our ED, his vitals were T 96.2, HR 70, BP 134/81, RR 16, 99% O2. He was disoriented and agitated and received haloperidol. Head CT revealed L parietal subarachnoid hemorrhage. Neurosurgery was consulted and recommended phenytoin and labetolol to keep SBP 110 to 140. His abd CT revealed no obstruction, no evidence of metastatic disease. CXR was unremarkable. He was transferred to OMED for further management. Past Medical History: Oncologic history: * Metastatic melanoma: - excisional biopsy of a nasal lesion in [**7-/2120**] with pathology revealing a lentigo maligna melanoma. Underwent wide local excision with reconstruction of the nasal dorsum with a transposition flap and sentinel lymph node biopsy on [**2120-9-3**]. - Reexcision pathology revealed a lentigo maligna melanoma, [**Doctor Last Name 10834**] level IV, 1.75 mm thick, nonulcerated without perineural invasion. One sentinel lymph node was negative for metastases. - In [**1-/2122**], a nasal recurrence was noted. He underwent surgical resection with reconstruction of the nasal defect with transposition nasolabial fold flap and sentinel lymph node biopsy with melanoma in one of two lymph nodes. - He underwent right radical neck dissection on [**2122-4-21**] with 33 lymph nodes removed, all negative for melanoma. - In [**8-/2122**], a left submandibular mass was noted with FNA confirming melanoma. He underwent left radical neck dissection on [**2122-9-28**] by Dr. [**Last Name (STitle) 1837**] with 1 of 12 lymph nodes positive with extracapsular extension. - He completed radiation therapy in mid [**2122-11-22**]. - He was not felt to be a candidate for interferon given his age and he declined participation in ECOG protocol 4697. - [**2124-8-21**]: radical resection of recurrent metastatic melanoma left neck. Pectoralis myofascial transpositional flap. Placement of meshed skin graft (1.5:1) measuring 10 cm x 20 cm in area. Closure of pharyngeal defect. Nasogastric tube placement . * prostate cancer: s/p brachytherapy [**2115**] . Non-oncologic history: HTN CKD vitiligo h/o colonic polyps Social History: No smoking, no drinking Family History: Non contributory Physical Exam: VS: T 97.6, BP 140/84, HR 76, RR 12, 96% RA GEN: Elderly man, unable to lie still in bed, frequently attempting to get out of bed, soft restraints on wrists, unable to cooperate with exam or history NEURO: Awake, not oriented to name, person, or date. No localized weakness observed. Moving all four extremities. Not cooperative with exam otherwise. HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear. NECK: Supple. Surgical flap on L neck clean, dry, nonexudative, cool. CV: Reg rate, normal S1, S2. [**12-28**] holosystolic murmur best heard at LLSB. No S3 or S4. CHEST: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, nondistended. No apparent pain illicit on palpation. EXT: No c/c/e. L thigh graft donor area erythematous, not warm, not exudative, well-healed. SKIN: No rash. Pertinent Results: * Head CT [**9-25**]: Left parietal subarachnoid hemorrhage with potential small foci of subarachnoid hemorrhage in the right frontal and temporal distribution. No definite mass lesion identified; however, evaluation is limited without contrast. * CXR [**9-25**]: no acute cardiopulmonary process * Abd CT [**9-25**]: No evidence of obstruction. Bilateral renal cystic hypodensities, most of which are too small to characterize but not significantly changed compared to [**2121**]. No evidence of metastatic disease in the abdomen or pelvis. . * CXR [**10-5**]: LLL opacity (my read), improving from [**9-29**] * Head CT [**10-3**]: unchanged SAH * Chest CT [**9-29**]: LLL aspiration pna, 1.2cm RUL nodule * CXR [**9-29**]: LLL atelectasis vs. aspiration * Head MRI [**9-27**]: no leptomeningeal metastasis, chronic microinfarctions * Head CT [**9-25**]: Left parietal subarachnoid hemorrhage with potential small foci of subarachnoid hemorrhage in the right frontal and temporal distribution. No definite mass lesion identified; however, evaluation is limited without contrast. * CXR [**9-25**]: no acute cardiopulmonary process * Abd CT [**9-25**]: No evidence of obstruction. Bilateral renal cystic hypodensities, most of which are too small to characterize but not significantly changed compared to [**2121**]. No evidence of metastatic disease in the abdomen or pelvis. Brief Hospital Course: Mr. [**Known lastname 27137**] was a 83-year-old man with history of metastatic melanoma status post left neck dissection on [**2124-8-21**] who was admitted for altered mental status. . * Altered mental status: Unclear etiology. He was found to have a subarachnoid hemorrhage on chest CT on admission. Neurosurgery was consulted and recommended medical therapy with blood pressure control, for SBP goal of 110 to 140, and anti-seizure prophylaxis with phenytoin, which was later switched to levetiracetam due to administration via a PICC line. A head MRI showed no leptominingeal enhancement and, except for the known SAH, no other acute process. LP was unrevealing with negative cytology. A bedside EEG was negative. Metabolic work-up did not reveal any abnormality. Geriatics and Neurology were consulted. The patient had long periods of somnolence interpersed with transient lucency when he recognized his family and was able to carry out small conversations. At times he was agitated and received olanzapine. By the second week of hospitalization, however, the patient became more somnolent and was unable to protect his airway with abundant secretions. He was transferred to the ICU, became more somnolent. . * SAH: unclear etiology. Due to his inability to take PO medications, clonidine 0.1 mg patch was started to achieve goal SBP of 110-140. He was put on phenytoin then levatiracetam. After his transfer to the ICU, the patient was more somnolent. A repeat head CT showed extensive new bleed. The family made the patient DNR/DNI and CMO. He was put on a morphine drip titrate to comfort and died on [**2124-10-10**]. . * Tachypnea, O2 requirement, fever: The patient had two episodes of transient hypoxia and tachypnea. During the first episode he was found to have a possible aspiration pneumonia and was started on clindamycin. CXR and chest CT later revealed likely aspiration pneumonia. A few days later the patient developed hypoxia with fever and was unable to control his secretions. He was started on cefepime, having been on daptomycin and clindamycin at this point. He was transferred to the ICU for close monitoring. . * Possible seizures: The patient experienced periods in which he had rapid tremor in his right arm, his eyes rolling. An initial EEG was negative, and a repeat EEG was inconclusive. His levatiracetam dose was increased from 500 mg [**Hospital1 **] to 750 mg [**Hospital1 **] to 1000 mg [**Hospital1 **]. . * Aspiration pneumonia: LLL opacity concerning for aspiration on chest imaging. The patient was started on clindamycin. . . * UTI: found to have VRE in the urine, which was sensitive to ampicillin, linezolid, and daptomycin. As the patient was allergic to amp-sulbactam and could not take PO, he received daptomycin 350 mg IV q24h. . * Code: FULL initially, then switched to DNR/DNI in [**Hospital Unit Name 153**]. Medications on Admission: HCTZ 12.5 mg PO qday Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "430", "041.04", "V09.80", "172.9", "599.0", "403.90", "585.9", "V10.46", "507.0" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

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5651, 5848

238, 244

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27933

Discharge summary

report

Admission Date: [**2168-9-20**] Discharge Date: [**2168-9-21**] Date of Birth: [**2115-6-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Epiglotitis - transfer from OSH for this radiographic finding Major Surgical or Invasive Procedure: Fiberoptic scope to visualize epiglottis/throat History of Present Illness: Mr. [**Known lastname 34030**] is a 53 year-old male with no past medical history who presents with sore throat and fever and possible epiglotitis. . Two days prior to admission, the patient noted fever ("greater than 100) and sore throat. He thought he was coming down with the flu. Denies any muscle aches, cough or rhinorrhea. The following day he felt "terrible" with continued low grade fever and sore throat. He was having mild onydnophagia to liquids but ate a full meal at 8:30pm. He went to work that day without issue. On the morning of admission, he continued to feel sore throat and presented to an OSH. . During this time period, he denies any shortness of breath or toubles breathing. Both he and his partner do report that his voice has changed somewhat (deeper) which has occured with sore throats before. He used occasional tylenol with some relief. . At the OSH his temperature was 99.4 with otherwise stable vital signs. Labs were significant for a WBC of 6.6. Plain film of the neck was suggestive of epiglotitis and CT of the neck showed "generalized pharyngitis with involvement of the epiglotis without airway obstruction. No evidence of prevertebral infection or paraphyngeal abscess." He was treated with ceftriaxone 2g, ibuprofen 400mg and percocet. Given the concern for epiglotitis, he was transferred to [**Hospital1 18**] for further evaluation. Note: ED was told that he recieved 10mg IV decadron though there is no documentation of this from OSH records. . In the ED, he was afebrile with a HR of 80 and a BP of 148/91. RR was 18 and he was satting 95% on room air. Past Medical History: Alopecia Areata Social History: Moved to US in [**2150**] from [**Country 13622**] Republic. He works at the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as a server. He does not smoke and drinks socially. No history of IVDA. Is MSM with one partner. [**Name (NI) 4084**] been tested for HIV. He believe he had all his vaccinations performed. Family History: Father: Died of colon cancer at 60. Mother: Coronary artery disease. Diabetes is in the family. Physical Exam: vitals - Afebrile, 150/84, 84, 20, 98% on room air. gen - Well appearing, talking with ease. heent - Anterior cervical LAD. cv - Regular rate and rhythm. No murmur. pulm - Clear with no wheeze. No stridor. abd - Soft and non-tender. Non-palpable liver and spleen. ext - Warm with no edema. neuro - Alert and oriented. Non-focal exam Pertinent Results: CT NECK (FROM OSH): Generalized pharyngitis with involvement of the epiglotis without airway obstruction. No evidence of prevertebral infection or paraphyngeal abscess. . LABS ON ADMISSION: [**2168-9-20**] 04:00PM BLOOD WBC-6.5 RBC-4.61 Hgb-14.5 Hct-43.3 MCV-94 MCH-31.5 MCHC-33.6 RDW-12.6 Plt Ct-172 [**2168-9-20**] 04:00PM BLOOD Neuts-87.5* Lymphs-10.5* Monos-1.7* Eos-0.2 Baso-0.1 [**2168-9-20**] 04:00PM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-141 K-4.1 Cl-107 HCO3-25 AnGap-13 . ON DISCHARGE [**2168-9-21**] 05:35AM BLOOD PT-12.7 PTT-25.7 INR(PT)-1.1 [**2168-9-21**] 05:35AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.4 [**2168-9-21**] 05:35AM BLOOD WBC-5.9 RBC-4.28* Hgb-13.1* Hct-38.6* MCV-90 MCH-30.7 MCHC-34.1 RDW-11.7 Plt Ct-202 [**2168-9-21**] 05:35AM BLOOD Neuts-68.6 Lymphs-24.3 Monos-6.9 Eos-0.1 Baso-0.1 [**2168-9-21**] 05:35AM BLOOD Glucose-145* UreaN-11 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 [**2168-9-21**] 05:35AM BLOOD LD(LDH)-127 Brief Hospital Course: 53 y/o healthy male with pharyngitis: 1. Pharyngitis/laryngitis, r/o epiglottitis: Seen by ENT in the [**Hospital Unit Name 153**]. Their exam showed an omega-shaped epiglottis, which they describe as a normal variant. In discussions with them, this is often mistaken for epiglottitis on radiographs. It is their feeling that this more accurately represents a pharyngitis /laryngitis. Patient treated with ceftriaxone and clindamycin on admission and overnight; however, given patient reports minimal cough, no secretions, has no WBC elevation, feel this was likely a viral pharyngitis. A throat culture was sent. On the day after admission the patient reported no throat pain, no fever/chills and reported feeling well. Patient is ready to be discharged home without antibiotics given likely viral picture. ----- [**Hospital Unit Name 153**] will f/u patient throat cultures and call if positive. Recognizing that because the patient was intially treated for epiglottitis he may have already received an adequate antibiotic course. . 2. Hyperglycemia: Patient mildly hyperglycemia while in the [**Hospital Unit Name 153**]. [**Month (only) 116**] be due to Decadron patient received at OSH. ----- Recommend patient follow-up with PCP to evaluate for diabetes/insulin resistance as patient has significant family history. . 3. Hypertension: Patient blood pressures while in [**Hospital Unit Name 153**] mildly elevated to systolics 140s. ----- Recommend patient follow-up with PCP for evaluation of hypertension and outpatient management. . 4. FEN: Tolerated full diet morning of discharge. Had only sips overnight. 5. Prophylaxis: No prophylaxis needed. 6. Access: PIV. 7. Communications: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. c - [**Telephone/Fax (1) 68040**]; h - [**Telephone/Fax (1) 68041**] 8. Code status: Full code. 9. Disposition: to home with outpatient PCP [**Name9 (PRE) 702**] Dr. [**Last Name (STitle) 7991**] on Tuesday [**2168-9-27**] at 9am. Dr. [**Last Name (STitle) 7991**] received a faxed copy of this discharge summary Medications on Admission: Centrum one tablet daily Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain for 5 days. Disp:*30 Tablet(s)* Refills:*0* 2. Centrum Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Pharygitis (r/o epiglottitis) Secondary: Hyperglycemia Discharge Condition: Stable, no stridor, no oxygen requirement, able to conduct all ADLs Discharge Instructions: Mr. [**Known lastname 34030**] you were admitted to the hospital due to a concern for epiglottitis. Evaluation by Ear, Nose and Throat revealed that you have a pharyngitis. It is most likely viral; therefore, you do not need any antibiotics. Your throat pain has improved overnight in the hospital and you are ready to go home. . Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68042**] [**Name (STitle) 7991**], [**Telephone/Fax (1) 2393**], about your recent illness. During this hospitalization your blood pressure and blood sugars were noted to be a little high, please ask your primary care physician to see you for these issues. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68042**] [**Name (STitle) 7991**], [**Telephone/Fax (1) 2393**], on Tuesday, [**9-27**] at 9am, [**2167**] about your recent illness. During this hospitalization your blood pressure and blood sugars were noted to be a little high, please ask your primary care physician to see you for these issues. .

[ "079.99", "401.9", "790.29", "462" ]

icd9cm

[ [ [] ] ]

[ "29.11" ]

icd9pcs

[ [ [] ] ]

6323, 6329

3923, 6006

377, 426

6437, 6507

2948, 3125

7251, 7660

2479, 2576

6081, 6300

6350, 6416

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6531, 7228

2591, 2929

276, 339

454, 2068

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2124, 2463

80,789

111,334

15471

Discharge summary

report

Admission Date: [**2201-2-17**] Discharge Date: [**2201-2-19**] Date of Birth: [**2124-5-9**] Sex: F Service: MEDICINE Allergies: Penicillins / Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Azithromycin / Iodine-Iodine Containing / Atenolol / Metoprolol Tartrate / Lipitor / Clindamycin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms [**Known lastname 3646**] is a 76 y/o F with hx of CAD, sCHF (EF 45% in [**Month (only) 1096**] [**2200**]), HTN, DVT on enoxaparin, and recent hospitalization in [**Month (only) 1096**] for asthma exacerbation c/b resp failure requiring mechanical ventilation, on home O2 2L NC, who came to the ED today reporting 4-5 days of worsening SOB, accompanied by substernal chest tightness and productive cough with sputum production. Also endorses orthopnea, and recently increased her pillows from 4 to 6 at night. No extremity swelling. No pleuritic chest pain. No nausea or vomiting. She has had worsening exertional dyspnea, though she is wheelchair bound and only intermittently ambulates. . In the ED, initial VS were: 99.4, 78, 180/106, 99% 4L NC. Exam initially unremarkable. Labs included hgb of 10.4, normal WBC/plt/chem7. Cardiac biomarkers were negative. BNP was 318. U/a was negative. CXR showed small bilateral pleural effusions, but no pulmonary edema or consolidations. ECG showed no new ischemic changes. BNP was normal and troponin was negative. The ED team initially planned on having the patient undergo a stress test, but she became acutely dyspneic with respiratory rate in the 30s. ABG 7.41/44/193 on BiPap. She was treated with methylprednisolone, magnesium, and nebulizers. She was also given benadryl, famotidine, and an epipen out of concern for possible anaphylactic reaction--the patient has had itching after taking her lovenox (last taken this morning). The ED team spoke with the patient's PCP, [**Name10 (NameIs) 1023**] reported that the patient has been recommended to pursue [**Hospital3 **]. Prior to departing the ED, her VS were 97.3, 80, 22, 128/71, 100% on Bipap. . On arrival to the MICU, the patient was agitated and repeatedly requested to be transferred to [**Hospital **] Hospital. Her only physical complaint was of heartburn, no worse than her usual acid reflux symptoms. Past Medical History: 1. Coronary artery disease. 2. Ischemic cardiomyopathy. EF 35-40% on ECHO in [**2198**]. 3. Asthma, though no PFTs in system and no documented outside PFTs. uses 2LNC at home 4. Lower extremity DVT that was diagnosed at [**Hospital1 2025**] at an unknown time and was treated for an unknown length of time, but this was many years ago. 5. Dyslipidemia. 6. Hypertension. 7. Normocytic anemia. 8. Chronic rhinosinusitis. 9. Depression. 10. Adenoid hyperplasia Social History: Home: Lives in [**Location 686**] with her daughter (40 y/o) and grand-son (16 y/o). However, the patient also states that her daughter frequently disappears from home for a few weeks at a time because she is "mixed up in drugs." The patient does not currently know where her daughter is or how to get in touch with her. She is tearful and worried when talking about her home situation. - Exposures: The patient states that there are no pets at home. There is no mold, dust, construction in or around the home. - ADL: The patient is wheelchair-bound at baseline but uses a cane to take a few steps. Her activity is limited due to musculoskeltetal discomfort as well as dyspnea. She is able to dress and shower by herself. - Smoking: denies. - EtOH: denies. - Illicits: denies Family History: She has several members of family with coronary artery disease and heart attacks, no diabetes, no cancer reported. Physical Exam: Physical exam General: Awake, alert, agitated, oriented, redirectable HEENT: No conjunctival icterus/pallor; mild conjunctival injection. MMM. OP clear. No JVD or LAD Neck: supple, JVP not elevated, no LAD CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Lungs: +moderate wheeze throughout, no crackles or rhonchi Abdomen: soft, NT/ND, NABSx4, no organomegaly Ext: warm, well perfused, 2+ pulses, trace edema to shins bilaterally Neuro: 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge exam pt left AMA Pertinent Results: Admission labs [**2201-2-17**] 11:40AM BLOOD WBC-4.1 RBC-3.66* Hgb-10.4* Hct-31.6* MCV-87 MCH-28.6 MCHC-33.0 RDW-13.7 Plt Ct-293 [**2201-2-17**] 11:40AM BLOOD Neuts-53.6 Lymphs-35.7 Monos-6.2 Eos-3.6 Baso-0.9 [**2201-2-17**] 11:40AM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-142 K-4.2 Cl-104 HCO3-28 AnGap-14 [**2201-2-17**] 11:40AM BLOOD CK(CPK)-88 [**2201-2-17**] 11:40AM BLOOD CK-MB-3 proBNP-318 Cardiac enzymes [**2201-2-17**] 11:40AM BLOOD cTropnT-<0.01 [**2201-2-17**] 08:18PM BLOOD cTropnT-<0.01 [**2201-2-18**] 04:45AM BLOOD cTropnT-<0.01 Discharge labs [**2201-2-19**] 04:23AM BLOOD WBC-11.8*# RBC-3.39* Hgb-9.9* Hct-29.0* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.1 Plt Ct-284 [**2201-2-19**] 04:23AM BLOOD Neuts-77.6* Lymphs-15.1* Monos-6.9 Eos-0.2 Baso-0.1 [**2201-2-19**] 04:23AM BLOOD Glucose-98 UreaN-27* Creat-0.9 Na-137 K-4.0 Cl-100 HCO3-28 AnGap-13 [**2201-2-19**] 04:23AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.3 Studies CXR [**2201-2-17**]: The heart is enlarged, stable. Aorta is tortous. No focal opacities are seen. Previously seen right middle lobe opacity is no longer evident. No pneumothoraces are seen. Bones are intact. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: 76 y/o F with hx CAD, CHF, DVT and recent hospitalizations for asthma exacerbation, presenting with progressively worsening cough, dyspnea, chest tightness, and sputum production, with hypertensive crisis on arrival to MICU. Respiratory status improved without major intervention, and she was briefly on a nitro gtt, then pt left AMA before anything could be done. . # Respiratory distress: Unclear what patient's intrinsic pulmonary dysfunction is due to, although prior documentation suggests she wears nasal cannula at home and prior episodes of respiratory distress have been attributed to asthma exacerbations. Pt had no oxygen saturation measurements on room air in ED, and pO2 only measured while on Bipap, so degree of hypoxia is uncertain, if any. Symptoms of progressive orthopnea, dyspnea on minimal exertion and leg edema suggestive of CHF, although pt not grossly volume overloaded, CXR generally clear, and BNP normal. Sudden onset of symptoms in ED in absence of exposure to asthma precipitants or allergens is atypical for true asthma exacerbation. No PFTs available in our system. No widened mediastinum or hemodynamic instability to suggest aortic dissection. Multiple reports of poor medication compliance in OMR; pt may not be using home inhalers. We tried to get PFT's but she left AMA prior to this. This was briefly given prednisone but this seemed to make littler difference as she was already at baseline after 12 hours in the MICU. . # Hypertensive urgency: likely [**3-12**] epinephrine she got in the ED (for what was thought to be an allergic rxn). Improved with nitro gtt. Generally normo/hypertensive in ED. on home meds hctz and diltiazem . # CAD/Ischemic cardiomyopathy: No ischemic changes on ECG, trop negative. No chest pain. Not on afterload reducing [**Doctor Last Name 360**]. Ruled out for MI . # Lower extremity DVT: Unclear if taking enoxaparin at home, though she tolerated it well in house. # Dyslipidemia: c/w statin . # Normocytic anemia: hgb/hct at baseline . The pt left AMA before further intervention could be made Medications on Admission: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1 puff . Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux. 9. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1 puff . Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux. 9. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: transient resp distress, atypical, possibly asthma though has had no PFTs 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: pt left AMA Followup Instructions: pt left AMA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V46.2", "428.22", "414.8", "786.09", "428.0", "493.92", "453.51", "414.01", "401.9", "V46.3", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9645, 9651

5654, 7733

436, 443

9768, 9768

4451, 5631

9982, 10132

3710, 3826

8702, 9622

9672, 9747

7759, 8679

9946, 9959

3841, 4432

389, 398

471, 2409

9783, 9922

2431, 2900

2916, 3694

21,937

167,289

26768

Discharge summary

report

Admission Date: [**2129-3-19**] Discharge Date: [**2129-3-23**] Service: MEDICINE Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 613**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: 83M with hx progressive lung disease (seen at [**Hospital **] hospital by pulmonologist Dr. [**Last Name (STitle) **] [**Last Name (STitle) **]) and acute worsening of dyspnea starting 2 days ago. He reports just a dry cough, no fevers, chills, no orthopnea, some slight LLE swelling, but no weight gain. He denies any CP/pressure, diaphoresis, nausea. He has about a 150 p-y history of smoking. At [**Location (un) **] he was noted to have bilateral lower lobe opacities on CXR, and a possible LL infiltrate. He was given ceftriaxone/azithro/and 10 mg IV lasix for concern of possible CHF. He had no EKG changes, but he did have an elevated Trop I at 0.88 and a BNP of 1,000. He was subsequently transferred to [**Hospital1 **] ED for further workup. . He had been in his usual state of health until about 4 weeks ago when he became very short of breath, and was admitted to [**Hospital **] Hospital for hypoxia. While there he was noted to have positive cardiac enzymes, and there was concern for ACS, however he was told he was a poor catheterization candidate due to his poor kidney function (Cr 1.7). He also had a chest CT which per his family's report was concerning for possible emphysema or intrinsic lung disease. He was sent home on home O2, about 4L NC. He was seen in follow up by a pulmonologist, Dr. [**Last Name (STitle) **], who was concerned about pulmonary fibrosis per his family. He apparently has also had PFTs at [**Location (un) **] as well. . At [**Hospital1 **] ED he was in mod resp distress satting 92% on NRB, was given an extra 40 mg IV lasix, with 400 cc uop, and his symptoms are slightly improved. His CXR here again shows bilateral lower lobe patchy infiltrates and some slight suggestion of CHF. Here he has no EKG changes, Trop T 0.35. Past Medical History: PMH: 1. ?COPD: has pulmonologist Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) **], need PFTs and chest Ct results 2. CAD MI [**2104**], CABG '[**14**], per report had a positive pMIBI at [**Location (un) **] during last admission, felt to be poor cath candidate, will need old Echo to get EF - EF 55-60%, mod ischem ant wall/apex, mild ischem lat wall, fixed defect of inf wall c/w old MI. 3. PVD: no prior interventions per his report, h/o bilateral carotid stenosis, 90% on R and 60% on L 4. HTN 5. IDDM 6. TIA [**2125**] . 7. Appy [**2085**] 8. L sided CVA 9. EGD esophagitis 10 squamous cell carcinoma o nthe R lateral nodes s/p labyrinthectomy, with RS total deafness 11 Cataract surgery Social History: SH: h/o 150 p-y tobacco, no EtOH, no drugs, 2L home O2, lives alone at home, retired, in baking, also with history of working in shipyard reports no asbestos, metal worker Family History: FH: 3 Aunts with [**Name2 (NI) 3730**], Mother died of heart disease Physical Exam: vitals: T 98 HR 74 BP 114/61 R 22 sat 95% on NRB gen: mild resp distress, A+OX3, speaking in full sentences HEENT: mmm, JVP at 12 cm CV: RRR no m/r/g pulm: bibasilar fine crackles, slight dullness at L base abd: s/nt/slight distension +BS ext: 1+ edema in L ankle, 1+ pulses bilat Pertinent Results: [**2129-3-19**] 09:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2129-3-19**] 09:50PM URINE RBC-8* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2129-3-19**] 07:26PM CK(CPK)-59 [**2129-3-19**] 07:26PM CK-MB-4 cTropnT-0.42* [**2129-3-19**] 07:25PM URINE HOURS-RANDOM UREA N-727 CREAT-62 SODIUM-40 TOT PROT-11 PROT/CREA-0.2 [**2129-3-19**] 07:25PM URINE OSMOLAL-490 [**2129-3-19**] 02:40PM GLUCOSE-249* UREA N-51* CREAT-1.8* SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 [**2129-3-19**] 02:40PM CK(CPK)-58 [**2129-3-19**] 02:40PM CK-MB-NotDone cTropnT-0.35* proBNP-7820* [**2129-3-19**] 02:40PM ALBUMIN-3.8 PHOSPHATE-4.4 MAGNESIUM-1.9 [**2129-3-19**] 02:40PM NEUTS-93.6* BANDS-0 LYMPHS-5.4* MONOS-0.8* EOS-0.1 BASOS-0.2 [**2129-3-19**] 02:40PM PT-15.2* PTT-48.8* INR(PT)-1.4* CXR AP [**3-19**]: 1. Congestive heart failure. 2. Left effusion with related opacity, most likely atelectasis. Pneumonia cannot be excluded however in the presence of infectious symptoms. 3. Emphysema. CT chest w/o contrast [**3-20**]: 1. Congestive heart failure with bilateral pleural effusions, superimposed on severe emphysema. If clinically indicated, reevaluation for interstitial lung disease may be performed after treatment. 2. Numerous mediastinal lymph nodes, which may be reactive in the setting of congestive heart failure. 3. Coronary artery atherosclerosis. 4. Cholelithiasis. CXR AP [**3-21**]: Mild pulmonary edema has improved substantially, small bilateral pleural effusions remain. Emphysema is moderate to severe. Heart size is top normal. ECHO [**3-21**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include basal to mid anteroseptal hypokinesis and basal to mid inferoseptal and inferior hypokinesis/akinesis. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-31**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 83yo M with ?severe emphysema presented to OSH w/ acute CHF likely due to cardiac ischemia. 1. hypoxemia: This was likely due to underlying intrinsic lung disease, as well as development of decompensated CHF from recent ischemia. CT chest w/o contrast also revealed CHF w/ bilateral effusions and evidence of severe emphysema. Planned to obtain PFT reports from [**Location (un) **], but requested PFTs with lung volumes and DLCO here as outpatient, as well. He had positive MIBI at OSH but deferred further intervention at that time due to CRI. His oxygen saturation improved to 96% on 3L NC and was breathing comfortably after diuresis. Urine and blood cultures were both negative, and he had no evidence of pulmonary infection. At time of discharge, he was breathing comfortably on room air, but still required supplemental O2 for ambulation. 2. CHF: He had been transferred from [**Location (un) **] to our ICU with elevated troponin - NSTEMI w/ flash pulmonary edema. Acute occurence of symptoms was c/w decompensated CHF, which improved after nitro and lasix. Given the recent change in his cardiac issue, as well as a positive MIBI (per pt), requested cardiology to consult on need for cath. Our cardiology service recommended optimizing his medical regimen - started daily and lasix, switched from labetolol to metoprolol, and discontinued norvasc. He will follow up with his outpatient cardiologist and continue his cardiac medications. 3. DM: He was continued on once daily NPH w/ good glucose control. 4. renal insufficiency: This was thought to be due to DM. Baseline is 1.8-1.9 per PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] improved to 1.7 prior to discharge. [**Last Name (un) **] was held on admission - pt was restarted on this after a brief trial of ACEI. 5. htn: Average BP 123/50; norvasc and avapro held at admission. Recommended continuing on home regimen with the exception of norvasc. 6. FEN: Pt was given DM/low Na diet. 7. PPX: He was given heparin sc and PPI for prophylaxis. 8. Code: Full 9. Contacts: Daughters [**Name (NI) 1785**] [**Telephone/Fax (1) 65919**] or cell [**Telephone/Fax (1) 65920**] [**Doctor First Name **] [**Telephone/Fax (1) 65921**] or cell [**Telephone/Fax (1) 65922**] Medications on Admission: Norvasc 10mg QD ASA 81mg QD Plavix 75mg QD Avapro 300mg QD Labetalol 600mg [**Hospital1 **] Prilosec QD Zocor 40mg QD Hytrin 5mg QD Insulin 30u NPH qam Combivent 2 puff QID oxygen 4L Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous qAM. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0* 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 10. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 11. 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* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 14. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day. 15. oxygen pt will need at least 4L NC while ambulating. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary: Troponin T elevation to 0.35 CHF COPD CRI - baseline 1.8 - 1.9 . Secondary: CAD MI [**2104**], CABG '[**14**] PVD HTN IDDM squamous cell carcinoma on the R lateral nodes s/p labyrinthectomy, with RS total deafness Discharge Condition: improved but still requiring O2 for ambulation Discharge Instructions: Please call Dr. [**Last Name (STitle) 65923**] or go to the ED if you have acute shortness of breath, requiring more oxygen, chest pain, nausea, vomiting, sweating, weight gain, leg swelling, dizziness, weakness or fainting. . Please note the following changes to your medications: - lasix: this is new for you. Please take 20mg daily - eating bananas could help prevent potassium levels from getting too low - metoprolol: changed from labetalol - tamulosin: changed from Hytrin for urinary retention - pantoprazole: you may take this or prilosec - they are interchangeable but pantoprazole may be less expensive - Stop taking Norvasc for now. . Please follow up with Dr. [**Last Name (STitle) 65923**] next week at the time scheduled for you. If you need to change the appointment, call [**Telephone/Fax (1) 65924**]. Also, you should have an appointment with Dr. [**First Name (STitle) 24344**]. If you choose to see a cardiologist here at [**Hospital1 18**], please have Dr. [**Last Name (STitle) 65923**] or [**Location (un) 24344**] make a referral. . Check your blood pressures daily - if the [**Location (un) 1131**] is less than 110/60, please let Dr. [**Last Name (STitle) 65923**] know. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 65923**] on [**4-1**] at 11:30am. Call Dr. [**First Name (STitle) 24344**] for an appointment in the next few weeks. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2129-7-5**]

[ "401.9", "515", "410.71", "518.81", "V45.81", "585.9", "428.0", "412", "443.9", "496", "250.40", "583.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9807, 9870

5831, 8081

253, 260

10137, 10186

3406, 5808

11432, 11748

3015, 3085

8315, 9784

9891, 10116

8107, 8292

10210, 10463

3100, 3387

10492, 11409

194, 215

288, 2062

2084, 2810

2826, 2999

14,012

125,363

8012

Discharge summary

report

Unit No: [**Numeric Identifier 28674**] Admission Date: [**2183-4-13**] Discharge Date: [**2183-4-21**] Date of Birth: [**2113-3-23**] Sex: Service: DATE OF DECEASED: [**2183-4-21**] HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old male with a history of metastatic renal cell carcinoma, status post right nephrectomy in [**2157**] with known lung metastases status post left lower lobe and right lower lobe resection, right bronchial stent, XRT therapy, and phototherapy on [**10/2182**] and [**12/2182**], history of CAD status post MI in [**2174**] and [**2178**] with LAD stent, history of congestive heart failure with ejection fraction of 25 percent, diabetes mellitus with chronic renal insufficiency, presented with increasing shortness of breath at outside hospital, found to have whiteout of right lung and obstructive right mainstem bronchial stent. Transferred here for possible intervention. On [**2183-4-15**], the patient underwent stent removal after the stent was noted to have migrated distally, with some granulation tissue present. In the PACU, the patient was noted to have left upper extremity and left lower extremity weakness. Neurology was called and MRI was limited by movement but per the neuro team showed multiple bilaterally likely embolic CVAs. On [**2183-4-16**], the patient had generalized tonic-clonic seizures. He was given Ativan and Dilantin. Had a recurrent generalized tonic- clonic seizure in the afternoon and was loaded with fosphenytoin again. He was transferred to the Neurology ICU and had one recurrent seizure on [**2183-4-17**] and since has been seizure free. He was transferred to the floor on [**2183-4-18**]. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.8, T-MAX 97.8, heart rate 78 to 89, blood pressure 112/52 to 155/76, and respirations 23. Saturation 97 percent on 40 percent face mask. GENERAL: He is mildly agitated with tangential speech, alert and oriented times 3. HEENT: Mucous membranes dry. No JVD, no carotid bruits. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops with distant heart sounds. PULMONARY: Breath sounds absent on the right and left with basilar coarse crackles. ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds. EXTREMITIES: Trace lower extremity edema, 2 plus dorsalis pedis pulses. NEUROLOGIC: Cranial nerves right facial flattening, bilateral eyebrows elevated. Tongue is midline. Right upper extremity is 5 out of 5. Strength in left upper extremity is 3 to 4 out of 5. Strength in right lower extremity 2 out of 5 and left lower extremity 0 out of 5. Bilateral downgoing toes. Light touch intact bilaterally. LABORATORY: White count 7.8, hematocrit 31.5, and platelets 183. Sodium 146, potassium 4.0, chloride 104, bicarbonate 32, BUN 69, creatinine 2.1, glucose 131, magnesium 2.1, and Dilantin 21. ABG; 7.35, 56, and 154 on 40 percent face mask. EKG 106 beats per minute, normal sinus rhythm, normal axis and intervals, left atrial enlargement, old inferior myocardial infarction, and T-wave inversions in 1 and aVL. EEG on [**2183-4-16**] showed left frontal swelling. MRI on [**2183-4-16**] was nondiagnostic with movement artifact but likely shows bilateral multiple CVAs, likely embolic. HOSPITAL COURSE: Respiratory. The patient with metastatic renal cell carcinoma to the lung, status post right mainstem bronchial stent, status post removal with post-obstruction pneumonia. Cultured for Streptococcus pneumoniae and MRSA on vancomycin and ceftriaxone. Saturating 90s on 40 percent face mask. We will continue 40 percent face mask. The patient's code status was DNR/DNI and after discussion with the family on prognosis, he was made CMO. Cardiovascular. CAD, status post MI and LAD stent. CHF with ejection fraction 25 percent, not complaining of any anginal symptoms. The patient was dry to euvolemic. He was given gentamicin and IV fluids 75 cc an hour. History of aspirin allergy. He was continued on Lipitor and his ACE inhibitor was held as the patient with single kidney. Blood pressure was well controlled. Chronic renal insufficiency. Creatinine roughly baseline secondary to diabetes and status post nephrectomy. He was continued on Epogen and was given gentle IV fluids as his urine output was low. Renal cell carcinoma with metastases. After discussion with the family on patient's poor prognosis, his treatment was converted to all palliative treatment, and Palliative Care consult was obtained. Neurological. Multiple embolic bilateral CVAs, source may be cardiogenic, although not a candidate for anticoagulation and history of aspirin allergy. The patient was continued on Dilantin with a level of about 20. He was not a candidate for barbiturate therapy. He was DNR/DNI. DISPOSITION: The patient's therapy was converted to palliative care and the patient's code status was converted to comfort measures only. On [**2183-4-21**] at 6:20 a.m., the patient was pronounced deceased. His family was alerted. DISCHARGE STATUS: The patient deceased. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 20314**] Dictated By:[**Last Name (NamePattern1) 15388**] MEDQUIST36 D: [**2183-7-8**] 15:22:40 T: [**2183-7-9**] 07:48:09 Job#: [**Job Number 28675**]

[ "482.41", "996.59", "197.0", "780.39", "428.0", "518.81", "997.02", "481", "518.0" ]

icd9cm

[ [ [] ] ]

[ "98.15", "32.01" ]

icd9pcs

[ [ [] ] ]

3297, 5353

1710, 3279

218, 1687

22,371

118,822

21631

Discharge summary

report

Admission Date: [**2132-9-12**] Discharge Date: [**2132-9-17**] Date of Birth: [**2053-9-17**] Sex: F Service: NSU Mrs. [**Known firstname 56926**] [**Known lastname **] is a 78-year-old white female, nonsmoker, history of angina, hypertension, transient ischemic attacks, who is being evaluated for somnolence after a fall four days ago on Monday night. Four days ago the patient was walking down the stairs of her home with a candle after the power went off, and the patient fell on the last step, hitting the back of her head on the wall. The patient did not have loss of consciousness nor did she have headache, yet she did present with some costal pain, where she was taken to the hospital. Rib fracture was found on chest X-ray and the patient was given Oxycodone; it is stated that the medicine made her sleepy during Tuesday, the patient lowered the drug dose by half, [**1-11**] tab q 4 hours on Wednesday and was still awake without pain. Yesterday, Thursday morning, the patient had asked for husbands help to get out of bed and get to bathroom at 6 AM; per medical record, the patient's husband did not think much of this, did not think she was weak. The patient's husband called EMS at noon after the patient had slept all morning and not gotten up. The patient was taken to [**Hospital3 3834**] and diagnosed with a fronto parietal subdural hematoma on CT; previous hospital note stated that the patient had left upper extremity posturing and blood pressure 193/88 initially. After being given two units of FFP and Vitamin K 1 mg the patient was transferred to this hospital placed in CC7. The patient is married, mother of six, house maker, allergic to Duricef and Phenobarbital; The patient does not use tobacco, ethanol or drugs. PAST MEDICAL HISTORY: Is relevant for hypercholesterolemia, angina, hypertension and transient ischemic attacks some years ago described as reduction in her ability to speak, lasting less than a day; the patient was then placed on Coumadin yet does not have atrial fibrillation. MEDICATIONS: 1. Amoxicillin for dental procedure. 2. Toprol. 3. Norvasc. 4. Lisinopril. 5. Coumadin. 6. Lipitor. 7. Digoxin. 8. Cosopt. 9. Alphagan 10. Calcium. 11. Multivitamin. PHYSICAL EXAMINATION: Blood pressure 151/71, heart rate 84, respiratory rate 18, O2 sat 99% on room air. .General lying in bed, eyes closed yet arouseable. Overweight, elderly white female in no apparent distress. Lungs: Clear and resonant. No wheezing, rales, rhonchi or rubs. Heart was regular rate and rhythm. Normal S1 and S2. 2 /6 systolic murmur. No rubs or gallops. Abdomen: Protuberant. Bowel sounds present and tympanic to percussion. Soft, nontender, no hepatosplenomegaly. Lower extremities: No edema, cyanosis, clubbing, ecchymosis. Neurological: Cranial nerves 1 not tested. II, III, IV, VI: Patient not cooperative, only opens eyes slowly when prompted and then closes eyes again. V and VIII: The patient not cooperative. VIII, VIV, X, [**Doctor First Name 81**]: Tongue midline. Motor: Patient can squeeze and grasp with the right hand. The patient does not squeeze or grasp with the left. The rest of the motor not available, the patient not cooperative. Normal bulk and tone. No vesiculation's, reflexes increased and brisk, bicipital, tricipital, patellar and Achilles. No sucking reflex present, no grasp reflex present, upgoing toes present bilaterally. Sensory not able to evaluate. Coordination and gait: The patient unable to walk at this moment. Orientation: To name, [**Hospital3 **], [**12-6**], does not know year. Two children. LABORATORY FINDINGS: Sodium 126, potassium 3.2, chloride 90, BUN 21, glucose 139, hematocrit 32.9, platelets 16.6. Urinalysis: Protein greater than 500, red blood cells greater than 50, bacteria occasional. CT scan showed right frontal and parietal lobe subdural hematoma, .5 cm convexity. Neurological: She continued to be lethargic through [**9-12**] but was much more awake by [**9-13**]. By [**9-14**] she was alert and oriented times two and responsive but slightly confused making weird statements. MAE were slight weakness on the left, the Aspen collar was removed on the 4th. After cervical spine was cleared she had CTL films of her spine to rule out fracture. The lumbar spine was poorly visualized but her back was cleared. She continues to complain of severe back pain on the 5th when turning at the level of T10- 12. Fall precautions were discontinued on the 5th. Cardiac wise, her blood pressure was 140 to 150/70, heart rate 70, potassium 3.3, received 20 of potassium and on the 4th repeat potassium was 3.4. Respiratory wise, the patient was on 2 liters nasal cannula with respiratory rate of 18 to 24. O2 sat was 94 to 96% Breath sounds were clear. Gastrointestinal: She is free water restricted. Her sodium was 126 on admission. She was on 3% normal saline at 20 to 30 cc's an hour increasing her sodium to 132 by the 5th. She was able to take liquids without difficulty. Diet was advanced and she had small form firmed stool. She was given Dulcolax suppository, Foley was draining clear yellow. She was diuresing with urine output as high as 150 cc's and hour. ID: White count was 10.7, she had a low grade temperature of 100.0 on the 4th but by the 5th it was 98.9. Again, she had multiple bruising around her arm from her fall especially her left flank and arm. Social: She has six children with multiple grandchildren and great grandchildren. Husband [**Name (NI) **] is spokesperson. She is a Full Code. Since discharge from the Intensive care unit the patient continues to improve at physical therapy, recommended stair climbing, gait training and treatment training with patient education and recommends to have acute rehabilitation. . PHYSICAL EXAMINATION: On discharge there is no complaints. The patient follows commands. The patient should follow up with Dr [**Last Name (STitle) 739**] in 6 weeks with another headt CT. [**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**] Dictated By:[**Last Name (NamePattern1) 15649**] MEDQUIST36 D: [**2132-9-17**] 12:06:13 T: [**2132-9-17**] 12:52:16 Job#: [**Job Number 56927**]

[ "E880.9", "276.1", "413.9", "780.6", "272.0", "852.21", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5862, 6277

1803, 2253

6,085

174,506

51603

Discharge summary

report

Admission Date: [**2104-10-3**] Discharge Date: [**2104-10-7**] Date of Birth: [**2042-9-3**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 2186**] Chief Complaint: bright red blood per rectum s/p transrectal prostate biopsy Major Surgical or Invasive Procedure: none History of Present Illness: CC:[**CC Contact Info 106943**]. HPI: 62M with h/o DM, HCV, and Parkinson's disease, s/p transrectal prostate biopsy 9d ago, c/b several episodes of BRBPR over the last week, who presents with orthostatic symptoms x 1d. He has had multiple episodes of large amounts of BRBPR daily for the past several days. He did not contact Dr. [**Last Name (STitle) 106944**] because he thought this was an expected side effect. He had RLQ pain associated with his first episode the day after the biopsy and this morning. He denies chest pain, palpitations, fevers, nausea/vomiting. He takes 2 Aleve daily. In the ED, his VS on presentation were T 99.9, HR 95, BP 89/56, RR 26, O2sat 97% RA. He had 2 large bore IVs placed, T&C for 8U was sent. Hct 24, glucose 714, HCO3 24. He was given 16U SC insulin after which his BG was still critically high (>500), and he was given another 8U insulin. He was also given vitamin K 5mg po for INR of 1.3. Urology was consulted and requested admission to Medicine. His BP improved to 118/63 after 2L NS. However, it subsequently dropped to 79/57 2h later. He was given 500cc NS bolus x 2 and 2U PRBC with improvement in his BP to 108/74. He was admitted to the MICU for further monitoring. Pt feeling well and has been hemodynamically stable SBP 100-120, last transfusion [**10-4**] RBCs and on [**10-6**] of PLT. No BM x 2 days. Urology and liver following. Low plts most likely related to liver disease. ROS: denies HA, CP, SOB, N/V/D. Past Medical History: 1. HCV- last VL 8,590,000 on [**9-22**], followed by Dr. [**Last Name (STitle) **], on colchicine week 146 in the COPILOT study, last biopsy [**8-26**] with gr 2 inflammation and stage 4 cirrhosis, gr I/II varices 2. DM- on NPH, last HgA1C 8.0 on [**9-22**] 3. Parkinson's disease- on Sinemet, followed by Dr. [**Last Name (STitle) **] 4. PTSD- followed by Dr. [**Last Name (STitle) 3704**] 5. Last colonoscopy [**7-25**] with adenomatous rectal polyp and sigmoid diverticulosis 6. s/p cholecystectomy 7. s/p R inguinal hernia repair ([**2097**]) Social History: Lives with wife and son, retired veteran, now volunteers at the VA. Occasional tobacco, <1 cig/d. Denies EtOH and IVDU Family History: Father died of unknown cause at age [**Age over 90 **], brother died in 60s of alcoholic liver disease, mother still alive, no cancer in the family Physical Exam: PHYSICAL EXAM: Vitals- T 97.8, HR 87, BP 118/66, RR 14, O2sat 100% RA General- pleasant man in NAD, lying flat in bed HEENT- NCAT, sclerae anicteric, moist MM Neck- supple Pulm- CTAB with good respiratory effort CV- RRR with some ectopy, no murmur/rub/gallop Abd- + BS throughout, mildly distended but soft, + RLQ and epigastric tenderness to deep palpation, no rebound/guarding, liver edge palpable 3cm below costal margin, no palpable spleen tip, RUQ transverse scar, no fluid wave Extrem- no peripheral edema, + clubbing Rectal: deferred Neuro/Psych- A&Ox3, bright affect, pressured speech, slightly tangential thinking, + pill-rolling tremor b/ Pertinent Results: [**2104-10-3**] 09:00PM COMMENTS-GREEN TOP [**2104-10-3**] 09:00PM HGB-8.0* calcHCT-24 [**2104-10-3**] 08:15PM GLUCOSE-715 UREA N-17 CREAT-1.5* SODIUM-127* POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-12 [**2104-10-3**] 08:15PM CK(CPK)-199* [**2104-10-3**] 08:15PM CK-MB-8 cTropnT-0.02* [**2104-10-3**] 08:15PM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.0 [**2104-10-3**] 08:15PM LITHIUM-1.2 [**2104-10-3**] 08:15PM WBC-6.6 RBC-2.39*# HGB-7.9*# HCT-23.9*# MCV-100* MCH-32.8* MCHC-32.8 RDW-13.6 [**2104-10-3**] 08:15PM NEUTS-75.2* LYMPHS-19.9 MONOS-4.1 EOS-0.6 BASOS-0.2 [**2104-10-3**] 08:15PM HYPOCHROM-1+ MACROCYT-1+ [**2104-10-3**] 08:15PM PLT COUNT-149* [**2104-10-3**] 08:15PM PT-14.5* PTT-30.6 INR(PT)-1.3* Brief Hospital Course: # BRBPR: With time frame and lack of other symptoms, BRBPR most likely secondary to prostate biopsy. However, with abdominal pain, may need to consider intraabdominal etiologies such as diverticular bleed, variceal bleed (but no hematemesis), brisk UGI bleed from other sources including PUD, Dieulafoy's, gastritis/duodenitis. Further eval postponed since HCT stable and no active bleeding. CT abd neg for retroperitoneal bleed. Hct down to 24 from baseline of 42 now stable at 33. No stooling x [**2-23**] day. On day of discharge, pt had one formed melanotic stool. Although bleed has been blamed on rectal biopsy, pt may need further eval for possible upper GIB. Pt hemodynamically stable and will follow up with the liver clinic in 6 days. - f/u with urology in 3 weeks #abd pain: Now has left UQ pain but CT neg 2 days ago, tolerating PO and afebrile. [**Month (only) 116**] be related to constipation x [**2-23**] days. Pt is passing gas. Pt started on bowel treatment but will make it more aggressive if need be today. -adv bowel treatment to goal of stooling # DM: Suboptimal control over last few months per HgA1C. On NPH at home. Had marked hyperglycemia but no anion gap acidosis on admission. No lethargy to suggest hyperosmolar coma. Inciting factor is likely blood loss, no clear symptoms of infection although has had difficulty urinating since the biopsy. CXR with no infiltrate, no h/o cough. Pt started in insulin drip in ICU which was stopped on [**10-5**]. UA and CXR neg for infection. has been stable in floor with minimal RISS requirements. -discharge on same medications with PCP f/u to reeval glucose control -DM diet . # ARF: On admission, likely prerenal with significant GI bleed. Baseline 1.1-1.2 On ACE-i, but has been on for long time. Elevated to 1.5 on admisison now resolved and at baseline. We held his lisinopril in setting of bleeding and nl BP - d/c home on home lisinopril dose . # Elevated troponin: Asymptomatic but diabetic, likely secondary to ARF. ECG with no new changes to suggest active ischemia. However, with anemia and CAD equivalent of DM, pt was ruled out for MI. - will need to clarify ASA allergy with PCP . # Hyponatremia: Likely combination of pseudohyponatremia with hyperglycemia and hypovolemia with bleed. Now appears euvolemic after resuscitation. - resolved . # HCV: No ascites or encephalopathy. If decompensates, will need evaluation of varices. AFP elevated x 2y but US with no hepatoma. - continue colchicine renally dosed - Liver will see pt at next scheduled visit. - CT Abd/Pelvis done on [**10-5**] and read without any evidence of bleed #thrombocytopenia: Unclear etiology, most likely related to hep C liver disease/sequestration. Stable after transfusion [**10-6**]. . # Bipolar disorder: Stable - continue lithium, renally dosed # Parkinson's: - continue Sinemet . # FEN: DM diet . # Code status: FULL CODE, confirmed with patient . # Communication: HCP is wife [**Name (NI) **] [**Name (NI) 106945**] ([**Telephone/Fax (1) 106946**]. PCP is [**First Name8 (NamePattern2) **] [**Name9 (PRE) **] ([**Company 191**], [**Telephone/Fax (1) 99157**]) . Dispo: home with urology, liver and pcp f/u Medications on Admission: Colchicine 0.6mg [**Hospital1 **] Clonazepam 500mcg [**Hospital1 **] Lithium 300mg tid Humulin N 100 16units qam, 10units qpm [**Hospital1 **] Neurontin 300mg tid Lisinopril 5mg qd Sinemet 25/100 mg 2 pills tid Rhinocort 32mcg NS 2 sprays [**Hospital1 **] Discharge Medications: Colchicine 0.6mg [**Hospital1 **] Clonazepam 500mcg [**Hospital1 **] Lithium 300mg tid Humulin N 100 16units qam, 10units qpm [**Hospital1 **] Neurontin 300mg tid Lisinopril 5mg qd Sinemet 25/100 mg 2 pills tid Rhinocort 32mcg NS 2 sprays [**Hospital1 **] Discharge Disposition: Home Discharge Diagnosis: rectal bleeding Discharge Condition: improved Discharge Instructions: Continue your medications from home. Return to the ED or call your primary care for continued bleeding from your bottom. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] on [**2104-11-5**] at 10:10am Follow up with Dr. [**Last Name (STitle) **] on [**2104-10-29**] at 11:15am [**Telephone/Fax (1) 106947**] Follow up with Dr. [**Last Name (STitle) **] on [**2104-10-13**] at 9:20am

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Discharge summary

report+addendum

Admission Date: [**2131-11-17**] Discharge Date: [**2131-12-5**] Date of Birth: [**2063-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Upper endoscopy Exploratory laparotomy, ligation of duodenal [**First Name3 (LF) **] with biopsy, vagotomy and J-tube placement. History of Present Illness: Briefly, this is a 69 year old male with hx COPD (on steroids) CAD s/p CABG, duodenal [**First Name3 (LF) **], admitted with recurrence of GI bleed. He was hospitalized at [**Hospital1 18**] from [**Date range (3) 83164**] for GIB. he had reportedly received 21 units of blood at outside hospitalizations but after an endoscopy at an OSH he remained without further bleeding for 48 hours before his [**Hospital1 18**] admission. During the [**Hospital1 18**] admission he had a nonbleeding duodenal [**Hospital1 **] clipped and another shallow, nonbleeding [**Hospital1 **] monitored; he required no blood transfusions. He was sent to [**Hospital3 **] rehab, found to have continued bleeding with 1-2 loose black stools/day and was sent to [**Hospital6 **] (hospitalization was [**11-8**]/-[**11-17**]). Initially, his primary issue was some respiratory distress for which he had an ultrasound guided right sided thoracentesis with removal of 600 cc of serious fluid. This improved his dyspnea but he has continued to have issues with unstable blood volume and chronic blood loss. He was transfused to 9.1 on [**11-12**] but then dropped back to 7.5 by [**11-14**]. He had an EGD on [**11-14**], which revealed a posterior dudodenal [**Month/Year (2) **] with visible vessel and active bleeding that was secured with clip, BiCap cautery, and epinephrine injection. He also had diffuse erosive gastropathy noted. Presumably, he was transfused again on [**11-14**] to a Hgb of 10 that had fell to 8.6 today on [**11-17**]. Thus, he was transfused a unit on [**2131-11-17**] before being transferred here for continued care. Overall he recieved 5U PRBC at [**Hospital3 **]. . On arrival to the floor he was found to have stable VS,denied any chest pain, worsened dyspnea from his baseline, abdominal pain, nausea, vomiting, hematemesis, constipation, syncope, presyncope, fevers, chills, night sweats or other acute issues. He reported he felt well but was frustrated with the continued issues relating to this bleed and was asymptomatic with a HCT of 33.6 decreased to 28.5 this am. He continues to have black tarry stools. A rectal this am showed brown stool in the vault, which was guiac positive. Past Medical History: - CAD s/p CABGx4 [**2127**] - CHF - Atrial Fibrillation/Flutter - HTN - Hyperlipidemia - DM type II complicated by neuropathy - COPD v. BOOP v. Asbestos (although per last D/C summary, NSIP, d/c'd on steroids) - Chronic Kidney Disease (baseline Cr 1.6-2) - Rheumatoid Arthritis - GERD - Duodenal [**Year (4 digits) **] - Skin cancer - Anemia - Guaiac positive stools - BPH - L cataract - s/p L total knee replacement Social History: Used to live alone but could not continue climbing 16 stairs each day; now lives with daughter (31yo); has many grandchildren; retired general contractor with exposure to asbestos; served in the Navy x5years; 50 pack-year smoking history (quit in [**2126**]); drinks 3-4 alcoholic drinks a couple times a week; no recreational drug use Family History: Father--died of lung cancer "from the shipyard" at 53; Mother--died of [**Name (NI) 2481**] at 70, hypertension; Brother--recent sudden death; Sister--CVA. Denies history of gastric or liver cancers. Physical Exam: VS: T 96.2, BP 138/96 Range 152/88, P 62 Range 58, RR 20, O2 Sat 98% on 1L Gen: Obese gentleman sitting up in chair in NAD HEENT: Normocephalic, anicteric, PERRL, OP benign, MMM Neck: No masses or lymphadenopathy, Right IJ CVL CV: Irregular, tachycardic, no M/R/G; there is no jugular venous distension appreciated Pulm: Expansion equal bilaterally, good air movement, diffuse end expiratory wheezes Abd: Obese, soft, nontender, nondistended, normoactive BS, no organomegaly or masses. Midline incision c/d/i. J tube site c/d/i Extrem: Warm and well perfused, 2+ lower extremity edema to knees Neuro: A and O*3 with appropriate mental status to gross exam, moving all extremities. Unable to extend R 3rd, 4th, 5th fingers Psych: Pleasant, cooperative, easily engaged Skin/integument: Mucous membranes dry. Mild tearing eyes Bilaterally. Hyperkeratotic lesions scattered over dorsal surface hands bilaterally s/p topical therapy. Onchomycosis of toenails. Pertinent Results: [**2131-11-20**]: X-ray Wrist Right. 1. There is no evidence of an acute bony injury. 2. There is deformity of the fifth metacarpal suggesting an old healed fracture. 3. There is joint space narrowing and there are large dorsal osteophytes at the fifth carpal/metacarpal joint. [**2131-11-17**] PICC line placement. One view. Comparison with the previous study of [**2131-11-4**]. Streaky density at the lung bases and bilateral pleural thickening and/or fluid are again demonstrated. There is a calcified pleural plaque at the right base as before. The patient is status post median sternotomy as demonstrated previously and mediastinal structures are unchanged. A right internal jugular catheter has been replaced. The new catheter terminates at the level of the cavoatrial junction or right atrium. There is no other significant change. IMPRESSION: Line placement as described [**2131-12-3**] 04:13AM BLOOD WBC-5.9 RBC-3.04* Hgb-8.8* Hct-27.8* MCV-92 MCH-29.1 MCHC-31.8 RDW-16.4* Plt Ct-269 [**2131-12-3**] 04:13AM BLOOD Glucose-163* UreaN-38* Creat-2.0* Na-146* K-3.7 Cl-107 HCO3-32 AnGap-11 [**2131-12-3**] 04:13AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2 [**2131-12-3**] 04:13AM BLOOD WBC-5.9 RBC-3.04* Hgb-8.8* Hct-27.8* MCV-92 MCH-29.1 MCHC-31.8 RDW-16.4* Plt Ct-269 Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. The patient presented with recurrence of his GI bleed. This has been a difficult to control issue over the last months. Most recent EGD revealed discrete duodenal ulcers with visible vessel and persistent bleeding as well as oozing gastritis. He has had multiple attempts to achieve permanent hemostasis of the [**Month/Day/Year **] that have likely been made more problem[**Name (NI) 115**] by his continued steroid use. An endoscopy on [**2131-11-19**] showed a 25mm duodenal [**Date Range **] with visible vessels and this was clipped and cauterized. The patient continued however to have melanotic stools and required additional blood transfusions although his vital signs were stable and he was asymptomatic throughout. A repeat endoscopy on [**2131-11-23**] showed active bleeding with blood clots at the previously clipped single bleeding [**Date Range **] in the pylorus channel. He was maintained on a PPI drip initially, and then transitioned to a [**Hospital1 **] oral PPI post endoscopy. His prednisone which he was taking for his pulmonary disease were tapered back to his baseline 10mg daily. Given the refractoriness of his ulcers to endoscopic intervention, he was transferred to the surgical service for surgical intervention. On [**2131-11-24**], the patient underwent an exploratory laparotomy, ligation of duodenal [**Date Range **] with biopsy, vagotomy and J-tube placement. The surgery went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient was transferred to the SICU intubated secondary to his lung disease, NPO, on IV fluids and antibiotics, with a foley catheter, and on propofol/fentanyl for pain control. He was extubated and tube feeds were started. The patient continued to do well and was transfered to the floor. The patient was hemodynamically stable. Neuro: The patient received roxicet with good effect and adequate pain control. CV: Postoperatively, the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. He presented with diffuse edema and anasarca. He did have a BNP in the 8000's and was found to be in a CHF flare. He received aggressive diuresis with effect. He received diuretics with all blood transfusions preoperatively. No signs/symptoms of active ischemia. Presistently elevated troponin (0.04) presumably due to renal failure. He was in atrial fibrillation. Because of his GI bleed, he was initially started on lower doses of his beta blocker, however he did not achieve good rate control on these lower doses, and so he resumed his home dose of metoprolol with effect. Pulmonary: The patient remained stable from a pulmonary standpoint; Pulmonology service was involved in his care and they made recommendations regarding his steroid regimen that he is currently on for his lung disease. Vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. He is on tube feeds (Nutren 2.0 @40cc/hour that we have been weaning down (now at 20cc/hour) as we advanced his diet to regular. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Wound care .... Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required postoperatively. MSK: Tendon rupture: The patient experienced the sensation of his wrist popping during use, although he had no hand trauma. Since then he was unable to extend his fourth and fifth right fingers, however sensation was [**Date Range 5235**]. Neurology was consulted and felt that there was no neurologic pattern to his deficit. Hand service was consulted and his hand was splinted, with recommendation for MRI. He was scheduled to follow up with the hand service as an outpatient. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet and tube feeds, ambulating, voiding with assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Home medications. 1. Simvastatin 10 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Date Range **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Finasteride 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 4. Glipizide 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. Clonidine 0.1 mg Tablet [**Date Range **]: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: Three (3) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable [**Date Range **]: Three (3) Tablet, Chewable PO DAILY (Daily). 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 10. Fluticasone 50 mcg/Actuation Spray, Suspension [**Date Range **]: Two (2) Spray Nasal DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Date Range **]: One (1) Cap Inhalation DAILY (Daily). 12. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]: One (1) inh Inhalation [**Hospital1 **] (2 times a day). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Leflunomide 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO daily (). 15. Fluconazole 200 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q24H (every 24 hours) for 2 weeks. 16. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) for 6 days. 17. Prednisone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily) for 7 days. 18. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily (). 19. Insulin Lispro 100 unit/mL Cartridge [**Hospital1 **]: see sliding sclae Subcutaneous four times a day: breakfast/lunch/dinner: 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units; bedtime 201-250 1 unit, 251-300 2 units, 301-350 3 units, 351-400 4 units. 20. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): please titrate for net negative 500mL-1L fluid balance daily. 21. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 22. Potassium Chloride 20 mEq Packet [**Hospital1 **]: One (1) packet PO once a day. MEDICATIONS ON TRANSFER 1. Humalog Insulin Sliding Scale 2. Simvastatin 20 mg PO QHS 3. Finasteride 5 mg PO QAM 4. Tamsulosin 0.4 mg PO QHS 5. Glipizide 5 mg PO QAM 6. Clonidine 0.1 mg PO QHS 7. Metoprolol tartrate 150 mg PO BID 8. Fluticasone nasal 2 sprays each nostril QAM 9. Tiotropium inhaler daily 10. Budesonide-Formeterol inhaler [**Hospital1 **] 11. Fluconazole 100 mg PO BID (through [**11-22**]) 12. Calcium Carbonate 1500 mg PO QAM 13. Prednisone 15 mg PO daily through [**11-21**] (then switch to 10mg daily) 14. Amlodipine 5 mg PO QAM 15. Albuterol neb 2.5 mg by neb Q6hrs and Q2hrs PRN 16. Feosol 5 grains PO BID 17. Furosemide 60 mg IV BID 18. Bacitracin to lower extremity ulcerations 19. Colchicine 0.6 mg PO daily 20. Leflunomide 20 mg PO QAM 21. Vitamin D 50,000 units weekly 22. KCl 20 mEq PO daily 23. Sucralfate 1 gm PO 4* daily 24. Pantoprazole 80 mg IV Q10 hours 25. APAP PRN Discharge Medications: 1. Simvastatin 40 mg Tablet [**Month (only) **]: 0.5 Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month (only) **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Clonidine 0.1 mg Tablet [**Month (only) **]: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Metoprolol Tartrate 50 mg Tablet [**Month (only) **]: Three (3) Tablet PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable [**Month (only) **]: Three (3) Tablet, Chewable PO QAM (once a day (in the morning)). 6. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month (only) **]: Two (2) Spray Nasal DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month (only) **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Finasteride 5 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily). 9. Sucralfate 1 gram Tablet [**Month (only) **]: One (1) Tablet PO QID (4 times a day). 10. Prednisone 10 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q8 (). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Month (only) **]: One (1) Cap Inhalation DAILY (Daily). 13. Glipizide 5 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily). 14. Diltiazem HCl 30 mg Tablet [**Month (only) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*12* 16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day). 17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*500 ML(s)* Refills:*0* 19. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: One (1) Inhalation twice a day. 20. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). Disp:*60 * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: Primary: 1. Duodenal [**Hospital **] . Secondary: 1. Right Extensor Tendon rupture 2. Congestive Heart Failure 3. Atrial Fibrillation Discharge Condition: stable, good, 02 saturation 98% on 1L NC. Mental status [**Hospital 5235**]. Ambulating with assistance. Discharge Instructions: You were admitted to the hospital because you were having bleeding. You had an endoscopy which showed a large duodenal [**Hospital **]. Please return to the doctor or call the clinic if you experience bleeding, black, tarry stools, feel light headed, have blurry vision, feel short of breath, or any other symptoms that are concerning to you. . Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . Please adhere to 2 gm sodium diet. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-29**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-29**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. J tube care: check J tube site daily for signs of infection, redness, swelling, discharge. Clean daily with alcohol swab or hydrogen peroxide. Followup Instructions: Provider: (pulmonary) Dr. [**Last Name (STitle) 575**] 8:30am Friday [**12-28**] [**Hospital Ward Name 5074**] [**Location (un) 86**] [**Hospital Ward Name 23**] [**Location (un) **] Medical specialty [**Telephone/Fax (1) 612**] Provider: (surgery) Dr. [**First Name (STitle) **] Phone: [**Telephone/Fax (1) 2998**] [**Hospital 620**] Campus Ground Floor surgical specialties [**12-27**] 2pm Provider: [**Name10 (NameIs) **] Clinic [**Telephone/Fax (1) 6331**] Monday [**12-24**] [**Hospital Ward Name 516**] [**Location (un) 86**] [**Hospital Ward Name 23**] [**Location (un) **] 9:30 Name: [**Known lastname 13263**],[**Known firstname 5204**] Unit No: [**Numeric Identifier 13264**] Admission Date: [**2131-11-17**] Discharge Date: [**2131-12-5**] Date of Birth: [**2063-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3149**] Addendum: The patient was unable to tolerate the hand MRI positioning so he was discharged with a follow up appointment with hand clinic. Discharge Disposition: Extended Care Facility: [**Hospital 2653**] [**Hospital **] Hospital [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**] Completed by:[**2131-12-4**]

[ "600.00", "250.60", "V58.65", "584.9", "496", "727.63", "112.84", "427.32", "532.40", "996.74", "173.6", "427.31", "285.1", "V45.81", "278.00", "280.0", "585.9", "357.2", "272.4", "714.0", "263.9", "403.90", "428.33", "428.0" ]

icd9cm

[ [ [] ] ]

[ "44.42", "44.29", "96.6", "46.39", "44.00", "44.43", "38.93", "45.13", "45.15" ]

icd9pcs

[ [ [] ] ]

20203, 20431

5986, 10861

324, 455

16777, 16884

4686, 5963

19065, 20180

3493, 3694

14241, 16505

16620, 16756

10887, 14218

16908, 18389

18405, 19042

3709, 4667

276, 286

483, 2683

2705, 3123

3139, 3477

57,752

108,032

40420

Discharge summary

report

Admission Date: [**2109-6-2**] Discharge Date: [**2109-6-8**] Date of Birth: [**2089-4-1**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Trauma: stab wound Major Surgical or Invasive Procedure: [**2109-6-2**] Trauma ex-lap, repair gastric perforation History of Present Illness: History Present Illness: 22M s/p stab to LUQ w/ 6" knife w/ large hematemesis ~2-3L, brought into ED via [**Location (un) **], received 2 units RBC, hemodynamically stable, intubated w/ more hematemesis post-intubation, additional 3units RBCs given during flight. Pt was then brought emergently to OR where on ex-lap, there was concern for aortic injury on top of gastric/hepatic injuries. Past Medical History: PMH: htn, hyperlipidemia Social History: NC Family History: NC Physical Exam: Vitals:T=98.8, Hr=77, bp=112/88, rr=18, sat=98%/ra Gen:A+Ox3 HEENT: PERRL, EOMI Chest: CTABL CVS: NS1S2 Abd:soft, appropriately tender, non distended, no rebound/ guarding wound:c/d/i Ext: no c/c/e Pertinent Results: [**2109-6-4**] 06:20AM BLOOD WBC-12.5* RBC-4.02* Hgb-12.1* Hct-36.6* MCV-91 MCH-30.1 MCHC-33.1 RDW-13.7 Plt Ct-159 [**2109-6-3**] 09:54AM BLOOD Hct-38.5* [**2109-6-4**] 06:20AM BLOOD Plt Ct-159 [**2109-6-3**] 01:48AM BLOOD Plt Ct-198 [**2109-6-3**] 01:48AM BLOOD PT-13.0 PTT-23.5 INR(PT)-1.1 [**2109-6-4**] 06:20AM BLOOD Glucose-140* UreaN-8 Creat-0.7 Na-135 K-4.0 Cl-102 HCO3-27 AnGap-10 [**2109-6-3**] 01:48AM BLOOD Glucose-136* UreaN-19 Creat-0.9 Na-142 K-4.4 Cl-110* HCO3-22 AnGap-14 [**2109-6-4**] 06:20AM BLOOD Calcium-8.5 Phos-1.8*# Mg-1.7 [**2109-6-3**] 02:04AM BLOOD freeCa-1.20 [**2109-6-2**]: chest x-ray: Endotracheal and nasogastric tubes in appropriate position. Clear lungs [**2109-6-2**]: x-ray of the abdomen: FINDINGS: Supine AP portable view of the abdomen and pelvis were obtained. A vertical line of skin surgical staples is seen coursing in the midline. The inferior aspect of a nasogastric tube is seen coiling in the left upper quadrant, in the expected location of the stomach. Coursing into the left upper quadrant, is a curvilinear radiopaque structure consistent with a JP drain. Additional scattered staples are seen projecting over the groin/buttock bilaterally, noted by Dr. [**Last Name (STitle) **] to be external to the patient, staples holding down drapes. No radiopaque foreign body concerning for surgical sponge or instrument is seen. No evidence of bowel obstruction. [**2109-6-3**]: chest x-ray: FINDINGS: In comparison with the study of [**6-2**], the endotracheal and nasogastric tubes remain in satisfactory position. The pulmonary vascularity in the apical region is somewhat sparse bilaterally, though no definite pleural line to indicate pneumothorax. If this is a clinical concern, repeat expiration view could be obtained. Brief Hospital Course: 22 year old gentleman admitted to the acute care service with an abdominal stab wound. He was intubated at the scene requiring fluid resuscitation including blood products. He was hemodynamically stable upon transport. Upon admission, he was taken emergently to the operating room where he underwent an oversewing of an anterior-posterior gastrotomy. He also had an injury to a branch of a gastric vessel which was oversewn. Because there was a concern for an aortic injury, he was evaluated by the Vascular team. He was found not to have an aortic injury. During his operative course, he had a 500cc blood loss and received 1 UPRBC. He was monitored in the intensive care unit after the procedure. He had an NG tube in place and a JP drain. On POD #1 he was extubated. His incisional pain was managed with a morphine PCA and changed to a dilaudid PCA because of reports of nausea. He was transported to the surgical floor POD #1. He was evaluated by Social services and they have provided additional support to him and his family and made recommendations about the availibility of community programs. His foley catheter was discontinued on POD #2 and he voided without difficulty. His vital signs are stable and he is afebrile. His hematocrit has stablized at 36.6. His [**Last Name (un) **]-gastric tube was discontinued on POD #3 and his JP drain was d/ced prior to his discharge. He had mild nausea which has been controlled with an anti-emetic. He had been out of bed.His diet was slowly advanced which he tolerated well.His diet was advanced to regular and he was started on oral pain meds on [**2109-6-7**] which he tolerated well. He was discharged on [**2109-6-8**], when he was tolerating a regular diet, voiding normally and ambulating without any difficulty. He would follow up with the [**Hospital 2536**] clinic in [**12-30**] weeks. Medications on Admission: none Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: stab wound 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 you received a stab wound to the abdomen. You were taken to the operating room where you underwent an exploratory laparotomy and repair of a stomach laceration. You are now preparing for discharge home with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-7**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule your appointment by calling # [**Telephone/Fax (1) 600**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2109-6-11**]

[ "E920.3", "864.15", "902.21", "E935.2", "863.1", "787.02" ]

icd9cm

[ [ [] ] ]

[ "39.31", "44.61" ]

icd9pcs

[ [ [] ] ]

5430, 5436

2931, 4793

319, 378

5491, 5491

1122, 2907

6889, 7160

883, 887

4848, 5407

5457, 5470

4819, 4825

5642, 6358

6374, 6866

902, 1103

260, 281

406, 799

5506, 5618

821, 847

863, 867

5,259

195,496

53314

Discharge summary

report

Admission Date: [**2144-3-7**] Discharge Date: [**2144-3-16**] Service: ORT/CARDIO CHIEF COMPLAINT: Left hip fracture. HISTORY OF PRESENT ILLNESS: This is an 84 year old female who had been in her usual state of health until the day of admission when she slipped at temple and fell onto her left hip that was found to be fractured in the emergency department. Admitted to the orthopaedic service for left hip arthroplasty. PAST MEDICAL HISTORY: 1. Seizure disorder. Last seizure 10 years ago. By history appears to be absence seizures. No further seizures since starting medication. 2. Asthma. No hospitalizations, no steroids, no intubations. 3. Hypertension. 4. Breast cancer status post right mastectomy, XRT in [**2107**]. 5. History of paroxysmal atrial fibrillation controlled on Betapace. 6. Recurrent sternal osteomyelitis status post sternectomy in [**2140**]. 7. Chronic right pleural effusion status post thoracoscopy and talc pleurodesis. 8. Osteoporosis. 9. Spinal stenosis. MEDICATIONS ON ADMISSION: Verapamil 60 mg q.i.d., Tylenol 350 mg every four to six hours, Depakote 250 mg b.i.d., calcium carbonate 500 mg t.i.d., albuterol inhaler p.r.n., sotalol, Fosamax, vitamin D. ALLERGIES: Amiodarone causes tremulousness. SOCIAL HISTORY: No tobacco, no ethanol. She lives with her daughter in [**Name (NI) **]. PHYSICAL EXAMINATION: On physical exam she was febrile temperature 98.6, pulse 72, blood pressure 134/54, respirations 16, sating 97% in room air. HEENT exam normocephalic, atraumatic. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Anicteric sclerae. Neck supple without lymphadenopathy. Lungs were clear on the left, but had fine crackles on the right throughout. Chest had a large right sided chest wall defect with paradoxical motion of the chest with inspiration. Cardiovascular exam regular rate and rhythm, normal S1, normal S2, no S3, no S4, holosystolic [**1-14**] ejection murmur radiating to the axilla, crescendo decrescendo systolic ejection murmur [**2-11**] radiating to the carotids, JVP 5 cm. Abdominal exam soft, nontender, nondistended with normoactive bowel sounds. Extremities showed no clubbing, cyanosis or edema. The incision site on the left hip was clean, dry and intact. LABORATORY DATA: Chem-7 139/4.2/102/27/28/0.8/191. Cardiac echo [**2144-3-9**] showed EF of 50%, normal LA size, mild aortic regurgitation, mild mitral regurgitation. PT 18.2, PTT 49.8, INR 2.2. Sed rate on day of discharge was 79. ALT 8, AST 18, alka phos 59, total bili 0.8, LD 160. TSH 2.6. LDL 37, HDL 29, triglycerides 54. Troponin was 10.1. Serial CKs were in the 400s, however, MB fraction was noted to be low at 11 to 14 with an index of 3. Abdominal ultrasound performed on [**2144-3-12**] showed diffuse thickening of the gallbladder with an intraluminal stone and possible wall edema. CT of the abdomen and pelvis showed no evidence of retroperitoneal hematoma and a small left gluteal hematoma with high attenuation of the gallbladder, slight thickening of gallbladder wall. Common bile duct was noted to be normal. Chest CTA done on [**2144-3-8**] showed no evidence of pulmonary embolism, small bilateral pleural effusions with bibasilar atelectasis. There were patchy areas of sclerosis in the mid-thoracic spine which could be related to metastatic breast disease and a small amount of pericardial fluid. Head CT on [**2144-3-8**] showed no evidence of intracranial hemorrhage and some sphenoid, maxillary and ethmoid sinus disease. HOSPITAL COURSE: The patient was admitted to the orthopaedic service on [**2144-3-7**]. The patient underwent left hip arthroplasty on [**Last Name (LF) 1017**], [**3-8**]. The patient tolerated the procedure well, however, the post-op course was complicated by hypotension, followed by bradycardia while in the PACU. The patient received atropine, dopamine and ephedrine and was transcutaneously paced without hemodynamic response. At this time the patient was started on IV epinephrine with increase in heart rate and systolic blood pressure. The patient was intubated for airway protection and transferred to the CCU. The patient underwent head CT and CTA to evaluate for the possibility of pulmonary embolism or cerebral event causing the hypotension. The patient's cardiac enzymes were also cycled. The patient was eventually weaned from IV pressors after approximately two days. The patient failed extubation on two separate occasions. It was thought this was due to sedation and weakness. The patient was eventually successfully extubated. The patient did well post extubation and was transferred to the general medicine floor. The patient did well on the general medicine floor. The patient was deemed stable and transferred to rehabilitation. Of note, the patient required four units of packed red blood cells over the course of her admission. DISCHARGE MEDICATIONS: 1. Depakote 250 mg q.i.d. 2. Colace 100 mg b.i.d. 3. Levofloxacin 250 mg q.day continue until [**3-18**]. 4. Flagyl 500 mg t.i.d. continue until [**3-18**]. 5. Sotalol 80 mg p.o. b.i.d. 6. Coumadin 3 mg q.day to be continued for five weeks. 7. Iron sulfate 325 mg p.o. b.i.d. 8. Calcium carbonate 500 mg t.i.d. not to be taken with food. 9. Aspirin 325 mg q.day. DISCHARGE DIAGNOSES: 1. Status post left hip arthroplasty. 2. Osteoporosis. 3. History of sternectomy. 4. History of paroxysmal atrial fibrillation. 5. History of breast cancer. 6. Hypertension. 7. Asthma. 8. Seizure disorder history. 9. Coronary artery disease. PLANS FOR THE FUTURE: 1. Coronary artery disease. The patient had a positive troponin while in the hospital. It is planned that she will have an outpatient stress test. 2. Orthopaedic. The patient is to be continued on low dose Coumadin, target INR 1.5 to 2, for six weeks from date of surgery. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Last Name (NamePattern1) 21698**] MEDQUIST36 D: [**2144-3-16**] 17:31 T: [**2144-3-17**] 09:42 JOB#: [**Job Number 4731**]

[ "E885.9", "493.20", "820.09", "427.31", "V10.3", "427.89", "780.39", "997.1", "458.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "81.52", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

5358, 6163

4964, 5337

1044, 1267

3591, 4941

1382, 3573

111, 131

160, 438

460, 1017

1284, 1359

29,952

171,886

32562

Discharge summary

report

Admission Date: [**2187-1-21**] Discharge Date: [**2187-2-28**] Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: AVR(#19 StJude tissue)MVR(#26 CE band)TVR(#32 MC3 band)[**2-2**] History of Present Illness: [**Age over 90 **]F w/AS, MR, TR, [**Hospital **] transferred from OSH on [**1-22**] to CT [**Doctor First Name **] for CABG, AVR, MVR, now transferred to CCU for refractory CP. She initially presented to [**Hospital **] Hospital in heart failure on [**1-20**]. Past Medical History: CAD s/p PCIX2, AF, CHF, HTN, AI/AS, Mitral insuficiency, Tricuspid regurgitation. Social History: H/o tob use but quit 40 yrs ago (80 pack-years). No Etoh. She lived independently prior to admission w/ her dog. Family History: Her father had a heart attack in his 50s. Physical Exam: PHYSICAL EXAMINATION: VS: T 97.1, BP 120/87, HR 123, RR 19, O2 98% on 5L NC 48Kg Gen: Elderly female in NAD, appears drowsy but able to respond appropriately to questions. Oriented x3. Mood, affect appropriate. Somewhat irritable. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Very dry MM. Neck: Supple with JVP of 14 cm (EJ) at 70 degrees. CV: Hyperdynamic precordium, PMI laterally displaced. irreg, IV/VI systolic murmur at LLSB. Chest: + kyphosis. Resp were unlabored, no accessory muscle use. Decreased BS bilaterally. Abd: Cachectic, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: + LE edema, pitting to knees (L>R). No femoral bruits. Skin: + Ulcer w/ scab over R lateral shin. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; trace DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: [**2187-2-28**] 03:00AM BLOOD WBC-7.5 RBC-3.23* Hgb-9.3* Hct-29.7* MCV-92 MCH-28.9 MCHC-31.4 RDW-16.5* Plt Ct-344 [**2187-2-27**] 03:59PM BLOOD Hct-30.9* [**2187-2-27**] 04:01AM BLOOD WBC-7.9 RBC-3.22* Hgb-9.3* Hct-29.0* MCV-90 MCH-28.9 MCHC-32.2 RDW-16.3* Plt Ct-366 [**2187-1-21**] 08:43PM BLOOD WBC-10.0 RBC-4.25 Hgb-11.1* Hct-34.6* MCV-81* MCH-26.0* MCHC-32.0 RDW-15.8* Plt Ct-274 [**2187-2-28**] 03:00AM BLOOD Plt Ct-344 [**2187-2-27**] 04:01AM BLOOD Plt Ct-366 [**2187-2-27**] 04:01AM BLOOD PT-20.5* PTT-32.8 INR(PT)-1.9* [**2187-2-26**] 02:19AM BLOOD PT-23.5* INR(PT)-2.3* [**2187-2-25**] 04:42PM BLOOD PT-26.7* INR(PT)-2.7* [**2187-2-25**] 02:58AM BLOOD PT-34.0* PTT-41.7* INR(PT)-3.6* [**2187-2-24**] 03:29AM BLOOD PT-27.6* PTT-38.1* INR(PT)-2.8* [**2187-1-21**] 08:43PM BLOOD PT-16.3* PTT-33.5 INR(PT)-1.5* [**2187-1-21**] 08:43PM BLOOD Plt Ct-274 [**2187-2-28**] 03:00AM BLOOD Glucose-108* UreaN-26* Creat-0.5 Na-135 K-5.4* Cl-101 HCO3-31 AnGap-8 [**2187-2-27**] 03:59PM BLOOD K-5.0 [**2187-2-27**] 04:01AM BLOOD Glucose-173* UreaN-26* Creat-0.4 Na-132* K-4.0 Cl-95* HCO3-33* AnGap-8 [**2187-1-21**] 08:43PM BLOOD Glucose-103 UreaN-19 Creat-0.7 Na-140 K-3.7 Cl-103 HCO3-29 AnGap-12 [**2187-2-28**] 03:00AM BLOOD ALT-32 AST-38 AlkPhos-144* Amylase-246* TotBili-0.6 [**2187-2-27**] 04:01AM BLOOD Amylase-168* [**2187-2-26**] 02:19AM BLOOD Amylase-226* [**2187-2-25**] 09:29AM BLOOD ALT-20 AST-21 LD(LDH)-167 AlkPhos-119* Amylase-215* TotBili-0.5 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2187-2-25**] 9:40 AM CHEST (PORTABLE AP) Reason: evaluate for effusion [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with s/p avr REASON FOR THIS EXAMINATION: evaluate for effusion CLINICAL HISTORY: Status post AVR. CHEST: Compared to the prior chest x-ray of [**2-23**] cardiac failure is still present. The distribution of the fluid is changed somewhat with increase in size of the left effusion and decrease in size of the right effusion and also in the areas of interstitial failure but the degree of failure probably is unchanged. IMPRESSION: No change in degree of failure. DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75919**]TTE (Complete) Done [**2187-2-12**] at 3:06:23 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2097-1-1**] Age (years): [**Age over 90 **] F Hgt (in): 61 BP (mm Hg): 117/61 Wgt (lb): 105 HR (bpm): 75 BSA (m2): 1.44 m2 Indication: Left ventricular function. Shortness of breath. ICD-9 Codes: 427.31, 799.02, V42.2 Test Information Date/Time: [**2187-2-12**] at 15:06 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 35981**], MD Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2007W000-0:00 Machine: Other Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 50% to 60% >= 55% Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - E Wave deceleration time: *120 ms 140-250 ms TR Gradient (+ RA = PASP): *33 mm Hg <= 25 mm Hg Findings bilateral pleural effusions. This study was compared to the prior study of [**2187-1-29**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: RV not well seen. Moderately dilated RV cavity. Paradoxic septal motion consistent with prior cardiac surgery. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated, normal leaflet/disc motion and transvalvular gradients. Trace AR. MITRAL VALVE: Well-seated mitral annular ring with normal gradient. Moderate mitral annular calcification. Physiologic MR (within normal limits). TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. patient. Echocardiographic results were reviewed with the houseofficer caring for the patient. Bilateral pleural effusions. Conclusions The left atrium is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral annular ring appears well seated and is not obstructing flow. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2187-1-29**], the overall left ventricular function is similar. A bioprosthetic valve is in the aortic position and functioning well. The mitral annular ring is also well seated and functioning well. The severity of tricuspid regurgitation has decreased. Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2187-2-12**] 18:10 Brief Hospital Course: She was admitted to cardiac surgery for preoperative workup. Her ocumadin was held and she was started on heparin. She was started on levofloxacin for pneumonia on CXR. She required 5 dental extractions which were done on [**1-28**]. POstoperatively she complained of chest pain and was transferred to the CCU. She ruled in for NSTEMI. Cardiac cath showed 90% in stent lesion in diag ostium and she underwent succesful PTCA. She was found to have facial droop and tongue deviation likley due to oral surgery, Head CT was negative. Her HCT dropped, CT abdomen/pelvis was negative for RP bleed. On [**2-2**] she was taken to the operating room where she underwent an AVR, MVRepair and TV repair. She was transferred to the ICU in critical but stable condition on milrinone, epinephrine and levophed. She was given 48 hours of vancomycin as she was in the hospital preoperatively. She was started on lasix and natrecor for diuresis. She was weaned from her milrinone by POD #2. She was started on amiodarone for atrial fibrillation. She was extubated on POD #4 but required reintubation for increased work of breathing. A dobhoff was placed and She was started on tube feeds. HIT antibody was positive. She was extubated again on [**2-9**]. On [**2-11**] she became somnolent and unresponsive, and she was reintubated. On [**2-13**] she had bilateral thoracentesis. She was extuabted on [**2-13**]. She was started on coumadin for atrial fibrillation. On [**2-15**] she was found to be unresponsive with a blown right pupil. She was reintubated. Stat head CT and subsequent MRI were negative, she was seen by neurology and her pupil began to react. She continued on anticoagulation. She was started on nitrofurantoin for +UA. She was again extubated on [**2-20**], and she began CPAP overnight. She again required intubation for hypercarbia on [**2-21**]. On [**2-22**] she underwent trach and open J tube. She was started on vanocmycin for MRSA in her sputum. On [**2-26**] she complained of abdominal pain and her amylase and lipase were elevated. She tolerated tube feeds and her pain and amylase and lipase improved. She was ready for discharge to rehab on [**2-28**]. Medications on Admission: Home meds: Lasix 20mg' Lopressor 50mg" Diltiazem 60mg' Coumadin 3mg alternate with 1.5mg ASA 81mg' Plavix 75mg' Discharge Medications: 1. Clopidogrel 75 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2 times a day). 3. Nystatin 100,000 unit/mL Suspension [**Month/Year (2) **]: Five (5) ML PO QID (4 times a day) as needed. 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-14**] Drops Ophthalmic PRN (as needed). 5. Dorzolamide-Timolol 2-0.5 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 9. Dornase Alfa 1 mg/mL Solution [**Last Name (STitle) **]: One (1) Inhalation [**Hospital1 **] (2 times a day). 10. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed. 11. Acyclovir 5 % Ointment [**Hospital1 **]: One (1) Appl Topical 6X/D (): right side mouth . 12. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 13. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 14. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 15. Ferrous Gluconate 300 mg (35 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 16. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 17. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 18. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 19. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 20. Potassium Chloride 20 mEq Packet [**Hospital1 **]: One (1) Packet PO BID (2 times a day). 21. Warfarin 1 mg Tablet [**Hospital1 **]: 0.5 Tablet PO ONCE (Once) for 1 doses: check INR [**3-1**]. 22. Diltiazem HCl 30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). 23. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4) Puff Inhalation Q4H (every 4 hours). 24. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: Five (5) units Subcutaneous at bedtime. 25. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Year (2) **]: sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: AI/AS, Mitral insuficiency, Tricuspid regurgitation now s/p AVR/MVR/TVR Chronic diastolic heart failure post-op respiratory failure s/p trach and J Tube placement A fib HIT CAD s/p PCIx2 HTN Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 14522**] 2 weeks Completed by:[**2187-2-28**]

[ "424.0", "428.0", "287.4", "424.2", "V45.82", "401.9", "518.5", "996.72", "997.1", "V09.0", "410.71", "427.31", "428.32", "482.41", "511.9", "379.41", "414.01", "424.1", "521.00", "379.43", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.22", "96.71", "00.13", "96.6", "23.19", "34.91", "96.04", "89.60", "46.39", "39.61", "99.04", "00.66", "35.33", "00.41", "31.1", "35.21", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

12739, 12819

7877, 10050

239, 306

13054, 13062

1833, 3412

13362, 13512

851, 894

10213, 12716

3449, 3496

12840, 13033

10076, 10190

13086, 13339

909, 909

931, 1814

189, 201

3525, 7854

334, 597

619, 702

718, 835

63,039

142,122

6041

Discharge summary

report

Admission Date: [**2154-9-7**] Discharge Date: [**2154-9-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4071**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: TEE Cardioversion Intubation Extubation PICC line placement History of Present Illness: 89 y/o F chinese-speaking female with severe diastolic heart failure, atrial fibrillation not on anticoagulation, diabetes, hypertension, hyperlipidemia who presents with worsening DOE/SOB for past 3 days. Patient was seen for worsening dyspnea and shortness of breath by Dr. [**First Name (STitle) 437**] in heart failure clinic [**2154-8-26**] and at that time the patient's was started on lasix 20mg daily and increased toprol dose. Per family, patient's lower extremity edema improved, but dyspnea persisted. Also intermittant CP, lasts >5min, occurring several times a day, no current pain and no pain in ED. . In ED, Temp 97.5, HR 75 BP 123/91 RR 26 Pox 98 on 3 LNC. CXR showed retrocardiac opacity and new bilateral pleural effusions. No n/v, abd pain, f/c, cough, chest pain. In ED, he received Levofloxacin 750 mg iv, and nitro SL. She initially had some relief with better dyspnea after getting nitro. Got 250 ml bolus and then had respiratory distress and was intuabted. Lactate 3.4. . On the floor, patient is intubated and sedated. Family is at the bedside. She is in atrial fibrillation and her BP is stable. Past Medical History: -Severe diastolic congestive heart failure -Pulm HTN -Mod to severe mitral regurgitation -Diabetes mellitus -Hypertension -Hyperlipidemia -Osteoporosis -Glaucoma -h/o gout ([**3-18**]) -h/o appendicitis last year with septic shock ([**Hospital3 **]) -h/o atrial fibrillation (during hospitalization one year ago, not on coumadin, and discussed at last cards visit [**8-26**] and daughter wanted to not initiate coumadin) - h/o TEE electrocardioversion during hospitalization; has not had atrial fibrillation until past few weeks Social History: The patient is originally from [**Female First Name (un) 8489**]. She lives in [**Location 583**] with her daughter currently. [**Name2 (NI) **] tobacco use, no alcohol use, no drug use. Functional status is poor, but does get around the house and has normal mental capacity, no known dementia. Family History: Circulatory disorders in her father and uncle, otherwise noncontributory. Physical Exam: PE on admission: Vitals: T: 96.6, BP: 118/75, P: 93 (afib), R: 16, O2: 100% AC 100%/5/450/16 with ABG 7.45/29/506 General: thin, eldery, intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear, pupils 3mm and reactive Neck: supple, JVP not elevated, no LAD Lungs: coarse lung sounds bilaterally, crackles at the bases, no wheezes, referred ventilator sounds CV: irregularly irregular, 2/6 systolic murmur best heard at LLSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, palp pulses, no clubbing, no edema Pertinent Results: LABORATORIES: [**2154-9-7**] 04:18PM BLOOD WBC-8.4 RBC-4.11* Hgb-13.1 Hct-41.9 MCV-102* MCH-32.0 MCHC-31.4 RDW-13.9 Plt Ct-232 [**2154-9-15**] 06:02AM BLOOD WBC-7.6 RBC-3.32* Hgb-10.9* Hct-33.0* MCV-99* MCH-32.9* MCHC-33.1 RDW-14.4 Plt Ct-225 [**2154-9-7**] 04:18PM BLOOD PT-14.7* PTT-37.2* INR(PT)-1.3* [**2154-9-15**] 06:02AM BLOOD PT-32.8* PTT-50.4* INR(PT)-3.3* [**2154-9-7**] 04:18PM BLOOD Glucose-144* UreaN-37* Creat-1.0 Na-143 K-4.2 Cl-107 HCO3-21* AnGap-19 [**2154-9-15**] 06:02AM BLOOD Glucose-101 UreaN-23* Creat-0.9 Na-142 K-3.6 Cl-104 HCO3-29 AnGap-13 [**2154-9-8**] 04:38AM BLOOD ALT-39 AST-51* LD(LDH)-295* CK(CPK)-59 AlkPhos-85 TotBili-1.2 [**2154-9-7**] 04:18PM BLOOD CK(CPK)-58 [**2154-9-7**] 09:30PM BLOOD CK(CPK)-62 [**2154-9-7**] 09:08PM BLOOD cTropnT-0.02* [**2154-9-7**] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2154-9-8**] 04:38AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-8079* [**2154-9-8**] 04:38AM BLOOD Calcium-7.5* Phos-3.6 Mg-1.8 [**2154-9-14**] 05:42AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 [**2154-9-7**] 11:42PM BLOOD Type-ART pO2-506* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 [**2154-9-8**] 03:21PM BLOOD Type-ART Tidal V-300 PEEP-5 FiO2-40 pO2-139* pCO2-30* pH-7.43 calTCO2-21 Base XS--2 Intubat-INTUBATED [**2154-9-10**] 12:38AM BLOOD Type-ART Temp-36.8 pO2-163* pCO2-34* pH-7.42 calTCO2-23 Base XS--1 Intubat-INTUBATED [**2154-9-7**] 04:27PM BLOOD Lactate-3.4* [**2154-9-7**] 09:30PM BLOOD Lactate-3.8* [**2154-9-7**] 11:42PM BLOOD Lactate-1.9 . ====================== IMAGING: TEE: [**9-9**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrial appendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is symmetric left ventricular hypertrophy with normal cavity size. LV systolic function appears depressed. There are simple atheroma in the aortic arch and descending thoracic aorta to 47cm from the incisors. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is a small pericardial effusion. IMPRESSION: No spontaneous echo contrast or thrombus in the LA/LAA/RA/RAA. Moderate to severe mitral regurgitation. Mild aortic regurgitation. . TTE [**7-16**]: The atria are moderately dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with normal free wall contractility. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior study (images reviewed) of [**2151-5-25**], pulmonary pressures are higher. The other findings are simlar. . CXR [**2154-9-7**]: Cardiac silhouette remains moderately enlarged. There are bilateral pleural effusions, which appear new from the prior study. The aorta remains tortuous with mural calcifications present. Pulmonary ascularity is normal. The osseous structures are unchanged. A retrocardiac opacity is nonspecific, which may represent atelectasis, but infection is excluded. IMPRESSION: 1. Small bilateral pleural effusions. 2. Retrocardiac opacity, which could represent atelectasis, but infection not excluded. 3. No evidence of pulmonary edema. Brief Hospital Course: 89F c diastolic dysfunction with worsening heart failure, atrial fibrillation not on anticoagulation and mod-severe MR+TR who presents with acute on chronic worsening of dyspnea. . # Dyspnea / Respiratory Failure: Differential diagnosis includes CHF vs PNA vs MI. Given rapid decompensation with small fluid bolus, and history of lack of fever, cough, no wbc, non-impressive CXR, the most likely cause of her dyspnea was acute on chronic diastolic heart failure, likely worsened recently by afib. MI was ruled out with unremarkable EKG and negative cardiac enzymes. In the MICU, patient was intially intubated and sedated. After a TEE ruled out thrombus in the heart, patient was cardioverted for persistent afib c RVR. She was on heparin gtt during TEE and cardioversion. She was successfully extubated and transferred to [**Hospital1 1516**] cardiology service. After patient was transferred to cardiology floor, she was diuresed with 20mg PO lasix daily, initially supplemented by another dose of IV 10mg lasix in the afternoon. Patient responded to lasix well, and her lung exams improved with diuresis. . # Acute on chronic diastolic heart failure: Likely exacerbated by Afib. After patient was transferred to cardiology floor, she was diuresed with 20mg PO lasix daily, with another dose of IV 10mg lasix in the afternoon. Patient responded to lasix well, and her lung exams improved with diuresis. Patient was discharged with 20mg PO lasix daily. . # MR: Likely contributing to her fragile fluid balance and heart failure. She was hypertensive on admission. We innitially were able to decrease her afterload with intubation and PEEP, but after extubation, her BPs were around 150s. We restarted a low dose ACEI for her. Blood pressure was in the 110s to 120s afterwards. . # Afib: Patient was initially found to have afib when she had appendicitis a year ago. She was not anticoagulated. Patient was in persistent afib with RVR in MICU, so heparin drip was started, and patient had a cardioversion after TEE showed no thrombus. She was started on coumadin for bridging. She was very sensitive to coumadin, INR was supratherapeutic after only 3 doses of coumadin (3mg, 3mg, 1mg), so coumadin was held. The plan is to re-start the patient's coumadin once INR < 3. She was also loaded with amiodarone 400mg [**Hospital1 **] for 7 days, followed by 200mg [**Hospital1 **] for 7 days ([**Date range (1) 23728**]), and will start to take 200mg daily from [**2154-9-22**]. After patient was transferred to cardiology service on [**9-10**], she was started on low dose 12.5mg metoprolol TID after she had 2 episodes of atrial tachycardia. She was doing better in the next few days. However, she was noted to be in junctional rhythm with a heart rate of 30s-40s, and SBP in the 80s on [**9-13**]. It is likely that after 6 days of amiodarone on board, she was finally seeing the effect of amiodarone. In the mean time, she was on beta blocker. Both amio and BB had a suppressive effect on the sinus node, and probably she has some intrinsic nodal disease and the combination of all three caused her to go into junctional rhythm. She had some retrograde p waves on EKG, rp interval was prolonged, suggesting she not only has sinus nodal disease but also has av block. Because of this bradycardia and hypotension, she was obseved overnight at CCU off beta blocker, and was doing well, so was transferred back to cardiology. Patient was off beta blocker during the rest of her hospital stay. . # Diabetes mellitus II: Metformin was held when patient was in the hospital, as patient needed imaging and metformin can cause elevated lactate. She was put on sliding scale humalong, and her blood glucose was well controlled. . # Hypertension: Low dose lisinopril was restared after extubation. Patient's blood pressure was stable during this hospital stay. . # Hyperlipidemia: Home statin was continued. . # Lactate: In the ED, lactate was 3.4. It was most likely due to poor tissue perfusion as a result of decompensated heart failure vs metformin effect. Unlikely due to infection as patient had no sign of infection. Metformin was held during this hospital stay. Lactate returned to [**Location 213**] with 3L NS IVFs in ED. . # Postive blood culture: Blood culture from the Emergency room grew coagulase negative staphylococcus in [**2-10**] tubes, however patient had no sign of [**Last Name (LF) 23729**], [**First Name3 (LF) **] this was thought most likely to be contamination. Patient was on vanc initially which was discontinued. Patient was afebrile and had no sign of [**First Name3 (LF) 23729**] during this hospital stay. . # Anemia: Hct was around 33-35, stable during this hospital stay. Patient was found to have coffee grounds in NGT in MICU, question TEE esophageal trauma. Patient was put on pantoprazole 40 mg IV Q12H, then was on PO pantoprazole. As a precaution, active type and screen were maintained, but patient did not require any blood transfusion. . # Hypokalemia: Patient had K of 3.0 after being transferred to floor. Question lasix effect. Beta-blocker could also decrease extracelluar K. Patient was not vomiting, so unlikely losing K from GI tract. K was repleted with appropriate bump. . # Osteoporosis: Patient is on weekly fosamax. . # h/o Gout: Patient had no gout symptoms during this hospital stay. . Patient had PICC line in place as she had very difficult IV access. Her code status was full after discussion with her daughter. Medications on Admission: Alendronate [Fosamax] 35 mg Tablet weekly (friday) Atorvastatin [Lipitor] 10 mg daily Furosemide 20 mg Tablet daily Lisinopril 10 mg Tablet daily Metformin 500 mg Tablet Sustained Release 24 hr daily Metoprolol Succinate 50 mg daily Polyethylene Glycol 17 gm daily Aspirin 81 mg Tablet daily Calcium 500 mg Tablet daily Multivitamin daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*28 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: day 1: [**9-15**] day 7: [**9-21**]. Disp:*14 Tablet(s)* Refills:*0* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: starting on [**2154-9-22**]. Disp:*30 Tablet(s)* Refills:*2* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 9. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Fosamax 35 mg Tablet Sig: One (1) Tablet PO once a week: on Fridays. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Please start once INR < 3. 15. Outpatient Lab Work INR check. Please check INR daily. Once < 3, restart Coumadin Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: - Acute on chronic diastolic heart failure - Atrial fibrillation treated with cardioversion Secondary diagnosis: - Hypertension - Hyperlipidemia - mod-to-severe MR - mod-to-severe TR Discharge Condition: Stable, afebrile. Discharge Instructions: It was a pleasure to be involved in your care, Ms. [**Known lastname **]. You were hospitalized to [**Hospital1 69**] because of shortness of breath. You have a diagnosis of heart failure that caused you to have too much fluid in your lungs. You were treated with a medicine called "lasix" which removed fluids from your lungs. Your symptom significantly improved on this medication. You were also found to have an abnormal heart rhythm called "atrial fibrillation", and you underwent a procedure called "cardioversion" which stopped the bad rhythm. Your medications have been changed. -- please discontinue metoprolol succinate -- please take 5mg lisinopril daily instead of 10mg daily -- please take amiodarone 200mg twice a day from [**2154-9-15**] to [**9-21**], thereafter take amiodarone 200mg once a day -- please continue to take lasix 20mg daily Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 9304**] below. If you develop worsening shortness of breath, chest pain, palpitations, leg swelling, dizziness or any other symptom that concerns you, please call your doctor or come back to the Emergency Department immediately. Followup Instructions: You have an appointment with your cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2154-9-23**] at 10:30am. Please make an appointment to see your primary care doctor Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 8236**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]

[ "733.00", "250.00", "365.9", "427.31", "276.8", "427.32", "428.33", "V45.89", "458.29", "401.9", "518.81", "425.4", "416.8", "424.2", "285.9", "276.51", "274.9", "272.4", "428.0", "424.0" ]

icd9cm

[ [ [] ] ]

[ "99.62", "38.93", "96.72", "88.72", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

14845, 14911

7632, 13099

269, 330

15158, 15178

3076, 7609

16398, 16791

2367, 2442

13489, 14822

14932, 15044

13125, 13466

15202, 16375

2457, 2460

222, 231

358, 1483

15065, 15137

2474, 3057

1505, 2037

2053, 2351

13,289

119,078

204

Discharge summary

report

Admission Date: [**2103-7-26**] Discharge Date: [**2103-8-9**] Date of Birth: [**2072-5-4**] Sex: F Service: [**Doctor First Name 147**] Allergies: Penicillins Attending:[**First Name3 (LF) 1556**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Status post exploratory laparatomy status post right colectomy status post appendectomy status post abdominal closure History of Present Illness: 31 yo Female who was status post normal spontaneous vaginal delivery approximately 10 weeks ago who presented on [**2103-7-25**] with a chief complaint of abdominal pain. She was well until about 12 hours prior to admission when she described the acute onset of sharp right lower quadrant pain and diffuse/poorly characterized dull general abdominal pain. The pain was described as sharp, constant. The pain radiated to the back. It got worse with motion, better with motrin. The pain was associated with nausea and bilious vomiting times 1, subsequent to the onset of pain. The patient also described subjective fevers and chills. The paitent did not have any constipation, diarrhea, change in the color of her stools, dysuria, hematuria, vaginal discharge, itching, or bleeding. No history of recetn truama, travel. she has not been sexually active since her delivery Past Medical History: recurrent respiratory infections allergies Gastroesophageal reflux disease removal of cystic mass of breast removal of labial cyst degenerating fibroid during pregnancy Social History: works in a research lab no tobacco, or alcohol travelled to [**Country 2045**] in [**2081**], bermuda in [**2088**] Family History: No history of bowel problems. Father had a history of hypertension Physical Exam: temperature 100.8, pulse 81, blood pressure 109/71, respirations 16, oxygen saturation 100% on room air General: patient was in moderate distress, appeared acutely ill Head and neck: head atraumatic/normocephalic. sclera anicteric. No lymphadenopathy, no jvd Card: regular rate and rhythm Lungs: clear to auscultation Abdomen: soft, mildly distended. Diffuse tenderness, RLQ>LLQ. Positive for rebound, especially in lower abdomen Back: no costovertebral angle tenderness. Pelvic exam: significantly limited secondary to discomfort, exquistite tenderness at the interoitus, unable to get in foot rests. Minimal thin white discharge, right adnexal and fundal tenderness consistent with peritonitis On discharge the patient had a well healing midline incision, as well as ostomy sites that were pink and healthy. Stool and gas were present in the ostomy bag. Her abdoment was soft and nondistended Pertinent Results: Blood cultures negative, CMV IgG positive, CMV IgM negative, CMV DNA negative, RPR negative, Fungal culture negative, Stool negative for (camplobacter, salmonella, shigella, vibrio, yersina, ecoli 0157:H7, Cdificile, virus), HSVI/II negative, Hep B SAb positive, Hep BSAg negative, Cervical cultures negative for GC and chlamidyia, Rheumatoid factor negative, HIT negative, Cystic fibrosis negative, sickle negative, lupus anticoagulant negative, cryoglobulin negative, [**Doctor First Name **] 1:40, ANCA negative, HCG negative. Cardiolipin antibiodies are pending. Pelvic Ultrasound [**2103-7-25**]: IMPRESSION: 1. Fibroid uterus. 2. Normal appearing ovaries bilaterally. No ovarian torsion seen at the time of the exam, although clinical correlation is needed to entirely exclude this diagnosis. 3. Mild-to-moderate amount of nonspecific free pelvic fluid. Abdominal CT [**2103-7-25**]: ABDOMEN CT WITH IV CONTRAST: There is a trace right pleural effusion and slight atelectasis at the right lung base. The NG tube extends into the stomach, where it makes a loop in the fundus. There is a large amount of fluid in the peritoneum. The liver, spleen, pancreas, adrenal glands, kidneys, and ureters appear unremarkable. The gallbladder is distended without CT evidence of wall edema. The proximal small bowel is collapsed. The mid small bowel is distended with air-fluid levels. The distal small bowel is not distended. Rectal contrast opacifies the colon, reaching the cecum. There is severe thickening of the cecal wall. The appendix seems to be normal in caliber although surrounded by inflammatory changes and fluid . These findings are most consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology is less likely. PELVIC CT WITH IV CONTRAST: The uterus is enlarged with multiple fibroids, some of which demonstrate calcified rims. The bladder and rectum are unremarkable. There is a large amount of fluid tracking down from the abdomen. BONE WINDOWS: The visualized osseous structures appear unremarkable. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in evaluating bowel anatomy. There is severe cecal wall thickening. The appendix is normal in caliber. IMPRESSION: 1) Inflammatory changes in the rigth lower quadrant most likely consistent with cecitis, which could be infectious or inflammatory. Ischemic etiology less likely. 2) Large amount of intraperitoneal fluid. 3) Dilated mid small bowel loops, likely secondary to ileus. 4) Fibroid uterus. Pathology: Appendix: Acute appendicitis with acute serositis. No evidence of vasculitis seen. Ileocecal resection specimen: 1. Ileum and proximal margin: Vascular congestion. 2. Colon: a. Severe vascular congestion, submucosal edema, and transmural acute hemorrhage. b. Areas of acute transmural ischemic infarction (slides C and D). c. Distal margin: No infarction. d. No convincing evidence of a primary vasculitis. Scattered small veins have mural acute inflammation and fibrin thrombi, but these changes are almost certainly secondary to the colonic wall injury. e. One lymph node: No diagnostic abnormalities recognized. Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. Echocardiogram: Conclusions: The left atrium is normal in size. 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 appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Small circumferential pericardial effusion. No 2D echocardiographic evidence for endocarditis identified.+ Brief Hospital Course: The patient was initially taken emergently to the operating room for exploratory laparascopy with general surgery back up. She was placed on broad spectrum antibiotics. They observed a normal left tube and [**Last Name (un) 2046**], and copius greenish yellow fluid, as well as right lower quadrant adhesions and a diffusely inflammed small intestine. The General surgery team became infvolved and noted that the appendix was acutely inflamed but there was no other pathology. after completion of the exploratory laparatomy, the patient remained tachycardic, with otherwise stable vital signs, but required >15 L of resucitation. Despite this the patients Hematocrit rose from 41.3 to 52, and her WBC rose form 12.9 to 39.7. The patients urine output also began to decrease. The patient was becoming edematous and the patient had increased respiratory distress. it was believed that the patient was third spacing, and the patient was transferred to the intensive care unit for monitoring. On post op day 2, the patient was taken back for a reexploration given that the patient had the hemodynamics above, and the patients abdominal exam worsened. In the operating room they discovered a retroperitoneum that was diffulsely petichial and ecchymotic, with significant retroperitoneal edema and bowel edema. the appendages eppiplocae were hemorrhagic. There was pathc purpuring darkening concerning for ischemia of the cecum. The patient underwent a right colectomy, with an ileosotomy and right transverse colon mucous fistula. the patient could not be closed and the abdomen was left open. The patient was sent back to the intensive care unit, intubated. The infectious disease and rheumatology services were consulted and were intimately involved, and the results of the studies they suggested are listed above. The patients hemodynamic status improved, although the patient remained tachycardic and intermittently febrile, although cultures remained negative and the patient remained on broad spectrum antibiotics. She continued to recieve fluid boluses for decreased urine output on post operative days 3 and 1. TPN was started on post operative days 4 and 2. On post operative days 5 and 3, the patient had an echocardiogram to rule out an embolic source for possible mesenteric ischemia, and a HIT panel was sent for decreased platelets. On post operative days 6 and 4 the patient was brought back to the operating room for closure of her abdomen. A vent wean was started on post operative days 7,5,and 1 and continued until postoperative days 10/8/4 when she was successfully extubated. Her NG tube was also discontinued. She was transferred to the floor and on postoperative days 12/10/6 the patient was started on sips. She was seen by physical therapy, as well as continued on her TPN. Her TPN was discontinued on the following day, while the patient started taking clears. The patient was also seen by enterostomy therapy to help in teaching. She remained hemodynamically stable, was passing stool through her ostomy bag, had a well healing incision, and was tolerating a regular diet, and was ready for discharge on post operative day 14/12/8, with a 1 week course of cipro flagyl to be completed per the Infectious disease team. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Cecitis Ischemic Right colon Acute appendicitis Status post Exploratory laparotomy with right colectomy Status post right appendectomy Respiratory failure requiring intubation Discharge Condition: Good Discharge Instructions: Please [**Name8 (MD) 138**] MD if you have spiking fevers, inability to tolerate food, intractable nausea or vomiting, increasing abdominal pain, bleeding, drainage or redness around your incision. You should change your ostomy bag as needed with the help of a visiting nurse. You should resume taking any medications you were taking prior to this admission You should not drive when you are taking narcotic medications for pain. No heavy lifting of objects greater than 10 pounds for the next 6 weeks. You should drink at least 1 liter of fluid day, and more if possible, because your ostomy will be putting a lot of fluid out. Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in [**12-1**] weeks. You can call his office for an appointment. You should follow up with your primary care physician over the next week to let him know about your situation and also to monitor your electrolytes.

[ "287.5", "557.0", "540.0", "276.5", "518.5", "427.89" ]

icd9cm

[ [ [] ] ]

[ "96.59", "54.63", "54.21", "54.91", "47.09", "99.04", "45.73", "46.21", "99.15" ]

icd9pcs

[ [ [] ] ]

10664, 10723

6744, 10012

304, 424

10943, 10949

2676, 6721

11631, 11906

1673, 1742

10067, 10641

10744, 10922

10038, 10044

10973, 11608

1757, 2657

250, 266

452, 1331

1353, 1523

1539, 1657

56,361

127,590

35897

Discharge summary

report

Admission Date: [**2163-12-28**] Discharge Date: [**2164-1-2**] Date of Birth: [**2114-11-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: [**2163-12-28**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to diagonal artery, with vein grafts to left anterior descending, first obtuse marginal and second obtuse marginal arteries. History of Present Illness: This is a 49 year old male with new onset chest tightness with minimal exertion. Subsequent stress test was positive for ischemia and cardiac catheterization revealed severe two vessel coronary artery disease. He was evaluated and cleared to proceed with surgical revascularization. Past Medical History: Coronary Artery Disease Dyslipidemia History of Kidney Stones, s/p Lithotripsy Social History: Denies tobacco. Occasional ETOH. No history of alcohol abuse. Employed as a machinist. Lives alone. Family History: Father with MI, s/p CABG in his 40's. Physical Exam: 146/77 59 5'3" 177lbs General: no acute distress HEENT: unremarkable Neck: supple with full range of motion Chest: lungs clear bilaterally Heart: RRR, normal S1S2. Abdomen: soft and nontender without rebound or guarding Extremities: warm and well perfused Discharge Exam: VS: 98.9, 125/84, 77SR, 20 94%RA Gen: NAD, WG, WN HEENT: unremarkable Chest: LCTAB CV: RRR, no murmur or rub Abd: +BS, soft, non-tender, non-distended Ext: warm, trace edema Incisions: sternotomy- c/d/i without erythema or drainage, healing nicely, EVH- c/d/i Pertinent Results: [**2163-12-31**] 05:12AM BLOOD WBC-9.5 RBC-3.51* Hgb-10.5* Hct-28.7* MCV-82 MCH-29.8 MCHC-36.5* RDW-14.4 Plt Ct-178 [**2163-12-30**] 06:30AM BLOOD WBC-12.4* RBC-3.80* Hgb-11.3* Hct-31.4* MCV-83 MCH-29.6 MCHC-35.9* RDW-14.7 Plt Ct-184 [**2163-12-28**] 03:26PM BLOOD WBC-7.0 RBC-3.28*# Hgb-9.9*# Hct-26.4*# MCV-81* MCH-30.1 MCHC-37.4* RDW-14.0 Plt Ct-165 [**2163-12-31**] 05:12AM BLOOD UreaN-17 Creat-1.2 K-4.4 [**2163-12-30**] 03:29PM BLOOD UreaN-18 Creat-1.3* K-4.3 [**2163-12-30**] 06:30AM BLOOD Glucose-138* UreaN-16 Creat-1.6* Na-139 K-4.6 Cl-104 HCO3-30 AnGap-10 [**2163-12-28**] 05:00PM BLOOD UreaN-15 Creat-1.0 Cl-113* HCO3-23 [**2163-12-30**] 06:30AM BLOOD Mg-2.0 [**2163-12-29**] 03:06AM BLOOD Mg-1.9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 81558**], [**Known firstname 5445**] [**Hospital1 18**] [**Numeric Identifier 81559**] (Complete) Done [**2163-12-28**] at 1:55:38 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2114-11-1**] Age (years): 49 M Hgt (in): 63 BP (mm Hg): 147/77 Wgt (lb): 177 HR (bpm): 70 BSA (m2): 1.84 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 786.05, 440.0 Test Information Date/Time: [**2163-12-28**] at 13:55 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW05-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: No MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. 1. Biventricular function is unchanged 2. Aorta appears intact post decannulation. 3. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2163-12-28**] 15:59 ?????? [**2157**] CareGroup IS. All rights reserved. Brief Hospital Course: Mr. [**Known lastname **] was admitted, taken directly to the operating room and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He was transfered to the telemetry floor where he continued to progress. Physical therapy was consulted to work on strength and conditioning. Chest tubes and pacing wires were discontinued without incident. By post-operative day 5 the patient was found suitable for discharge to home with VNA services. Medications on Admission: Atenolol 25 qd Simvastatin 40 qd Aspirin 81 qd Fish Oil MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary Artery Disease, s/p CABG Dyslipidemia Discharge Condition: Good Discharge Instructions: ) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-18**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**1-17**] weeks, call for appt Dr. [**Last Name (STitle) 11487**] in [**1-17**] weeks, call for appt Completed by:[**2164-1-2**]

[ "V13.01", "272.4", "411.1", "414.01", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "36.15", "38.93" ]

icd9pcs

[ [ [] ] ]

7572, 7623

5833, 6514

337, 568

7714, 7721

1725, 5810

8497, 8727

1115, 1154

6624, 7549

7644, 7693

6540, 6601

7745, 8474

1169, 1429

1445, 1706

282, 299

596, 880

902, 982

998, 1099

1,436

178,183

24343

Discharge summary

report

Admission Date: [**2156-4-20**] Discharge Date: [**2156-5-6**] Date of Birth: [**2110-1-10**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5341**] Chief Complaint: Elevated intracranial pressure Major Surgical or Invasive Procedure: VP shunt History of Present Illness: This is a 46 y/o M with h/o metastatic melanoma s/p C&D, radiation and on [**Doctor Last Name 1819**] study of DTIC plus or minus sorafenib who was admitted electively for a VPS placement ([**2156-4-20**]). Procedure went well without complications. About 48 hours later, patient decompensated and the CT scan showed multiple areas of hemorrahge thorughout the brain. After Family meeting with Hem onc, neurosurgery and Neurology it was decided that given his youth they will press ahead with radiation if his clinical status and CT scans were stable. If CT scans showed significant hemorrhage, further aggressive treatment would be stopped. Patient was trasfered to NSICU on [**4-23**] for IV BP management. He developed SIADH. On [**4-24**] patient was only arousable to sternal rub per neurology notes. It was felt to be a result of peak edema from his bleed on [**4-21**]. Today, apparently patient has been more arousable to voice, talking and moving all 4 extremities. Patient transfered to [**Hospital Unit Name 26481**] for brain radiation in the AM. Plan for 10 sessions. Past Medical History: Oncologic History Melanoma [**Initials (NamePattern4) 10834**] [**Last Name (NamePattern4) **] level dx in [**2142**] - right lateral thigh. [**5-5**] Resection of inguinal mass that showed evidence of melanoma and positive lymph nodes and extracapillary extention. Bronchoscopy with biopsy + for metastatic melanoma on lung nodules. [**8-4**]: Started Chemotherapy with clinical trial C1 DTIC +/- SORAFENIB [**1-/2156**]: visual disturbances. MRI right occipital small lesion. [**2-/2156**]: Prior to Cyberknife procedure- b imaging showed bleed 3x3 cm. Resected on [**2-12**]/[**2156**]. [**3-8**]: cyberknife to resection cavity. [**2156-4-14**]: Headaches, N/V x 2 3 days. LP OP of 32 cm H2o, removed 30 cc. cytology confirmed presence of malignant cell. Past Medical History: Metastatic Melanoma as above Left shoulder surgery Arthoscopic surgery on left knee Social History: From past d/c summary: "He has a bachelor's degree. He is a systems administrator. He is single. He has smoked on and off for 20 years, about two to five cigarettes a day. He drinks about anywhere from zero to five drinks a week, and he denies any recreational drug use. Strong family support." Family History: From past d/c summary: "His mother is alive at 86 with breast cancer. His father died at 82 of perhaps a melanoma related death although this is uncertain, and his brother is 58 and does not have any medical conditions that he is aware of." Physical Exam: On arrival to [**Hospital Unit Name 153**]: T 98 BP 150 /70 HR 102 RR 17 Sats 97 % RA General: Patient in non apparent distress, somnolent but arousable. HEENT: No JVD, no lymphadenopathy, scalp wound covered- clean PEERLA CV: RRR, s1-s2 normal, tachycardic. Lungs: Clear to auscultation bilaterally Abdomen: BS+, soft, non tender, non distended. Surgical wound clean Extremities: No peripheral edema, distal pulses strong bilaterally. Neuro: Alert, oriented to name, no to place or date. Moving 4 extremities spontaneously. Cranial nerves- grossly intact, mouth and tongue in midline. Face symmetric, no dysarthria. Bilaterall upgoing bilaterally, DTR +/++++ Pertinent Results: [**2156-4-20**] CT head: 1. Interval ventriculoperitoneal shunt catheter placement. 2. Interval subarachnoid hemorrhage, as described. While this subarachnoid hemorrhage likely relates to that procedure, hemorrhage related to underlying leptomeningeal disease in this melanoma patient cannot be entirely excluded. Close followup is recommended. . [**2156-4-22**] CT head: IMPRESSION: Interval development of several parenchymal hemorrhages compared to two days previous. Subarachnoid hemorrhage unchanged. There is interval development of mass effect on the right lateral ventricle. . [**4-23**], [**4-24**], [**4-26**], [**4-27**], [**5-1**] CT head Scans: No significant interval change. . [**2156-4-25**]: Chest X ray INDICATION: Question aspiration event. Heart size remains normal. There is stable mediastinal lymphadenopathy in the aorticopulmonary window. The lungs demonstrate no focal areas of consolidation to suggest the presence of aspiration or evolving pneumonia. . [**2156-4-28**] ECHO: Mild left ventricular cavity enlargement with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. . [**2156-5-2**] RUQ US: Limited right upper quadrant study. No evidence of stones, gallbladder wall thickening, or pericholecystic fluid. No evidence of acute cholecystitis. . [**4-24**], [**4-25**], [**4-26**], [**4-30**], [**5-1**], [**5-2**], [**5-4**] CXR: evidence of atalectasis, no consolidations. . [**2156-5-3**] CT L spine: 1. No CT evidence of osseous or epidural metastatic disease. Please refer to the follow-up lumbar spine MRI for evaluation of intrathecal disease. 2. L5/S1: Degenerative disk disease and endplate changes, with disk bulge, endplate and facet joint osteophytes resulting in neural foraminal stenosis and possible exiting nerve root impingement. 3. Possible free fluid in the pelvis. . [**2156-5-3**] MRI L spine: 1. Diffuse thickening of the cauda equina from L1 through S1 levels which enhances following gadolinium administration and is highly suggestive of metastatic disease involving the entire cauda equina. There is also thickening of the nerve roots individually seen within the thecal sac. 2. Degenerative changes seen at L5-S1 level with small central disc protrusion and moderate stenosis of the foramina. 3. Large degenerative Schmorl's node involving the superior endplate of L1. 4. Increased T2 signal seen on sagittal images involving the lower thoracic cord. Correlation with gadolinium-enhanced MRI of the thoracic spine would be recommended. 5. The findings are consistent with diffuse metastatic disease most likely from metastatic melanoma involving the cauda equina. Correlation with CSF findings would be recommended with follow-up. Brief Hospital Course: Mr. [**Known lastname 61665**] was admitted [**2156-4-11**] for elective placement of VP shunt to relieve elevated intracranial pressure caused by metastatic melanoma and it's treatment. Following placement of the shunt, he developed multiple areas of intracranial hemorrhage with resulting elevation of his intracranial pressure. He was started on Mannitol and dexamethasone, and transferred to the [**Hospital Unit Name 153**] to receive palliative whole brain radiation. Initially his [**Hospital Unit Name **] status was alert, agitated, disoriented at times. Shortly after transfer to the [**Hospital Unit Name 153**] he became less responsive. He was also spiking fevers. Given concern for possible shunt infection he was treated empirically with vancomycin. He continued to spike through this, and was started on ceftriaxone as well for broader gram negative and anaerobe coverage. He began whole brain XRT, and tolerated 5 treatments well. However, during this time he had an episode of desaturation, hypotension, fever, and tachycardia. He was intubated for airway protection, and his antibiotic coverage broadened with flagyl as he was thought to be septic, with possible aspiration pneumonia. His antibiotics were subsequently changed to vanco and zosyn to provide broader coverage including psudomonas. He was successfully extubated after 48 hours. Throughout this he was pan-cultured multiple times, with no clear source of infection identified. He did have sparse growth of coag + staph on one sputum culture, but no other positive cultures. He was subsequently afebrile. . Shortly after extubation, Mr. [**Known lastname 61665**] [**Last Name (Titles) **] status improved dramatically: he was much more alert, answering questions, but still confused. Unfortunately his neurological exam also began to change around this time. He was no longer moving his lower extremities, with no reflexes, and no withdrawal to pain. He also had diminished rectal tone. Emergent CT was unrevealing, so an MRI was performed. This showed extensive tumor involvement of his entire cauda equina. The case was discussed with neuro-oncology, oncology, neuro, and it was felt that there was no possible treatment. A family meeting was held with Mr. [**Known lastname 61665**] Oncology and ICU doctors, his brother, and some close family friends to discuss his poor prognosis, and clarify goals of care. It was decided to change his code status to DNR/DNI. . He was tranfer to the floor with the goal of weanign fo his manitol to attempt to send him home with hospice or to a hospice facility. On the floor, patient became more somnolent and also his respiratory stauts became very tenous. He started having increased work of brathing, chest x ray show a new left lower lobe consolidation that was concerning for aspiration. After talking with family members, they re-confirm goals of care and patient's goal of care was directed towards confort. Morphine dripped was started for air hunger and patient past away peacefully with family by his side. is to continue current medical treatments at this time, with the goal of comfort. He was then transferred to the oncologic service for weaning of his mannitol to attempt to send him home with hospice or to a hospice facility. Medications on Admission: Keppra 1000 [**Hospital1 **], Sorafenib 200 [**Hospital1 **], DTIC every 3 weeks and ativan PRN. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2156-5-11**]

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icd9cm

[ [ [] ] ]

[ "96.04", "92.29", "96.71", "38.93", "02.34" ]

icd9pcs

[ [ [] ] ]

9855, 9864

6411, 9679

346, 357

9912, 9918

3630, 3646

9970, 10005

2687, 2930

9826, 9832

9885, 9891

9705, 9803

9942, 9947

2945, 3611

276, 308

385, 1469

4002, 6388

2273, 2358

2374, 2671

22,359

158,006

21840

Discharge summary

report

Admission Date: [**2101-10-27**] Discharge Date: [**2101-11-3**] Date of Birth: [**2026-5-6**] Sex: F Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Location (un) 1279**] Chief Complaint: pre-chemo evaluation CAD Major Surgical or Invasive Procedure: left heart cath History of Present Illness: This 75 year old woman was recently diagnosed with right breast cancer (stage 2 invasive ductal carcinoma) likely metastatic given positive CT finding. There are plans for chemotherapy, and she was referred for cardiology evaluation prior to beginning treatment. She was found to have a positive stress test with Pt is a poor historian, and her daughter reports that her mother is short of breath all the time. With walking to the bathroom or getting dressed, she easily is dyspneic. Her daughter believes this has been progressive over the years. The patient also does admit to prior episodes of chest pressure. She sleeps with three pillows and often will get up to sleep in the recliner d/t PND. Pt denies claudication,lightheadedness, but has + Bilateral leg edema, left > right. Past Medical History: Newly diagnosed stage II right sided breast cancer-invasive ductal carcinoma Arthritis of lower back/Low back pain Hyperlipidemia Hypertension Depression Paranoid schizophrenia diagnosed approximately 20 years ago, not under psychiatric care CHF Total Hysterectomy in her early 30's for heavy bleeding and pain Bilateral knee replacements Gout Social History: Patient is widowed and has six children. She currently lives with her daughter [**Name (NI) 4248**]. She usually lives with different child at different time period so her medical care is scattered. Pt walks with a cane. Physical Exam: T96.0 BP99/49(85-109/49-60) HR75(74-84) RR18 O2sat95%RA GEN: elderly female lying in bed, breathing comfortably in room air, got frustrated when not able to answer questions. HEENT: PERRL, EOMI, sclera anicteric, OP clear Neck: supple, no JVD (though difficult to estimate given her neck size) CV: reg rate, s1 s2, no m/r/g, nondisplaced PMI Lung: Not able to exam given pt just had cath need to lie on her back, CTA from front. Breast: rt breast had well healed bx scar with a palpable 3x3cm non mobile mass at 6 oclock. No palpable axillary lymph nodes bilaterally. Abd: soft, obese, NT/ND +bs, no organmegaly. Ext: LE slightly erythematous, +pitting edema bilat, +DP pulses. WWP. Full strength on both UE and LE. Neuro: CNII-XII intact, anxious, poor historian. Pertinent Results: Cath: [**2101-10-27**] 1. Two vessel coronary artery disease. 2. Mild diastolic ventricular dysfunction. COMMENTS: 1. Coronary angiography of this codominant circulation revealed severe 2 vessel coronary artery disease. The LMCA was very short and instantly gave rise to the LAD, the LCX, and a large RI. The LAD had a 60% hazy lesion at its ostium. The LCX had serial 90% lesions at the ostium and in the proximal vessel. The RCA was a relatively small vessel with a 20% ostial lesion. 2. Resting hemodynamics revealed only mildly elevated right and left heart filling pressures with an LVEDP of 12 mmHg, a mean PCW pressure of 15 mmHg, and a mean RA pressure of 9 mmHg. The cardiac output was borderline low at 4.2 L/min. No gradient across the aortic valve was detected. 3. Left ventriculography demonstrated preserved left ventricular systolic wall motion with a calculated LVEF of 64%. No significant mitral regurgitation was seen. CAth: [**2101-10-28**] Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] of LCx with mild jailing of OM1 but normal flow. CAse complicated by failed Perclse device resulting in moderate size hematoma and hypotension (SBP 60 mm Hg) and bradycardia responive to IVF, atropine and brief infusion of dopamine. The patient left the lab with the arteriotomy site under control, with no evidence of active bleeding, asymptomatic except for nausea and stable vital signs. Left Foot XR - no evidence of inflammation, lytic lesion, joint effusion, or fracture. Femoral U/S - no pseudoaneurysm, AV fistula LABORTORY: Hct 36.3-->29.7 stable >24hrs Cr 0.8, 2.1, 2.2, 1.6 (b/l 1.2) TnT <0.01 FENa 1.7%, FeUrea 50% UA no casts Brief Hospital Course: 75 year-old woman recently dx with breast cancer undergoing cardiac eval prior to have chemo Rx found to have abnormal ETT. She underwent a left heart cath that found 2 vessel disease with 60% LAD and 90% LCx. She underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**] PCI of LCx however it was complicated by a failed Perclose device and she developed a significant groin hematoma with hypotension requiring dopamine and IVF and monitoring in the CCU. She was quickly weaned from dopamine and transferred back to the floor. Her Hct continued to slowly decrease however stabalized for >48hrs prior to discharge without further expansion of her hematoma. Groin u/s showed no pseudoaneurysm or AVF. She remained pain free with nml cardiac biomarkers. Her hospital course was also complicated by the development of atrial fibrillation with rapid ventricular response with rates in the 150's and worsening of her pulmonary edema. SHe had no prior history of atrial fibrillation and so was loaded on amiodarone without TTE or anticoagulation. She underwent successful chemical cardioversion in less than 24 hours and maintained sinus rhythm with PACs. She is to be continued on amiodarone and lopressor. She will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as the ordering attending. She does have relatively severe diastolic heart failure and received IV hydration for cath and BP management. She was effectively controlled with diuresis and chemical cardioversion of her single episode of atrial fibrillation. She will require her twice daily lasix and daily potassium replacement. 4 days post cath, she developed acute renal failure with a peak creatinine of 2.2. FENa and FEUrea supported an intrinsic vs. obstructive pattern. Her creatinine was decreasing on day of admit. She was never oliguric. The etiology is likely secondary to contrast nephrotoxicity. Her baseline creatinine is 1.2. She will need qod blood draws to monitor her creatinine, potssium, and hematocrit. Antibiotics were initiated for her cough with a faint infiltrate in the LLL. She remained afebrile without a leukocytosis. Becasue she will be starting chemotherapy for her metastatic breast CA, we started levoquin 250mg qod (renal dosing) for a total of 10 days of treatment (last day [**2101-11-8**]). Medications on Admission: Klor Con 10meq [**Hospital1 **] Ziprexa 5mg [**Hospital1 **] Lisinopril 10mg daily Toprol 100mg daily Depakote 250mg every morning, 500mg every evening Zocor 10mg qhs Furosemide 80mg [**Hospital1 **] Celebrex 200mg daily Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: CAD paranoid schizophrenia hypertension hyperlipidemia breast cancer CHF gout Discharge Condition: stable Discharge Instructions: Continue using your [**Doctor Last Name **] of Hearts Monitoring as instructed. Please go to all of your scheduled doctors' appts. Please call your doctor or 911 for chest pain, shortness of breath, abnormal bleeding or any concerning symptoms. Avoid NSAIDs (ibuprofen, motrin, advil) for treatement of pain. this can damage the kidneys and may worsen your heart failure. Followup Instructions: Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 3670**]: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2101-11-1**] 2:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 17688**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2101-11-4**] 1:00 Provider: [**Name10 (NameIs) 5338**] [**Name8 (MD) 5339**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2101-11-4**] 2:00 Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] at [**Company 191**], phone: [**Telephone/Fax (1) 250**], to make an appointment within 1 week of your discharge from the rehab hospital. Contact your cardiologist within 1 week of your hospital discharge. If you don't have a cardiologist, contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone [**Telephone/Fax (1) 3512**] to schdule an appointment within 1 week of your rehab hosp discharge.

[ "311", "272.4", "274.9", "174.8", "414.01", "427.31", "V43.65", "295.62", "401.9", "998.12", "584.9", "428.31" ]

icd9cm

[ [ [] ] ]

[ "88.53", "36.01", "36.07", "99.20", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

7014, 7084

4294, 6742

357, 374

7206, 7214

2600, 4271

7636, 8733

7105, 7185

6768, 6991

7238, 7613

1814, 2581

293, 319

402, 1190

1212, 1560

1576, 1799

6,811

114,210

26365

Discharge summary

report

Admission Date: [**2165-11-5**] Discharge Date: [**2165-11-10**] Date of Birth: [**2098-11-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: EGD [**2165-11-6**]: no complications. History of Present Illness: This is a 67 y.o. gentleman with h/o Atrial Fibrillation s/p elective ventral hernia repair with mesh placement on [**2165-10-30**] at [**Hospital6 33**] now transferred with upper GI Bleed. He did well post-op but had mild heartburn without nausea or ABD pain. On POD #3 he was started on heparin for his Afib and had melanotic stools and small volume hemoptysis (less than a cup). There was concern for PE leading to hemoptysis and a CT Chest was obtained which although negative for PE, demonstrated an intraluminal mass in the distal esophagus. On [**2165-11-5**] he had melanotic stools and his Hct dropped from 37 to 33. An EGD was performed demonstating a large clot at the GE junction with question of intramural mass. He was transferred to [**Hospital1 18**] for further evaluation and endoscopic ultrasound. ROS: POSITIVE: NSAID use at home. NEGATIVE: no prior colonoscopy, black stools, bloody stools, tums or pepto bismol use, eating spinach, fevers, dysphagia, odynophagia, wt change, chest pain, dyspnea, palpitations, edema, weakness, numbness. Past Medical History: Chronic Atrial Fibrillation s/p attempted cardioversion x 2. Gout Benign Prostatic Hypertrophy Chronic Ankle Edema Hypertension Obesity Left Total Hip Repair Laryngeal Polyps removed in [**2149**] with subsequent tracheostomy for 1 month s/p Ventral hernia repair [**2165-10-30**] Social History: Lives in [**Location **], MA. Quit smoking 15 years ago. 15 py history. EtOH <2x/week. Worked for the City of [**Hospital1 8**]. No exposures. Now retired and runs a charter fishing boat business. Family History: No GI disorders Sister: CNS Malignancy with resutling cervical cord compression and paraplegia Father: HTN Physical Exam: Temp:99.9 BP:140/85, HR:120 irreg irreg RR:16 O2:96% 2L Wt:132 kg Ht:5'8" Gen: NAD, A/O x3 HEENT: PEARLA. EOMI. OP: dry membranes. No LAD. Right ear with 1x1 cm lesion on pinna, well circumscibed. CV: irreg irreg, tachy, No M Pulm: CTA b/l ABD: Horizontal surgical incision with staples in place c/d/i. JP Drain with serosanginous fluid, c/d/i. Non-TTP. Soft. Ext: Trace brawny edema b/l. 1+DP/PT b/l Neuro: Motor [**4-4**] at all flex/ex. Sensation: GI to LT. CN II-XII GI. Rectal: Guaiac + Brown Stool. No hemorrhoids Pertinent Results: Ventral hernia tissue: Fibroconnective and Fibroadipose Tissue with Non-specific Degenerative Changes [**2165-11-5**] KUB: Illeus. Improved compared to prior [**2165-11-5**]: Cardiomegaly. No infiltrates/effusions [**2165-11-4**]: CT Chest: No PE. Moderate left-sided effusion and left basilar atelectasis. 5.5 maximal diameter oval low attenuation structure lateral to the distal esophagus which may represent a diverticulum or mass. The structure does not fill with oral or IV contrast. [**2165-11-5**] 08:23PM GLUCOSE-107* UREA N-19 CREAT-0.9 SODIUM-147* POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-28 ANION GAP-13 147 109 19 -------------<107 3.1 28 0.9 ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-169 ALK PHOS-45 AMYLASE-14 TOT BILI-0.5 LIPASE-17 WBC-9.0 RBC-3.51* HGB-11.2* HCT-31.3* MCV-89 MCH-31.8 MCHC-35.6* RDW-14.2 PLT COUNT-194 Brief Hospital Course: 67 year old male with atrial fibrillation. He was on his post-operative day #8 post ventral hernia repair complicated by upper GI Bleed after starting heparin and found to have question of a mass at GE Junction. 1. Question of Mass at GE Junction: On CT a 5.5 cm low attenuation mass lateral to distal esophagus was seen which may represent a diverticulum or mass. GI performed EGD in MICU on [**11-7**] that showed esophagitis and question of mild bulging at distal esophagus. EUS scheduled as an outpatient for further evaluation of the mass . 2. Recent GI bleed: Patient found to have melanotic stool after being started on heparin post-op for anti-coagulation for Afib. EGD showed clot at GE junction initially which was likely source of bleed. A later EGD did not show active bleed. He remained hemodynamically stable. . 3. Atrial fibrillation: He is not being anti-coagulated secondary to recent GI bleed. Patient was discharged on home regimen of metoprolol and nifedepine . 4. HTN: Patient is on 5 anti-hypertensive agents at home. SBPs elevated at 150-170. He was restarted on PO Metoprolol, ACE-I and nifedipine in house. Further blood presssure management is deferred to outpatient physician. [**Name10 (NameIs) **] lasix had been discontinued because he was having diarrhea . 5. Left pleural effusion on CT: patient's o2 sats are stable. This is likely from congestive heart failure. Patient refuse to consider thoracentesis . 6. Post-op from ventral hernia repair Medicine team spoke with Dr. [**First Name (STitle) **] at [**Hospital6 33**] ([**Telephone/Fax (1) 57700**]). Patient will follow up with Dr. [**First Name (STitle) **] on discharge. 7. infection: Patient had blood culture growing [**12-4**] GNR on the day of discharge. Patient have been informed that his blood culture is positive. However, he was adamant about leaving the hospital despite knowing potential risk. He had been advised to finish all his antibiotic and closely follow up with his PCP. [**Name10 (NameIs) 65228**] blood culture was sent and he was advised to follow up with his PCP for that. He also developed UTI and was started on ciprofloxacin. Medications on Admission: Meds on transfer: Protonix 40 daily, Heparin SC, Kcl, Tylenol, lopressor 5 IV q6, Phenergan, Lasix prn, Ativan prn, diltiazem prn, percocet. Meds at home: Metoprolol daily, Lisinopril 40 daily, Allopurinol 300 daily, coumadin 6 daily, lasix 20 daily, dyazide 1 daily, Doxazosin 4 daily, Nifedical XL 60 daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. Disp:*33 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 days. Disp:*26 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Esophageal Mass UGI bleed Atrial Fibrillation Discharge Condition: Stable with no further episodes of bleeding and stable hematocrit. Discharge Instructions: Please take your medications as prescribed. . Please do not take your coumadin until after your biopsy on [**11-19**]. . You have been informed that your blood culture is positive. You have also been inform that this is potentially dangerous and that you need to stay until we have another [**Month/Year (2) **] culture. However, after understanding your risk, you have chosen to leave the hospital. Please be vigilent in monitoring your own symptoms. If you have fever, chills, more severe diarrhea, chest pain, shortness of breath, abdominal pain, cannot keep up with oral intake, dizziness or any concerns at all, please return to the hospital. . Your lasix has been discontinued since you are having diarrhea, your blood pressure is well controlled and your potassium is low. Please discuss with your doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 9533**] that. . Please finish all the antibiotics prescribed. Followup Instructions: You have an appointment for an endoscopic ultrasound (EUS) scheduled on [**2165-11-19**]. You should go to the information desk on the [**Location (un) 448**] of the [**Hospital Ward Name 1950**] building in [**Hospital Ward Name 516**] at 6:40 AM on [**2165-11-19**] to find out where you should go for your procedure. Please call [**Telephone/Fax (1) 65229**] with any questions or if you need to change your appointment. . You have an appointment with Dr. [**First Name (STitle) **] on [**2165-11-11**] at 2pm. You will have your staples removed at this appointment and your JP drain evaluated. . Please follow up withyour PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39411**], next week to check your potassium. Also follow up with him after [**11-19**] to discuss resuming your coumadin. You also need to recheck your urine after you finish your antibiotic to make sure that you cleared your infection. You should also ask your doctor regarding the pending blood culture. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2166-1-17**]

[ "560.1", "276.8", "511.9", "578.9", "274.9", "790.7", "E878.8", "997.4", "600.00", "427.31", "401.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

7171, 7177

3546, 5693

324, 365

7267, 7336

2677, 3523

8312, 9457

1999, 2109

6053, 7148

7198, 7246

5719, 5719

7360, 8289

2124, 2658

276, 286

393, 1460

1482, 1764

1780, 1983

5737, 6030

9,976

115,380

10359

Discharge summary

report

Admission Date: [**2199-8-4**] Discharge Date: [**2199-8-8**] Date of Birth: [**2126-2-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: nausea, vomitting, poor po intake x2-3 days Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: Mr. [**Known lastname **] is a 73 year old male with history of CAD s/p CABG, hypercholesterolemia, depression, GERD who presents with 2 days of nausea and vomiting. He had been in his usual state of health when he began to feel "bad", developed nausea and non-bilious, non-bloody emesis. He has been unable to take PO for the past two days which is in addition to his typical poor diet. He reported some right sided sharp chest pain during episodes of emesis as well as some LUQ pain with emesis as well. He had no chest pain aside from that which he experienced with wretching. He denies any subjective fevers, chills, cough. He has not had any diarrhea, last BM was normal and was 2-3 days PTA. Denies lightheadedness, dizziness. He has no dysuria and no change in urinary frequency. . On a usual day he eats toast and scrambled eggs for breakfast then he will have a frozen meal 4x/week. He often does not have much of an appetite and will often not eat anything after breakfast. He drinks 2 vodka drinks/night to help him sleep. He denies any history of alcohol withdrawal seizures or symptoms of any kind. . In the ED his vitals were T 101.6 rectally, HR 84, BP 137/58, RR 18, O2 sat 100% on 2L NC. Labs were remarkable for ARF (Cr 1.4), bicarb 8, lactate 2.8, and anion gap of 34. ABG 7.28/18/148/9. Breathalyzer negative for alcohol. Blood cultures were sent. He was given aspirin 325mg, zofran x1, tylenol, and 2L NS. CT Abd/Pelvis was negative for acute infection. Also seen by EP in ED, interrogated pacer showed normal pacemaker function. . On arrival to floor he denied chest pain, shortness of breath, abdominal pain, fevers, chills, lightheadedness or weakness. Past Medical History: 1. Coronary artery disease. The patient is status post coronary artery bypass graft one and a half years ago. 2. Hypercholesterolemia 3. Hypertension 4. Depression 5. GERD. 6. Chronic anemia with pancytopenia 7. EtOH abuse 8. History of asthma. 9. History of allergic rhinitis. 10. Status post pacemaker placement. 11. Status post tonsillectomy. Social History: The patient lives alone in [**Location 1268**]. Married, wife lives elsewhere. Smoked " a lot" from the ages of 20-31. History of chronic alcohol use, drinks 2 vodka drinks/night. No drug use. No history of EtOH withdrawal. Family History: mother and father died in their 80s of an unknown cancer Physical Exam: VS T 98.5, HR 76, BP 125/51, O2sat 99% RA, RR 21 Gen: Well appearing elderly male in NAD. Conversant. Asking for water. HEENT: dry MM, OP clear. PERRL. EOMI. Neck: No JVD, supple CV: Regular rhythm, nl s1 s2, no m/r/g appreciated Chest: Mild wheezing. Otherwise clear Abd: Soft, NT, moderately distended, +BS. No rebound or guarding. Ext: No edema, 1+ DP pulses Neuro: A&Ox3. Appropriate affect. Grossly normal strength and sensation. No asterixis. Rectal: Guaiac negative in ED. Pertinent Results: [**2199-8-4**] 09:54PM GLUCOSE-209* UREA N-28* CREAT-1.3* SODIUM-135 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16 [**2199-8-4**] 09:54PM CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-2.4 [**2199-8-4**] 03:36PM GLUCOSE-113* UREA N-26* CREAT-1.3* SODIUM-136 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-15* ANION GAP-24* [**2199-8-4**] 03:36PM LD(LDH)-135 [**2199-8-4**] 03:36PM cTropnT-0.02* [**2199-8-4**] 03:36PM CALCIUM-7.9* PHOSPHATE-3.4 MAGNESIUM-1.9 [**2199-8-4**] 03:36PM VIT B12-331 FOLATE-GREATER TH [**2199-8-4**] 03:36PM OSMOLAL-301 [**2199-8-4**] 03:36PM ASA-NEG [**2199-8-4**] 03:36PM WBC-5.6 RBC-2.84* HGB-9.5* HCT-28.0* MCV-99* MCH-33.5* MCHC-33.9 RDW-13.8 [**2199-8-4**] 03:36PM PLT COUNT-134* [**2199-8-4**] 11:48AM TYPE-ART PO2-148* PCO2-18* PH-7.28* TOTAL CO2-9* BASE XS--15 [**2199-8-4**] 11:13AM LACTATE-2.8* [**2199-8-4**] 09:36AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2199-8-4**] 09:36AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2199-8-4**] 09:36AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2199-8-4**] 09:36AM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE EPI-0 [**2199-8-4**] 09:00AM GLUCOSE-124* UREA N-26* CREAT-1.4* SODIUM-139 POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-8* ANION GAP-39* [**2199-8-4**] 09:00AM ALT(SGPT)-13 AST(SGOT)-35 CK(CPK)-51 ALK PHOS-122* AMYLASE-102* TOT BILI-1.1 [**2199-8-4**] 09:00AM LIPASE-16 [**2199-8-4**] 09:00AM cTropnT-0.01 [**2199-8-4**] 09:00AM CK-MB-NotDone proBNP-6659* [**2199-8-4**] 09:00AM ACETONE-LARGE [**2199-8-4**] 09:00AM ASA-NEG ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2199-8-4**] 09:00AM WBC-9.1 RBC-3.38* HGB-10.8* HCT-33.9* MCV-100*# MCH-32.1* MCHC-32.0 RDW-13.8 [**2199-8-4**] 09:00AM NEUTS-94.8* BANDS-0 LYMPHS-3.2* MONOS-1.8* EOS-0.2 BASOS-0 [**2199-8-4**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2199-8-4**] 09:00AM PLT SMR-NORMAL PLT COUNT-180 . CT abd [**8-4**]: Small bilateral pleural effusions and stable parenchymal calcifications which may reflect amiodarone usage. Cholelithiasis. Stable 1.3 cm left adrenal lesion statistically representing an adenoma. Stable 2.2 cm septated right renal cyst. Nodular liver reflecting underlying cirrhosis. . CXR [**8-4**]: Small right pleural effusion. No evidence of congestive heart failure. No focal infiltrates. There is a small right pleural effusion. There is no left pleural effusion. Old rib fractures of several right ribs are unchanged compared to [**2196-12-27**]. Brief Hospital Course: Hospital Course by Problem: . 1) Acidosis: The patient was found to have an anion gap metabolic acidosis with pH 7.28 in ED. Ketones were noted in his urine. Gap in ED was 34 prior to fluids, improved to 19 after 2L NS in ED. Delta delta is 22, so corrected bicarb is 30 - some component of metabolic alkalosis possibly from vomiting. Differential diagnosis for anion gap metabolic acidosis includes DM, alcohol, starvation - all of which are typically seen with ketones as in this patient. Lactic acidosis (also mildly present here) caused by circulatory/respiratory failure, sepsis, ischemic bowel, sz, liver failure - patient is hemodynamically stable so makes these unlikely. Ingestions also a possibility - urine and serum tox negative. Osmolar gap is 13, typically osmole gap > 10 indicative of ingestion. Likely a component of starvation ketosis/ alcoholic ketosis and lactic acidosis in setting of dehydration and renal failure. . Etiology was felt most likely [**12-28**] starvation ketosis (acute on chronic), with possibility of some component of ingestion. Pt was hydrated with 2L IVF in ED, then given additional 3L IVF (2L d5w + HCO3, 1L D5 NS) in MICU, with closure of GAP. ethylene glycol, methanol, isopropyl alcohol level were sent and were unremarkable. salicylates unremarkable. D lactate was not sent. . After being transferred form the MICU to the regular floor, the patient's electrolytes were followed and remained stable. . 2) EtOH abuse: The patient reports drinking two drinks each night. LFTs were within normal limits. A CT scan showed signs c/w likely cirrhosis. The patient was treated with CIWA scale for withdrawal symptoms (did not require any benzos), IV thiamine, and folic acid. B12, folate levels were normal. Coags unremarkable, albumin c/w poor nutritional status. The patient was seen by social work. He admitted to drinking more than he should, but was not interested in AA or other programs. He was given information on antabuse, which he will follow up with his PCP [**Name Initial (PRE) **]. He also consented to meals on wheels service, which will call him when he gets home for interview/set up, and his wife will help him with his food until that service begins. . 3) Nausea/Vomiting: The patient's nausea and vomitting quickly improved after admission, and may have been due to viral gastroenteritis or acidosis. He was given PO Zofran, which helped a lot, and he was eating well without nausea or vomitting prior to discharge. . 4) Cardiac: * Ischemia: CAD s/p CABG: Chest pain with wretching. The patient's cardiac enzymes were negative x3 and EKG not significantly changed from prior EKGs. On further interview, symptoms suggestive of GERD (typically occur with pepsi, [**Location (un) 2452**] juice, right side chest burning, never elicited by exertion). The patient was continued beta blocker and statin. He was continued on a PPI for GERD symptoms, and his chest pain resolved. * Rhythm: Seen by EP in ED, normal pacemaker function. Multiple polymorphic PVCs. The patient was moniroed on telemetry with no events. He was continued on his outpatient beta blocker. Because his pacemaker was interrogated during this admission, the is no need for follow up at device clinic next week. * Pump: Euvolemic on exam. . 5) Acute renal failure: The patient's ARF was likely related to dehydration, and quickly improved with rehydration (Cr 1.4-->0.9). . 6) Pancytopenia: On admission, the patient was 9.1>33.9<180 which steadily decreased to a low of 2.1>25.8<78 before starting to stabilize the day prior to discharge. His CBC on the day of discharge was 2.5>28.7<81. In [**Hospital1 34374**] records, the patient has had episodes of pancytopenia in past, thought to be [**12-28**] chronic alcohol use. He was last seen on heme onc at [**Hospital1 **] in [**2193**] when counts had recovered after stopping alcohol use. Talking to his PCP revealed that the patient's baseline chronically low with his last outpatient CBC being 3.3>29.1<132. He was referred to a hematologist at [**Hospital6 **] and scheduled for a bone marrow biopsy in [**7-1**] but never followed up. . The hematology-oncology team was consulted and performed a bone marrow biopsy prior to discharge. Results are pending. He will follow up with Dr. [**First Name (STitle) **] in hematology clinic on [**2199-8-16**] for the results. . 7) Hypertension: Well controlled, pt continue on home regimen of beta blocker. . 8) Asthma: The patient had mild wheezing on exam. A CXR showed only a small effusion. The patient was treated with nebulizers and inhalaers PRN. He was breathing comfortably on room air prior to discharge (o2 sat 97% on RA) with only occasional wheezes. . 9) Depression: The patient was continued on his home dose of zoloft. He was seen by social work, who also spoke with his wife who says that he has been depressed for some time now. He will follow up with his PCP. . 10) GERD: Continued on his outpatient PPI. . 11) FEN: The patient was fed a regular diet, and electrolytes were aggressively repleted to prevent against refeeding syndrome. As mentionned above, the patient will be set up with meals on wheels to help encourage better nutritional habits at home. . 12) PPx: The patient was on SC heparin for DVT prophylaxis. . 13) Code: He was full code during this admission. Medications on Admission: Medications: (List lost in ED. Confirmed with [**Location (un) 535**]) Lipitor 10 mg daily Vicodin 7.5/750 mg 1 tablet every 6 hours p.r.n. low back pain Multivitamins 1 tablet daily Zoloft 50 mg daily Prevacid 30 mg daily Metoprolol 25 mg b.i.d. (oer pharmacy daily dosing) Iron pills 324 mg daily Zyrtec 10 mg daily Folic acid Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every 6 hours as needed as needed for low back pain. 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 7. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every 8 hours as needed as needed for nausea for 7 days: If you continue to feel nauseated, please see your primary care doctor, Dr. [**Last Name (STitle) **]. . Disp:*5 Tablet, Rapid Dissolve(s)* Refills:*0* 11. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: anion metabolic acidosis pancytopenia Secondary: Coronary artery disease s/p CABG Status post pacemaker placement hyperlipidemia Hypertension Depression GERD EtOH abuse asthma Discharge Condition: vital signs stable, afebrile, eating, ambulating Discharge Instructions: Please take all of your medications as presribed. Return to the ED if you have chest pain, shortness of breath, fevers, chills, nausea, vomiting, or any other symptom that is of concern to you. Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 30623**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 30837**]) on Thursday [**2199-8-15**] at your original appointment time. Please follow up with Dr. [**First Name (STitle) **] at the hematology clinic on Friday [**2199-8-16**]. His office will call you with the exact time. If you do not hear from his office, you should call to find out the time of your appointment. ([**Telephone/Fax (1) 34375**] Completed by:[**2199-8-11**]

[ "284.1", "276.51", "493.90", "311", "272.4", "V45.81", "401.9", "530.81", "414.00", "584.9", "008.8", "V45.01", "276.2", "305.00" ]

icd9cm

[ [ [] ] ]

[ "41.31" ]

icd9pcs

[ [ [] ] ]

12951, 13008

6011, 6011

357, 378

13238, 13289

3326, 5988

13533, 14061

2743, 2801

11742, 12928

13029, 13217

11388, 11719

13313, 13510

2816, 3307

274, 319

6039, 11362

406, 2101

2123, 2482

2498, 2727

67,635

138,871

43435

Discharge summary

report

Admission Date: [**2103-9-18**] Discharge Date: [**2103-9-22**] Date of Birth: [**2043-7-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Traumatic fall down stairs. Major Surgical or Invasive Procedure: None History of Present Illness: Injuries identified: L frontal epidural hematoma Non-depressed L frontal bone fx L maxillary sinus fx C2 non-displaced lateral mass fx C5-C6 non-displaced transverse foramen fx's L supraorbital laceration T 12 compression fracture, right 11th rib and L1 to L4 right transverse process fractures. Past Medical History: HTN, Alcohol abuse Social History: Lives at home Family History: Non-contributory Pertinent Results: IMAGING: [**9-18**] CT Head: Enlargement of the ventricles is out of proportion to the size of the sulci. This may be seen in central atrophy or normal pressure hydrocephalus. [**9-18**] CTA Neck: No evidence of arterial dissection. Left thyroid nodule. [**9-18**] CT Face: Nondisplaced fx of left lateral mass of C2. Fx through left foramen transversarium of C5. ?fx through right foramen transversarium of C3. Nondisplaced left frontal bone fx involving the left orbital roof, with ?small extraconal hematoma. This fx also involves the anterior and posterior walls of the left frontal sinus, and it extends into the anterior left ethmoid sinus. Comminuted fxs of the posterior and lateral left maxillary sinus walls. Likely left zygomatic arch fx of uncertain chronicity. Left frontal epidural hematoma. [**9-18**] CT Torso: T12 compression fracture, right 11th rib and L1 to L4 right transverse process fractures. Small left renal cyst. [**9-19**] CT Head: Unchanged left epidural hematoma with stable mass effect. [**9-19**] MR [**Name13 (STitle) **]: Pending [**2103-9-18**] 10:18PM SODIUM-127* POTASSIUM-3.4 (at lowest, 125) [**2103-9-22**] Sodium 134 Brief Hospital Course: Seen by neurosurgery for L frontal epidural hematoma. On serial CTs, the bleed was stable, as was her neuro exam. On HD#2, she started manifesting laboratory evidence of SIADH, but was asymptomatic. A nephrology consult was obtained and she was treated until she resolved. Last sodium was 136. She is to be on a 1 liter fluid restriction and she is NOT to resume her HCTZ which is contraindicated. For her spine fractures, she was evaluated by the orthopedic spine team and was fitted for a [**Doctor Last Name **] brace, to be worn at all times while out of bed. She is to wear a soft collar for comfort for her neck fractures. She is discharged home after being deemed safe to ambulate with the [**Doctor Last Name **] brace. She has strict instructions to get her sodium checked on [**2103-9-25**], and to follow up with the spine surgeons in [**3-18**] weeks. Medications on Admission: Atenolol 50', Zanax 0.5'', Celebrex 40mg QHS, Trazadone 30 QHS. Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Traumatic fall Epidural hematoma, stable Facial fractures Lumbar compression fracture SIADH, resolved Discharge Condition: Stable Discharge Instructions: You must stop taking your hydrochlorthiazide. Wear your [**Doctor Last Name **] brace when out of bed or walking around. Call your primary care doctor or go to an emergency room if you have: * fever above 101F * loss of consciousness * nausea, vomiting, diarrhea that doesn't stop Use the soft collar for comfort for neck pain. No driving until you are off narcotic pain medication for 1 week. You must restrict your water intake to one liter per day. This is equal to about 20 ounces. Followup Instructions: Follow up in the orthopedic/spine clinic (Dr. [**Last Name (STitle) 1352**]) for your spine fractures in [**3-18**] weeks. The telephone number for appointments is [**Telephone/Fax (1) 1228**]. See your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**2103-9-25**] to have your sodium level checked. If your doctor has any questions, he/she can call the nephrologist Dr. [**Last Name (STitle) 4920**] ar [**Telephone/Fax (1) 3637**]. Completed by:[**2103-9-22**]

[ "805.2", "305.00", "805.05", "E880.9", "V85.0", "276.1", "V10.3", "805.02", "276.52", "873.42", "805.06", "401.9", "305.1", "801.26", "800.26", "805.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3000, 3006

1988, 2856

342, 349

3152, 3161

802, 822

3700, 4197

765, 783

2971, 2977

3027, 3131

2882, 2948

3185, 3677

275, 304

377, 675

1762, 1965

697, 718

734, 749

419

148,312

43632

Discharge summary

report

Admission Date: [**2113-6-11**] Discharge Date: [**2113-8-11**] Date of Birth: [**2054-1-15**] Sex: F Service: SURGERY Allergies: Anzemet / Latex Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain, low grade fever and vomiting Major Surgical or Invasive Procedure: 1. Total abdominal colectomy 2. Sternal marrow aspirate 3. Fluoroscopy for IVC filter placement 4. Inferior vena cava filter 5. Partial secondary closure of abdominal wound with VAC application 6. Tracheostomy 7. Ileostomy 8. Gastrojejunostomy tube placement History of Present Illness: 59-year-old woman with ALL who is receiving chemotherapy. She currently was at the nadir of her white count and she presented today to the emergency room with a white count of 0.1 and abdominal pain with altered mental status and hypotension. She was found to be in septic shock and was resuscitated. CT scan revealed pneumatosis of the colon, a small amount of free air and very extensive portal venous air throughout the liver. She received approximately 9 liters of crystalloid and pressors to reestablish perfusion and urine output in the ER. This was done over a period of approximately 45 minutes. She was given antibiotics in consultation with the bone marrow transplant service who follows her (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**] attending). After a discussion with the family, she was taken to the operating room for treatment of presumed dead bowel of unknown origin with progression to infarction and septic shock. Past Medical History: Vancomycin SENSITIVE enterococcus faecium bacteremia from port during induction chemotherapy [**1-/2113**] PCP [**Name Initial (PRE) 1064**] [**2-/2113**] - not confirmed by culture Hypothyroidism Hypertension Seasonal allergies s/p hysterectomy s/p appendectomy . OncHx: (From Prior Notes) ALL, Precursor B-phenotype (Induction with Hyper-CVAD [**2113-1-7**], Negative for [**Location (un) 5622**] Chromosome). Pt was in USOH until [**12-12**] [**2111**], when she had a cold with dry cough, fevers and chills, all improved by [**12-18**]. After a few days, pt had vomiting, abdominal pain, and fatigue increasing for about a week until [**12-28**], when the pt went to [**Hospital3 1443**] for the above symptoms. She was found to have an enlarged spleen and thrombocytopenia. Bone marrow biopsy was suggestive of pre-B ALL. She was discharged [**12-30**] in stable condition and followed up with Dr. [**First Name (STitle) 1557**] in clinic [**1-5**], and felt the biopsy should be repeated here to confirm the diagnosis and possibly begin treatment if positive for ALL. Social History: Unmarried, lives with her mother (85) and brother (64). Retired clerk for insurance company. Rare EtOH use, no smoking, no IVDU. Family History: Aunts and uncles with breast cancer and asbestos related lung cancer by report. Father with diabetes. Physical Exam: SBP low on 10 dopa/max levophed 63; SBP increased to 134 on dopa 20/max levophed- received 8+L fluid gen: ill appearing, intubated, facial erythema, no scleral icterus cv: tachycardic, no m/r appreciated lungs: occ wheeze on anterior ausculation; bilateral breath sounds noted abd: distended, tender to palp ext: no rashes [**2113-6-11**] pH 7.20 pCO2 48 pO2 223 HCO3 20 BaseXS -9 Pertinent Results: On admission: . [**6-11**] colon pathology: Ileo-total abdominal colectomy: Colon with extensive transmural ischemic type necrosis, extending to the distal resection margin. Ileum with patchy ischemic type necrosis, extended focally to the resection margin. . [**6-11**] CT head: IMPRESSION: 1. 4.2 x 3.5 cm calcified hyperdense mass within the right frontal lobe. Differential diagnosis includes calcified meningioma and, much less likely calcified cavernoma. MRI is recommended for further characterization. 2. No evidence of intracranial hemorrhage. . [**6-11**] CT chest/abd/pelvis: IMPRESSION: 1. Diffuse pneumatosis along the ascending, transverse, and descending colon with dilatation of the ascending and transverse colon, mucosal wall thickening, lack of enhancement, mesenteric and portal venous gas. These findings are consistent with ischemic bowel.The severe stranding around the cecum suggests that this may be perforated locally.There is also a questionable small focus of eccentric extraluminal air here 2. Free fluid within the abdominal cavity. 3. Basilar airspace consolidations in the dependent portions may represent atelectasis or aspiration pneumonia. 4. No evidence of PE. Dilated pulmonary artery suggestive of pulmonary hypertension. 5. Tiny cyst within the pancreatic tail, not fully characterized. 6. 2.2 x 2.2 cm soft tissue density mass in left anterior pelvic wall. 7. L1 compression fracture. . Brief Hospital Course: On arrival to the ED, she was confused, tachypneic, cyanotic in septic shock (WBC=0.1). At CT of the abdomen showed pneumatosis of colon with free air. She was immediately intubated; Levophed was started for her hypotension, and sent to the operating room. . She underwent emergent exploratory laparotomy on day of admission [**2113-6-11**]. Colonic necrosis from the cecum to upper rectum without perforation was discovered and Total abdominal colectomy and damage control packing of the abdomen was performed. . On [**2113-6-14**] she was taken back to the operating room for unpacking of the abdomen, Abdominal washout, ileostomy, and Gastrojejunostomy. . On [**2113-6-30**] she returned to the operating room due to abdominal wound dehiscence, prolonged respiratory failure, need for vascular access, and abdominal fat necrosis. She underwent exploratory laparotomy with incision and drainage and re closure of laparotomy incision, drainage of intraabdominal collection (most likely sterile fat necrosis), tracheostomy, and placement of right subclavian central venous catheter. Her open wound was managed by VAC therapy. . The patient's post-operative course was also complicated by the development of a gastrocutaneous fistula out of the wound bed, assumedly due to erosion of gastric wall by the G-J tube. This was initially managed by NPO and frequent VAC changes. As her wound began to granulate, we progressively sutured her wound closed. . NEURO: The patient's post-operative course was also complicated by profound upper and lower extremity weakness. The etiologies considered included critical illness myopathy, critical illness neuropathy vs. ?[**First Name9 (NamePattern2) 7816**] [**Location (un) **]. As part of her work-up for this, she underwent a lumbar puncture on [**7-19**], which was essentially negative. She was treated with a 5-day course of IVIG as empiric treatment for [**Month/Day (4) 7816**]-[**Location (un) **]. On the day of discharge she had made significant progress in regaining strength but had not returned to full-strength baseline. . CARDIOVASCULAR Due to anemia, she received several units of PRBCs over the course of her hospital stay. She was also started on erythropoietin in consultation with the heme/onc service. She did require repletion of her electrolytes intermittently during her hospital stay. Her most recent chemistry panel [**8-11**]: Glucose UreaN Creat Na K Cl HCO3 AnGap 143* 12 0.2* 138 3.8 98 32 12 PULMONARY As noted above, she suffered from prolonged respiratory failure and required tracheostomy placement. Her tracheostomy was removed and her incision site healed without complication. On the day of discharge she was >95% Sp02 on room air without respiratory symptoms. . GI As described above. She was started on tube feedings which she has tolerated and at approximately HD #55 she was started on an regular diet which she has tolerated quite well. Her tube feeds have been cycled; she will need to be on calorie counts once at rehab with decrease in cycle tube feeds with the goal of eventually having her on a regular diet with supplements as her nutritional support. . MUSCULOSKELETAL: Physical and Occupational therapy were consulted and have recommended acute rehab stay given her lengthy and complicated hospital course. . HEMATOLOGY/ONCOLOGY: On [**2113-7-24**] she underwent sternal aspirate by the Heme/Onc service which did NOT show evidence of leukemia: (CELLULAR BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS. THERE IS NO MORPHOLOGIC EVIDENCE OF LEUKEMIA). On discharge she was provided plans for follow-up with hematology/oncology. . ID She did have a urinary tract infection on [**7-21**] and was treated with Zosyn for 7 days once the sensitivities were back. Medications on Admission: Neupogen 480 mcg daily x 10 days Acyclovir 400 mg every 8 hours Hydralazine 25 mg every 6 hours Levothyroxine 75 mcg daily Bactrim DS every monday/wed/friday Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ML Injection QMOWEFR (Monday -Wednesday-Friday). 14. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): Applt to affected areas. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale: See Attached sliding scale. 18. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 19. magnesium sulfate replacement Sig: Four (4) GM once a day as needed for Mg <1.2. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Acute lymphoblastic leukemia 2. Pancolonic ishemia 3. Critical illness myopathy/neuropathy vs. [**Hospital1 7816**]-[**Location (un) **] Syndrome 4. Gastro-cutaneous fistula 5. Pancytopenia of malignancy 6. Hypothyroidism 7. Hypertension Discharge Condition: Good Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] in Surgery. Please call to make an appointment: [**Telephone/Fax (1) 6429**] 2. Please follow-up with Dr. [**First Name (STitle) 1557**] in Hematology/Oncology. Please call to make an appointment: [**Telephone/Fax (1) 3237**] Completed by:[**2113-8-11**]

[ "557.0", "359.81", "357.0", "V09.80", "204.00", "427.31", "288.03", "244.9", "567.21", "401.9", "038.3", "357.82", "567.82", "E933.1", "E879.9", "285.22", "518.81", "995.92", "569.81", "599.0", "998.32" ]

icd9cm

[ [ [] ] ]

[ "99.14", "54.91", "96.72", "96.6", "99.62", "38.7", "46.23", "44.32", "99.04", "38.93", "00.17", "99.05", "03.31", "31.1", "45.8", "54.12", "33.24", "41.31", "99.07" ]

icd9pcs

[ [ [] ] ]

10640, 10719

4827, 8637

320, 581

11004, 11011

3359, 3359

11034, 11347

2838, 2941

8848, 10617

10740, 10983

8663, 8823

2956, 3340

236, 282

609, 1576

3640, 4804

3373, 3631

1598, 2674

2690, 2822

28,505

141,976

32602

Discharge summary

report

Admission Date: [**2172-5-10**] Discharge Date: [**2172-6-30**] Date of Birth: [**2114-3-2**] Sex: M Service: MEDICINE Allergies: Haldol / Ativan Attending:[**First Name3 (LF) 338**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Paracentesis (diagnostic and therapeutic) Arterial Line Placement Central Venous Line Placement PICC Line Placement Intubation Mechanical Ventilation Bronchoscopy Endoscopy PICC line placement History of Present Illness: 58 y/o M with history of alcoholic cirrhosis (grade I varices on nadolol, recent GI bleed at [**Location (un) **], mutliple paracentesis, never had SBP) who presented with hepatic encephalopathy, developed hematemesis while on [**Doctor Last Name 3271**]-[**Doctor Last Name 679**], and transferred to ICU for further management. He initially presented with dyspnea for the past few days to weeks and altered mental status. No ligthheadedness, cough, fever. Complains of abdominal pain to palpation. Of note, the patient reports still drinking. He says his last drink was [**2172-5-6**]. In the ER, intial vitals 97.3, BP 110/50, 70, 18, 96% RA. he was given 2L NS, Kayexalate 30g PO, Lactulose 30mg PO, Levofloxacin 750mg IVx1 and flagyl 500mg IV x1 to treat hepatic encephalopathy and prophylaxis for SBP. He was empirically treated with ceftriaxone. Patient underwent a paracentesis on [**2172-5-11**] that revealed 134 WBC in ascitic fluid. In the evening of [**2172-5-11**] he vomited up about 50 cc of bright red blood. SBP was in the 130s then 110s, HR 70s. He briefly desated to 90% on NC and was put on face mask. Transferred to MICU for further management. Past Medical History: 1) COPD - not O2- or steroid-dependent 2) ETOH abuse - no h/o DT's, withdrawal symptoms, last drink 6 months ago per pt. 3) PVD s/p aortobifemoral bypass ~10 yrs ago 4) HTN 5) GERD 6) Pancreatic mass 7) Remote PUD 8) Anxiety d/o 9) Cirrhosis with PHTN s/p tap x1 10) DM2 Social History: Retired. Continues to drink 2 glasses/wine most days of the week. Smokes [**12-27**] ppd. Has a 80 pack year smoking history. No illicit substances. Used to work at a car dealership. Family History: Mother - PVD; Father - CVA; two daughters healthy; no known h/o liver disease or malignancy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2 BP: 114/78 P: 63 RR: 15 O2Sat: 100% On 2l. Gen: confused, jaundiced obese male HEENT: dry MM, scleral icterus NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: crackles at bases ABD: distended, typanetic, shifting dullness, tense EXT: 4+ edema SKIN: No lesions NEURO: confused, +flapping asterixis . MICU PHYSICAL EXAM ([**2172-5-24**]): Vitals: T: 95.9 BP: 126/60 P: 116 RR: 11 O2Sat: 97% on vent. Gen: intubated, sedated HEENT: ETT in place NECK: Supple, No LAD, No JVD CV: Tachy, regular, NL S1, S2. No murmurs, rubs or gallops LUNGS: course BS at bases, no bases ABD: distended, slighty tense, hyperactive BS EXT: 2+ edema NEURO: sedated . MICU PHYSICAL EXAM ([**2172-6-30**]): T 99.2, HR 96, BP 114/63, RR 20, O2 sat 98% on RA Gen: No acute distress, obese, oriented to self, not place or time HEENT: L eye dilated, +dobhoff CV: RRR, NL S1, S2. No murmurs, rubs or gallops LUNGS: Symmetric, coarse breath sounds anteriorly bilaterally ABD: Soft, non-tender, BS+, distended, + fluid wave, + bulging flanks Extremities: Warm and well perfused, 2+ edema in both upper and lower extremities, 1+ pulses in distal extremities Neurologic: AAO x 0-1, + asterixis Pertinent Results: ADMISSION LABS: ================ [**2172-5-10**] 02:05PM WBC-9.0 RBC-3.43* HGB-12.4* HCT-37.9* MCV-111* MCH-36.2* MCHC-32.7 RDW-18.8* [**2172-5-10**] 02:05PM NEUTS-67.4 LYMPHS-21.5 MONOS-8.6 EOS-1.5 BASOS-1.0 [**2172-5-10**] 02:05PM PLT COUNT-128* [**2172-5-10**] 02:05PM PT-20.3* PTT-44.4* INR(PT)-1.9* [**2172-5-10**] 02:05PM AMMONIA-159* [**2172-5-10**] 02:05PM CK-MB-5 cTropnT-0.04* [**2172-5-10**] 02:05PM ALT(SGPT)-300* AST(SGOT)-889* CK(CPK)-162 ALK PHOS-295* TOT BILI-14.8* [**2172-5-10**] 02:05PM GLUCOSE-80 UREA N-45* CREAT-3.2*# SODIUM-129* POTASSIUM-8.9* CHLORIDE-97 TOTAL CO2-20* ANION GAP-21* [**2172-5-10**] 02:16PM LACTATE-2.2* DISCHARGE LABS: [**2172-6-30**]: WBC 14.6, Hct 24.6, Plts 104 Calcium 8.8, Mg 1.7, Phos 3.8 Sodium 138, K 3.5, Cl 96, HCO3 23 BUN 10, Cr 0.8 INR 1.9 STUDIES: ========= ABDOMINAL U/S [**5-10**] IMPRESSION: 1. Limited evaluation of hepatic parenchyma with moderate ascites noted. Please note that diffuse and more advanced liver disease (i.e., hepatic fibrosis/cirrhosis) cannot be excluded on this study. 2. Limited Doppler evaluation of the liver with to-and-fro portal vein flow again suggestive of portal hypertension. ABDOMINAL XRAY [**5-13**] IMPRESSION: Multiple dilated loops of small bowel, concerning for obstruction. ABDOMINAL U/S [**5-18**] IMPRESSION: Moderate four-quadrant ascites. Right lower quadrant largest pocket marked for paracentesis to be performed by the clinical team. ABDOMINAL XRAY [**5-19**] IMPRESSION: Worsened appearance of small bowel obstruction. CT ABD/PELVIS [**5-20**] IMPRESSION: 1. Mildly dilated loops of small bowel which decompress in the distal ileum, without evidence of a discrete transition point. 2. New right greater than left small pleural effusions and adjacent atelectasis. RENAL U/S [**5-26**] IMPRESSION: No evidence of hydronephrosis bilaterally, as questioned. A small echogenic focus at the right interpolar region shows no shadowing, and may represent a small crystal or early atherosclerotic change within a renal artery branch. Large-volume ascites. CT CHEST/ABD/PELVIS [**5-26**] IMPRESSION: 1. Increased patchy opacities in the bilateral lungs with bibasilar consolidations concerning for multifocal pneumonia. 2. No evidence of obstruction. 3. Persistent ascites, unchanged. 4. Mediastinal lymphadenopathy as described above which may be reactive. TTE [**6-5**] The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2171-10-28**], the left ventricle now appears hyperdynamic. IMPRESSION: no obvious vegetations seen, but technically suboptimal study PORTABLE CXR [**2172-6-25**] Feeding tube and central venous catheter remain in place. Cardiomediastinal contours are unchanged. Widespread bilateral alveolar and interstitial opacities have slightly worsened in the interval and may reflect asymmetric pulmonary edema, with or without superimposed process such as infection or aspiration. UPPER ENDOSCOPY [**2172-5-13**]: Multiple Grade II varices were seen in the esophagus at the GE junction. There were stigmata of recent bleeding with some oozing of one varix. 4 bands were successfully placed. UPPER ENDOSCOPY [**2172-6-17**]: 3 cords of grade II varices were seen in the gastroesophageal junction. 3 bands were successfully placed. MICROBIOLOGY: ============== [**2172-5-25**] 4:04 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2172-5-25**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2172-5-27**]): OROPHARYNGEAL FLORA ABSENT. ENTEROBACTER CLOACAE. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S YEAST. MODERATE GROWTH. [**2172-6-22**] 6:30 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Preliminary): ENTEROBACTER CLOACAE. FINAL SENSITIVITIES. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2172-6-23**]): GRAM NEGATIVE ROD(S). Brief Hospital Course: 58 y.o. M with alcoholic cirrhosis s/p esophageal banding for variceal bleed, who presented with hepatic encephalopathy on [**2172-5-10**] requiring multiple ICU transfers for respiratory failure and intubation, likely secondary to aspiration events. Respiratory Failure / Aspiration Pneumonia: the patient had recurrent aspiration events (x2) which caused multifocal PNA and sepsis requiring broad spectrum abx (meropenem for ESBL enterobacter and empiric vancomycin). His PNA improved and superimposed pulmonary edema (as a result of fluid resuscitation) was diuresed off. His sepsis resolved w/ treatement of his pneumonia on both occasions and the patient required short courses of stress dose steroids in order to be weaned off of pressors. During his hospitalization the patient had a code blue called for respiratory code for both of his aspiration events, both requiring intubation. Disucssions were held with the family and the patient regarding tracheostomy which would not help prevent aspiration but would improve our management of likely future aspiration events; the patient and family decided to pursue tracheostomy. However, pt self-extubated on [**2172-6-22**] prior to procedure and subsequently was able to manage his secretions adequately. At the time of discharge he was maintaining oxygen saturations in the mid 90s on room air. GI Bleed: Secondary to variceal hemorrhage. The patient had EGD x 2 for variceal banding and following initial bleed the patient was very stable. He was transitioned from PPI gtt to [**Hospital1 **] IV dosing. He was transfused 1 U PRBC on [**2172-6-29**] for anemia to 22 which had gradually trended down from 26 several days earlier. Cirrhosis: Related to ETOH abuse. The patient was an active ETOH abuse prior to admission to the hospital so had not been a candidate for liver transplant. The patient underwent diuresis w/ lasix and 1 therapeutic paracentesis of 4L. He was continued on rifaximine and lactulose although the dose of the latter was decreased to maintain more regular dosing given concern for increasing tremor with skipped doses. His diuretics are currently being held and will need to be restarted as an outpatient. He continues to have a significant degree of hepatic encephalopathy complicated by ICU delerium which makes it difficult to maintain the security of lines and tube without restraints. He currently opens his eyes to voice and will follow simple commands but is oriented only x 1 with significant asterixis. He frequently requires restraints. He will follow up with the hepatology center for further management. Ileus: The patient was started on standing reglan, this was weaned off on [**2172-6-20**]. Thrombocytopenia: The patient was noted to have fluctuating platelet counts during his hospitalization. The nadir of his platelets was 44. The etiology was felt to be related to bone marrow suppression, his underlying liver disease, as well as related to his antibiotics (meropenem). It was felt to be less likely related to heparin given the time course. When the patient was restarted on meropenem for enterobacter bacteremia. His platelet count slowly trended down when meropenem was restarted. He will need close monitoring of his platelet count while at rehab. Bacteremia: Patient grew enterobacter sensitive to meropenem on [**6-22**] bcx from PICC. Brief vanco course given for GPC in [**6-23**] bcx from left IJ which returned with coag negative staph, likely contaminant. PICC and IJ were both removed, and new PICC placed on [**2172-6-26**]. To complete 14-day course of meropenem (last dose on [**7-6**]). As above, starting meropenem was again associated with a trending down of his platelet count. His platelets will need to be monitored closely while on this medication. Hypernatremia: Patient was noted to have elevated serum sodium secondary to decreased PO intake. This resolved with free water flushes per NGT. . Diabetes Mellitus: Controlled on NPH and humalog insulin sliding scale. FEN: The patient had pulled out feeding tubes (NGT x 1, dobhoff x 2) but dobhoff replaced without further incident once patient was placed in mitts and restraints. He will need to continue on tube feeds for nutrition with free water flushes for hypernatremia. Prophylaxis: Pneumoboots and SC heparin Code Status: Full Communication: Girlfriend [**Name (NI) 75994**],[**Name (NI) **] Phone: [**Telephone/Fax (1) 75995**] Medications on Admission: Albuterol as needed Advair 250mcg/50mcg twice daily Folic Acid 1mg daily Lasix 80mg daily Glimepiride 4mg daily Lantus 36units every morning Humalog sliding scale Nadolol 30mg daily Omeprazole 40mg daily Spironolactone 100mg daily Aspirin 81mg daily Benadryl 25mg daily Multivitamin Thiamine MEDICATIONS UPON TRANSFER TO ICU [**5-24**] Insulin SC Sliding Scale & Fixed Dose Lactulose 30-60 mL PO qid titrate to [**2-26**] BM/day Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob Ampicillin/Sulbactam 3gm IV q6h day 1=[**5-18**] Vancomycin 100mg IV q12 Multivitamins 1 TAB PO DAILY Octreotide Acetate 50 mcg/hr IV DRIP INFUSION Cyanocobalamin 100 mcg PO DAILY Ondansetron 4 mg IV Q8H:PRN nausea Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] Pentoxifylline 400 mg PO TID FoLIC Acid 1 mg PO DAILY Rifaximin 400 mg PO TID Thiamine 100 mg PO DAILY Furosemide 40mg daily Pantoprazole 40mg IV bid Spironolactone 100mg daily Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 3. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 5. Cyanocobalamin 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for rash. 7. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection TID (3 times a day). 9. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation. 10. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q6H (every 6 hours). 11. Meropenem 1 gram Recon Soln [**Hospital1 **]: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 6 days: to end on [**2172-7-6**]. 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Artificial Tears Ointment [**Date Range **]: One (1) application Ophthalmic once a day as needed for dry eyes: to both eyes. 14. Guaifenesin 100 mg/5 mL Syrup [**Date Range **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 15. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Date Range **]: Thirty (30) Units Subcutaneous twice a day. 16. Humalog 100 unit/mL Cartridge [**Date Range **]: One (1) Units Subcutaneous four times a day: 0-70 - 1 amp D50 71-150 - 0 units 151-200 4 Units 201-250 8 units 251-300 12 units 301-350 16 units 350-400 20 units. 17. Dextrose 50% 25 gm IV PRN glucose <70 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Hepatic encephalopathy Esophageal varices Aspiration pneumonia Enterobacter bacteremia Discharge Condition: Hemodynamically stable Discharge Instructions: You were admitted for treatment of hepatic encephalopathy. You had a episode of bloody vomiting and found to have esophageal varices which were banded. Your hospital course was complicated by two episodes of respiratory failure thought to be due to aspiration of secretions. You were treated for pneumonia. You are now successfully extubated and managing your secretions adequately. You do have an infection in your blood for which you will need to continue antibiotics. You will be transferred to a [**Hospital 65799**] Rehab center for further care. Please take all your medications as prescribed. Please keep all your follow up appointments as scheduled. Please seek immediate medical attention if you experience any fevers > 101.5 degrees, chest pain, difficulty breathing, worsening abdominal distension, abdominal pain, bloody emesis, black or bloody bowel movements, or any other concerning symptoms. Followup Instructions: Please follow up with your PCP after discharge from Rehab. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2172-8-19**] 3:30

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icd9cm

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icd9pcs

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119,849

52793

Discharge summary

report

Admission Date: [**2163-11-4**] Discharge Date: [**2163-11-17**] Date of Birth: [**2079-1-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol / Torsemide / Heparin Agents Attending:[**First Name3 (LF) 2763**] Chief Complaint: Bacteremia/ Bleeding from G tube site Major Surgical or Invasive Procedure: Endoscopy x3: Performed by Dr. [**Last Name (STitle) **] on [**2163-11-7**] and [**2163-11-8**] History of Present Illness: 84 year old male per omr with history of CAD s/p stenting, CHF (EF 55%), Afib, prior cardiac arrest and heart block s/p pacer/AICD placement, chronic trach, and recent MRSA bacteremia transitioned from vancomycin to daptomycin presenting from rehab facility with continued bacteremia and bleeding around G-tube site. . Briefly patient was doing well until [**6-/2162**] when he suffered a fall that caused multiple fractures. He was hospitalized and intubated and subsequently trached. He was transferred to rehab where he spent a good deal of time with multiple readmissions for various infections and chronic GI Bleeds. In [**2153-8-15**] was admitted to [**Hospital1 18**] for PNA and found to have MRSa bacteremia. Was dicharged on Vancomycin. Was readmitted later that month for a GI bleed. EGD/[**Last Name (un) **] was deferred [**2-16**] to family wishes and comorbidites. He was discharged again to [**Hospital 100**] Rehab. Surveilece cultures remained positive and he was readmitted for infectious work up. TTE, TEE and tagged WBC scan were all negative for ocult infectious source. On that admission he was diagnosed with concurrent Pseudomonas and Klebsiella UTI and treated with Meropenam. Given his persistent MRSA bacteremia he was switched from Vancomycin to daptomycin. . Over the last several days he has been febrile with intermittent AMS. Blood cultures are persistently positive. Per notes form his PCP and discussions with the family, he is being admitted for evaluation for ICD lead explantation and for managment of fevers. . With regards to the bleedign at the G-tube site, the nursing staff at the rehabilitation facility noted oozing of blood from around the G-tube site. There was no bleeding at the lumen of the site. The patient remained normotensive. He remained normal mental status. The G-tube was clear and patent. There were no exacerbating or relieving factors. There was no known preceding trauma to the G-tube. . In the ED, initial VS were: 88 130/70 99% 15L . FAST positive but hemodynamic stable CT abd non-con: simple fluid in the abdomen and pelvis, but no evidence for hematoma. left ventral wall hernia containing non-obstructed loops of bowel. . On arrival to the MICU, he was alert and cooperative and following commands. Past Medical History: Rectal cancer s/p excision and XRT ([**2157**]) CAD s/p stents (?[**2159**]) CVA in [**2150**] with residual right hand dysthesia Complete heart block s/p pacemaker H/o cardiac arrest (now with AICD) GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p cauterization via EGD Atrial fibrillation, not on coumadin Systolic CHF (EF 40-45%) S/p Fall with multiple rib fractures ([**2163-6-23**]) MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from trach Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **] Social History: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with his wife, now w some depression about moving out of their 42 year home. Has two children. Retired computer science professor. - Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA - Alcohol: Previously [**1-16**] glasses/week, generally per wife "affects him quite a bit," changing his mood and making him sick - Illicits: Denies 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 Exam: General: Alert, no acute distress HEENT: Trached NC AT Neck: trach in place CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse bilateral breath sounds Abdomen: soft, non-tender, non-distended, bowel sounds present Ostomy in place GU: Foley in place Ext: WWP 3+ pitting edema to theknees with bilateral venous stasis changes. Pertinent Results: [**2163-11-4**] 04:15PM PT-16.8* PTT-38.5* INR(PT)-1.5* [**2163-11-4**] 04:15PM PLT COUNT-110* [**2163-11-4**] 04:15PM NEUTS-82.7* LYMPHS-10.0* MONOS-6.5 EOS-0.5 BASOS-0.2 [**2163-11-4**] 04:15PM WBC-17.4*# RBC-3.50* HGB-9.7* HCT-30.0* MCV-86 MCH-27.6 MCHC-32.2 RDW-17.0* [**2163-11-4**] 04:15PM CALCIUM-8.4 PHOSPHATE-3.3# MAGNESIUM-1.9 [**2163-11-4**] 04:15PM estGFR-Using this [**2163-11-4**] 04:15PM GLUCOSE-130* UREA N-88* CREAT-1.9* SODIUM-141 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 [**2163-11-4**] 04:24PM GLUCOSE-123* LACTATE-2.1* NA+-140 K+-3.7 CL--105 TCO2-26 [**2163-11-4**] 04:24PM COMMENTS-GREEN TOP [**2163-11-4**] 07:14PM TYPE-ART PO2-60* PCO2-34* PH-7.51* TOTAL CO2-28 BASE XS-3 [**2163-11-4**] 07:42PM URINE WBCCLUMP-MOD MUCOUS-OCC [**2163-11-4**] 07:42PM URINE AMORPH-OCC [**2163-11-4**] 07:42PM URINE RBC-47* WBC->182* BACTERIA-MANY YEAST-FEW EPI-0 [**2163-11-4**] 07:42PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [**2163-11-4**] 07:42PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013 . CT ABDDOMEN AND PELVIS Study Date of [**2163-11-4**] 5:01 PM MPRESSION: . 1. Diffuse anasarca with small to moderate amount of ascites within the abdomen and pelvis, but no evidence for hemorrhage. 2. Moderate bilateral pleural effusions which have increased since the most recent examination. Small pericardial effusion, increased. 3. Cholelithiasis without evidence for cholecystitis. 4. Parastomal hernia containing nonobstructed, nondilated loops of small bowel. 5. Prostatic hypertrophy. 6. 15-mm hyperdense left upper pole renal lesion which is unchanged and may represent a hemorrhagic cyst. This can be further assessed with MRI if clinically indicated (as prior renal ultrasound from [**2163-9-5**] did not demonstrate any abnormality within this area). . The study and the report were reviewed by the staff radiologist. . . EKG: AV paced at 70 . AP CHEST 1:43 P.M. ON [**11-6**]. HISTORY: New right subclavian line. IMPRESSION: AP chest compared to [**10-18**] through [**11-6**] at 10:45 a.m.: Tip of the new right subclavian line ends low in the SVC. There is no change in the small-to-moderate right pleural effusion and no pneumothorax or mediastinal widening to suggest complications of line insertion. Severe cardiomegaly is longstanding. Pulmonary vascular engorgement and bibasilar atelectasis are unchanged. Tracheostomy tube is midline. Transvenous right atrial and right ventricular pacer defibrillator leads are in their expected locations, unchanged. No pneumothorax. . [**2163-11-5**] 1:18 am BLOOD CULTURE Site: ARM Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. VANCOMYCIN Sensitivity testing confirmed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final [**2163-11-6**]): Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2163-11-6**] AT 0515. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . [**2163-11-5**] 3:45 am URINE Source: Catheter. URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | PSEUDOMONAS AERUGINOSA | | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S 16 I CEFTAZIDIME----------- =>64 R 4 S CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S 8 I MEROPENEM-------------<=0.25 S =>16 R NITROFURANTOIN-------- =>512 R TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 84 YOM with MMP most notable of which inclue persistent MRSA bacteremia of unknown source, recurrent MDR UTI's, PNA, chronic renal failure presented with fevers, MRSA bacteremia, UTI and UGIB. . # Brief Hospital course: Patient was initially admitted for infectious w/u due to fevers, and was found to have MRSA bacteremia (chronic, likely [**2-16**] seeding of ICD), and Klebsiella/Pseudomonas UTI. These were treated with IV vancomycin and meropenem. He subsequently developed bleeding at his G-tube site as well as increased dark output from ostomy bag. His hct trend was: 30 ([**11-4**]) -> 28 ([**11-5**]) -> 25 ([**11-5**]) -> 22 ([**11-6**]). He was transfused 1 unit pRBC. Hct [**11-7**] was 18 and bleeding persisted. GI and surgery were consulted. He was given reglan, and started on ppi iv bid. GI performed 3 EGDs that large amounts of blood and an ulcer with visible vessel around peg insertion site; An initial attempt at clipping the ulcer caused bright red blood, confirming that this was likely the cause of the patient's recent bleed. 10cc of epinephrine were injected around the ulcer. 2 clips were applied around the ulcer with hemostasis successfully achieved. The PEG was removed. Because of his chronic MRSA bacteremia (thought likely [**2-16**] ICD seeding), TPN was not an option and family felt that a feeding tube would cause him too much discomfort. The palliative care team was consulted for assistance with the family's decision-making regarding goals of care. The family ultimately felt that his current quality of life was not consistent with what he would have wanted based on remarks he had made in the past. They elected to change his goals of care to comfort-measures only. On HD#9 he passed away with family at bedside. Family declined autopsy. Medications on Admission: Tylenol 650 q4h PRN Acetylcysteine 100mg TID Citalopram 20 mg QD Daptomycin 500mg Q 48h Docusate 100mg [**Hospital1 **] Ferrous Sulfate 325mg QD Lidocaine patch Metoprolol 12.5mg BIDSimethicone 80mg TID Sucralfate 1 Gram TID with meals Fentanyl patch 12 mcg Q 3Days (Last applied [**2163-11-2**]) Albuterol inhaler 2 puffs Q 6hours Oxycodone 5mg QHS COMPAZINE 5MG q 8 HOURS Psyllium seed 1 tsp TID Discharge Disposition: Expired Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Anemia due to upper GI bleed Bacteremia Urinary tract infection Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

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icd9cm

[ [ [] ] ]

[ "99.15", "38.97", "97.51", "44.43", "38.93", "96.72", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

11762, 11822

9735, 11312

401, 499

11930, 11941

4418, 7123

11993, 12092

3855, 4007

11843, 11909

11338, 11739

11965, 11970

4022, 4399

7167, 8478

323, 363

8513, 9492

527, 2801

2823, 3393

3409, 3839

25,482

181,038

23907

Discharge summary

report

Admission Date: [**2122-4-11**] Discharge Date: [**2122-4-17**] Date of Birth: [**2051-10-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 99**] Chief Complaint: Failure to wean from ventilator s/p intubation for a COPD exacerbation. Major Surgical or Invasive Procedure: Peg tube placement on [**2122-4-15**]. History of Present Illness: Mrs. [**Known lastname 60965**] is a 70-year-old woman with a history of COPD, HTN, and CAD who was transferred from [**Location (un) 60966**] for failure to wean from a ventilator after intubation and eventual trachetomy after a COPD exacerbation. The patient was initally admitted to the OSH on [**3-25**]. Her course was complicated by multifocal atrial tachycardia, steroid induced hyperglycemia, alcalagines oxyosidans bronchitis, and c. diff colitis. Pt was eventually trached secondary to her failure to wean. On [**4-11**], the pt was transferred to [**Hospital1 18**] for continued care due to her failure to wean. Past Medical History: 1. [**Name (NI) 3672**] Pt has had COPD for 10 to 15 years. She has required multiple intubation inthe last 5 years. 2. HTN 3. CAD 4. GERD 5. S/P TIAs 6. S/P vertebral fractures 7. Osteopenia Social History: Pt is married and lives with her husband. [**Name (NI) **] is her primary care giver. They have seven children who are very involved. She quit smoking 20 years ago after smoking 1 PPD for many years. Occasional ETOH. No drugs. Family History: [**Name (NI) 1094**] father had a CVA at age 38. Her mother died from complications of ovarian cancer. Physical Exam: PE on admission: 67 kg 98.9 145/38 56 14 100% on AC FiO2- 0.40 Peep-5 MV- 9.5 [**Name (NI) 2420**] Pt was sedated and intubated. HEENT- Sclera anicteric. Neck- Supple. No carotid bruits. Cardiac- RRR. S1 S2. No m,r,g. Pulm- CTAB. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- 2+ pitting edema bilateral LE. Pertinent Results: [**2122-4-12**] 02:00AM BLOOD WBC-13.6* RBC-2.78* Hgb-8.4* Hct-25.5* MCV-92 MCH-30.3 MCHC-33.0 RDW-15.9* Plt Ct-220 [**2122-4-12**] 02:00AM BLOOD Neuts-91.0* Lymphs-6.8* Monos-2.1 Eos-0.1 Baso-0.1 [**2122-4-12**] 02:00AM BLOOD PT-12.8 PTT-24.1 INR(PT)-1.0 [**2122-4-12**] 02:00AM BLOOD Glucose-121* UreaN-29* Creat-0.2* Na-142 K-4.0 Cl-111* HCO3-26 AnGap-9 [**2122-4-12**] 02:00AM BLOOD ALT-47* AST-28 CK(CPK)-9* AlkPhos-46 Amylase-34 TotBili-0.3 [**2122-4-12**] 02:00AM BLOOD Lipase-29 [**2122-4-12**] 02:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2122-4-12**] 02:00AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.8 [**2122-4-17**] 05:33AM BLOOD WBC-4.8 RBC-3.41* Hgb-10.4* Hct-31.1* MCV-91 MCH-30.5 MCHC-33.4 RDW-15.3 Plt Ct-169 [**2122-4-14**] 04:29AM BLOOD Neuts-93.6* Bands-0 Lymphs-3.7* Monos-2.6 Eos-0 Baso-0.1 [**2122-4-17**] 05:33AM BLOOD Plt Ct-169 [**2122-4-17**] 05:33AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.0 [**2122-4-17**] 05:33AM BLOOD Glucose-117* UreaN-12 Creat-0.2* Na-136 K-3.5 Cl-101 HCO3-27 AnGap-12 [**2122-4-17**] 05:33AM BLOOD Calcium-7.7* Phos-2.9 Mg-5.2* LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2122-4-12**]: RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic, consistent with fatty infiltration. More advanced forms of liver disease such as advanced fibrosis/cirrhosis cannot be excluded on this study. There is no intrahepatic biliary ductal dilatation or focal hepatic mass. The gallbladder is not distended. There are low level echoes in the dependent portion of the gallbladder that is consistent with sludge. There is no gallbladder wall thickening or edema. No stones are identified. The common duct measures 2 mm. There is a small amount of free fluid in the abdomen and pelvis noted, with small slivers of fluid around the liver, a small amount of fluid between the liver and gallbladder, and a sliver of fluid in the left lower quadrant. IMPRESSION: 1) Echogenic liver consistent with fatty infiltration. More advanced forms of liver disease cannot be excluded. 2) There is sludge within the gallbladder. There is no intra- or extrahepatic biliary ductal dilatation. The gallbladder is otherwise unremarkable. 3) Very small amount of ascites as described. PORTABLE ABDOMEN [**2122-4-12**]: INDICATION: Abdominal tenderness. Question free air or obstruction. A single portable abdominal radiograph is submitted for interpretation. It demonstrates a nonobstructed bowel gas pattern. The exam is not labeled as to whether it was performed in the upright or supine position. A nasogastric tube terminates in the stomach with the sideport near the GE junction level. Scoliosis is noted as well as degenerative change in the spine. There are also apparent compression fractures within the spine. IMPRESSION: Nonobstructed bowel gas pattern. Additional left lateral decubitus abdominal radiograph may be helpful given clinical suspicion for free intraperitoneal air. CHEST (PORTABLE AP) [**2122-4-12**]: A left subclavian vascular catheter terminates within the superior vena cava at the junction with left brachiocephalic vein. There is no pneumothorax. Allowing for rotation of the patient, a tracheostomy tube is in satisfactory position. A nasogastric tube terminates in the stomach. Heart size is normal, and the lungs appear clear. IMPRESSION: Vascular catheter in satisfactory position with no pneumothorax. Cardiology Report ECHO Study Date of [**2122-4-13**]: MEASUREMENTS: Aortic Valve - Peak Velocity: *3.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 38 mm Hg Aortic Valve - Mean Gradient: 21 mm Hg Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A Ratio: 0.82 Mitral Valve - E Wave Deceleration Time: 280 msec Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF. Cannot assess LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild (1+) MR. LV inflow pattern c/w impaired relaxation. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is difficult to assess but is probably mildly depressed. Overall left ventricular EF cannot be reliably assessed. 2. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**2122-4-13**] 8:45 am STOOL CONSISTENCY: WATERY PRESENCE OF BLOOD. Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2122-4-14**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 12:00 NOON ON [**2122-4-14**]. 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). FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2122-4-14**]): NO E.COLI 0157:H7 FOUND. URINE CULTURE (Final [**2122-4-15**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. YEAST. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML ___________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- 128 R VANCOMYCIN------------ <=1 S Brief Hospital Course: 1. Pulmonary: The patient's failure to wean from the ventilator seemed secondary to deconditioning. She was continued on a slow IV steroid taper for her COPD, though she seemed to do well from a bronchospasm and inflammation standpoint. She was exercised on CPAP but will require continued pulmonary rehab as she is weaned from the ventilator. 2. ID: The patient had been treated at the OSH with metronidazole for c. diff colitis. She spiked at temperature at [**Hospital1 18**]. Blood, urine, and stool cultures demonstrated persistent c. diff infection and an Enterococcus UTI, sensitive to vancomycin. The patient was treated with oral vancomycin and metronidazole for her colitis. She was treated with IV vancomycin for her UTI. In addition, the patient grew out Staph. epi. from her line. Her subclavian central line was discontinued and she was already on Vanco for her other infection. 3. Anemia: The patient dropped her hematocrit by six points on [**4-14**]. Hemolysis labs were negative. Her stool was guiac postive, though not frankly bloody or melanotic. She was transfused with 2U PRBC. Thereafter her hematocrit remained stable. Most likely this drop was [**1-21**] bleeding associated with her colitis. 4. Cardiac a. Cor: Patient reports a history of CAD. She was treated with ASA and an ACE inhibitor. Beta-blockade was held sedcondary to her COPD and cholesterol studies were acceptable without indication for statin therapy b. Rhythm: Patient with history of MAT at here OSH. Patient was treated with diltiazem c. HTN: The patients blood pressure was well-controlled on captopril and diltiazem. 5. Nutrition: Given her need for tube feeds, a PEG was placed on [**4-15**]. She had some difficultly with reflux symptoms intially, so was changed to an elemental formular of tube feedings. Medications on Admission: Medications on Transfer to [**Hospital1 18**]: 1. Cardizem 60 mg Q6H 2. Calcitonin nasa spray 200 U daily 3. Enoxaparin 40 mg SC daily 4. RISS 5. Methylprednisolone 12 mg Q12H 6. Metronidazole 500 mg TID 7. Protonix 40 mg daily 8. Propofol drip 9. Oxycodone acetaminophen PRN 10. Alpraxolem 0.25 mg QID PRN Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2-3H (every 2-3 hours) as needed. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). 4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): While not ambulatory. 6. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 12. Insulin Regular insulin sliding scale per protocol 13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Vancomycin HCl 10 g Recon Soln Sig: Two [**Age over 90 1230**]y (250) mg Intravenous Q6H (every 6 hours) for 10 days. Disp:*[**Numeric Identifier 961**] mg* Refills:*0* 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 16. Prednisone 20 mg Tablet Sig: 20 mg for 3 days; then 10 mg for 5 days; then 5 mg for 5 days; then off mg PO DAILY (Daily). 17. Vancomycin HCl 1,000 mg Recon Soln Sig: 1,000 mg Intravenous twice a day for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: COPD exacerbation with failure to wean from mechanical ventilation Secondary diagnosis: Urinary Tract infection C. diff colitis Hypertension Multifocal atrial tachycardia Anxiety Discharge Condition: Stable, requiring ventilator support Discharge Instructions: 1. You will initially be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) **]. However, once you are discharged, you should keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, increased SOB, or other concerning sympoms. Followup Instructions: 1. Initially, you will be followed by the physicians at [**Hospital1 **]. 2. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 60967**] within one week of discharge from rehab. You should call [**Telephone/Fax (1) 2573**] to make an appointment.

[ "599.0", "414.01", "491.21", "300.00", "518.81", "285.9", "401.9", "V44.0", "008.45", "427.89" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.72", "93.90" ]

icd9pcs

[ [ [] ] ]

11704, 11783

7714, 9541

351, 391

12026, 12064

1988, 7691

12444, 12749

1521, 1625

9898, 11681

11804, 11804

9567, 9875

12088, 12421

1640, 1643

240, 313

419, 1046

11912, 12005

11823, 11891

1658, 1969

1068, 1261

1277, 1505

19,442

120,879

13889

Discharge summary

report

Admission Date: [**2135-7-4**] Discharge Date: [**2135-7-6**] Date of Birth: [**2075-7-1**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old white male with a past medical history of coronary artery disease status post coronary artery bypass graft in [**2126**], hypertension, hypercholesterolemia, who presented to [**Hospital1 1444**] on [**2135-7-4**] as a transfer from [**Hospital3 4527**] Hospital for catheterization. In [**2126**], he underwent coronary artery bypass graft times three after presenting with exertional chest pain and a positive exercise stress test. Catheterization showed severe left anterior descending coronary artery and diagonal branch disease, moderate right coronary artery disease. The patient denies any anginal symptoms since the time of his coronary artery bypass graft until this presentation. On [**2135-7-2**] the patient experienced chest pressure without nausea, vomiting, shortness of breath, diaphoresis. Symptoms, however, did not resolve so the patient went to [**Hospital3 4527**] Hospital. The pain was relived with one sublingual nitroglycerin. Electrocardiogram at [**First Name (Titles) 4527**] [**Last Name (Titles) 4351**] with [**Street Address(2) 4793**] depressions in leads 1, 2, AVL, V4-V6. The patient ruled in for myocardial infarction with a peak troponin I of 4.0, CK 209, MB 9.27, MBI 5.4. At [**Hospital3 4527**] the patient was started on a beta blocker, aspirin, Lovenox, Integrilin. His chest pain recurred and he was started on a nitroglycerin drip. He is transferred to [**Hospital1 188**] on [**2135-7-4**] in the morning for catheterization that day. Catheterization showed left main coronary artery without obstructive disease, left anterior descending coronary artery to patent left internal mammary coronary artery, 90% lesion proximal left circumflex, right coronary artery with patent saphenous vein graft to distal right coronary artery, saphenous vein graft patent to D1, left internal mammary coronary artery to left anterior descending coronary artery patent. The patient had a drug coated stent placed in to the left circumflex artery at approximately 1:00 p.m. and was loaded with Plavix and Integrilin. At 3:30 p.m. he complained of sudden onset of severe, 10 out of 10 right flank pain with pallor, diaphoresis, heart rate to 37, blood pressure to 57/palp. His hypotension was slow to respond to 1 mg of atropine. He received 1.5 liters of intravenous fluids. He required transient Dopamine 5 to 10 mcg per minute to keep his systolic blood pressure greater then 100. A stat hematocrit was drawn, which showed a value of 37%, down from 40% on admission. A repeat hematocrit approximately 20 minutes later was 34%. The Integrilin was turned off and femoral sheath was removed. The patient was sent for a stat CT scan to rule out retroperitoneal bleed. CT showed a moderate sized retroperitoneal bleed. He was transferred to the Coronary Care Unit for further monitoring after receiving 2 liters total of intravenous fluids. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2126**]. Catheterization at that time revealed severe left anterior descending coronary artery disease, diagonal branch disease, moderate right coronary artery disease. Three vessel coronary artery bypass graft with left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to diagonal, saphenous vein graft to right coronary artery. 2. Hypertension. 3. Hypercholesterolemia. 4. Chronic headaches. 5. Status post discectomy [**2124**]. 6. Status post appendectomy. 7. Asthma as a child. ALLERGIES: The patient reports an allergy to sulfa drugs resulting in hives. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 81 mg po q.d. 2. Keflex 250 mg po q.d. 3. Lipitor 20 mg po q.d. 4. Paxil 20 mg po q.d. 5. Multivitamin po q.d. 6. The patient is enrolled in a study through his primary care physician where he is either receiving a cholesterol lowering study drug versus placebo. SOCIAL HISTORY: The patient works as a salesman. He denies any tobacco history. He reports occasional alcohol use. He denies any intravenous drug use. FAMILY HISTORY: The patient's mother deceased from myocardial infarction at the age of 80. REVIEW OF SYSTEMS: The patient denies any edema, orthopnea, paroxysmal nocturnal dyspnea, claudication. He does report a positive history of dyspnea on exertion, decreased exercise tolerance, increasing fatigue over the past several months. PHYSICAL EXAMINATION: Vital signs blood pressure 123/32. Heart rate 65. Respiratory rate 13. Oxygen saturation 100% on 2.5 liters nasal cannula O2. General appearance, well developed, well nourished white male lying supine, pleasant on O2 via nasal cannula, no acute distress. HEENT normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oral mucosa moist. Sclera anicteric. Oropharynx clear. Neck supple without masses or lymphadenopathy. No carotid bruits auscultated. Lungs clear to auscultation anterolaterally. No rhonchi, rales, wheezes. Cardiovascular regular rate and rhythm. S1, S2 heart sounds auscultated. No murmurs, rubs or gallops. Abdomen firm, positive right lower quadrant tenderness to deep palpation, nondistended. Hypoactive bowel sounds. No ecchymotic lesions over abdomen or flank noted. Groin right groin bandage clean, dry and intact. Left groin without bruit. Extremities warm and dry. 1+ dorsalis pedis pulse, posterior tibial pulses bilaterally. No clubbing, cyanosis or edema. PERTINENT LABORATORIES AND OTHER DATA: Complete blood count status post catheterization showed white blood cell 7.7, hemoglobin 11.6, hematocrit 34.1 (down from 40.6 on transfer from [**Hospital3 4527**]), platelet count 210. Serum chemistries prior to transfer showed sodium 144, potassium 4.3, chloride 104, bicarbonate 30.4, BUN 17, creatinine 1.1, glucose 95, calcium 8.4. Cholesterol panel showed total cholesterol 208, triglycerides 228, HDL 44, LDL 119. Electrocardiogram number one at [**Hospital3 4527**] showed normal sinus rhythm at 70 beats per minute, positive left axis deviation, normal intervals, no left atrial enlargement, right atrial enlargement, left ventricular hypertrophy, right ventricular hypertrophy, positive left anterior vesicular block, [**Street Address(2) 1766**] elevations noted in leads V1, AVR. [**Street Address(2) 1766**] depressions noted in leads V4-V6. [**Street Address(2) 4793**] depressions in lead V3. Electrocardiogram obtained post catheterization showed normal sinus rhythm at 55 beats per minute, left axis deviation. Left anterior vesicular block, borderline PR interval, lateral leads with flattened T waves, noted in leads, 1, AVL, V4-V6. No Q waves. [**Street Address(2) 4793**] depressions in V5 and V6. Catheterization showed left ventricular ejection fraction 50%. Hypokinesis of apex. 1+ mitral regurgitation. Saphenous vein graft patent. Right dominant system. Left ventricular and diastolic pressure at 22 mmHg. 95% lesion noted in the obtuse marginal one. HOSPITAL COURSE: The patient is a 60 year-old white male with known history of coronary artery disease status post coronary artery bypass graft times three in [**2126**], hypertension, hypercholesterolemia, who presented from an outside hospital with an episode of left chest pain, ruled in for a non ST elevation myocardial infarction at outside hospital with peak CK 209, CKMB 9.27, troponin I 4.0. He underwent catheterization on [**2135-7-4**] with placement of a left circumflex coronary artery stent. Post catheterization he had an episode of back pain, falling hematocrit, CT scan with evidence of retroperitoneal bleed. 1. Coronary artery disease: The patient underwent catheterization of his left circumflex coronary artery. A drug coated stent was placed. Although he has a CT of evidence of a retroperitoneal bleed, he was continued on aspirin and Plavix post catheterization to prevent acute stent thrombosis. He was also continued on Lopressor 25 mg po b.i.d. for beta blockade and Lipitor 40 mg po q.d. for hypercholesterolemia. His blood pressure was controlled initially with Captopril 12.5 mg po t.i.d. and Lopressor 25 mg po b.i.d. As he was experiencing episodes of sinus bradycardia he was monitored on telemetry for evaluation of any post myocardial infarction arrhythmias or events. He spent the evening in the Coronary Care Unit and did not exhibit any hemodynamic instability or arrhythmic events on telemetry. On hospital day number two he was transferred out of the Coronary Care Unit to the regular floor. He is continued on aspirin, Plavix, Lopressor, Lipitor. His Captopril was changed to Lisinopril 2.5 mg po q.d. He tolerated this regimen well with no hemodynamic instability. In order to assess his left ventricular function more completely, an echocardiogram was performed on hospital day number two. Echocardiogram revealed left ventricular ejection fraction of 60%. Left atrium mildly dilated. Mild/borderline symmetric left ventricular hypertrophy with normal cavity size and systolic function. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal, which revealed mitral regurgitation. There was no mitral valve prolapse. There was mild pulmonary artery systolic hypertension. There was a very small inferolateral pericardial effusion. The impression was that this was preserved global and biventricular systolic function. At the time of discharge the patient was chest pain free with no evidence of hemodynamic instability on his current medication regimen. 2. Retroperitoneal bleed: The patient experienced severe back and flank pain suggestive of retroperitoneal bleed. A vascular surgery consultation was obtained. They recommended a CT scan of the abdomen and pelvis. CT showed a moderate size retroperitoneal bleed. The patient was volume resuscitated with intravenous fluids. He was typed and crossed for 2 units of packed red blood cells. Serial hematocrit values were checked. Repeat hematocrit values remained stable greater then 30. Therefore the patient did not require any blood transfusion or blood products. Initially his pain was controlled with morphine. Hospital day two he was able to tolerate Percocet. At the time of discharge he was pain free and his hematocrit values were stable with a value at discharge of 32.3. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Myocardial infarction. 2. Status post PTCI, coronary artery stenting of left circumflex. 3. Status post retroperitoneal bleed. 4. Coronary artery disease status post coronary artery bypass graft. 5. Hypertension. 6. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. Atorvastatin 40 mg one po q.d. 2. Paroxetine 20 mg one po q.d. 3. Cefalexin 250 mg one po q.d. 4. Multivitamins one po q.d. 5. Percocet one to two tablets po q 4 to 6 hours as needed for pain. 6. Aspirin 325 mg one po q.d. 7. Plavix 75 mg one po q.d. 8. Metoprolol 50 mg 0.5 tablets po b.i.d. 9. Lisinopril 5 mg 0.5 tablet po q.d. FOLLOW UP PLANS: The patient was instructed to call his primary care physician or visit [**Name Initial (PRE) **] local Emergency Room if he experiences any chest pain, shortness of breath, back pain, groin pain at his catheterization site, nausea, vomiting, lightheadedness or fainting. He was instructed that we added some new medications to his regimen for better control of his blood pressure and cholesterol and instructed to take them as directed. Additionally he was instructed to change his aspirin dosing from 81 mg po q.d. to 325 mg po q.d. However, a prescription was not given for aspirin. He was also instructed to call his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6163**] to make a follow up appointment within the next seven to ten days. Additionally he was told to contact his cardiologist Dr. [**Last Name (STitle) 6148**] to make a follow up appointment within the next two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 18814**] MEDQUIST36 D: [**2135-7-6**] 04:43 T: [**2135-7-15**] 11:08 JOB#: [**Job Number 41623**] cc:[**Last Name (NamePattern1) 41624**]

[ "272.0", "998.11", "V45.81", "414.01", "410.71", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.07", "37.22", "88.56", "36.01", "99.20", "88.53" ]

icd9pcs

[ [ [] ] ]

4276, 4352

10833, 11081

11104, 12739

7212, 10724

3822, 4103

4619, 7194

4372, 4596

158, 3072

3094, 3790

4120, 4259

10749, 10812

28,131

172,434

34038

Discharge summary

report

Admission Date: [**2176-7-19**] Discharge Date: [**2176-7-22**] Date of Birth: [**2103-2-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p 20 ft Fall Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo male s/p 20ft fall from roof to pavement, ?LOC, GCS15 at scene. He was transported to [**Hospital1 18**] for further care. Past Medical History: BPH Hypercholesterolemia Hemorrhoidectomy Family History: Noncontributory Pertinent Results: [**2176-7-19**] 12:02PM GLUCOSE-117* LACTATE-3.6* NA+-146 K+-3.5 CL--107 TCO2-23 [**2176-7-19**] 11:40AM UREA N-17 CREAT-1.2 [**2176-7-19**] 11:40AM AMYLASE-123* [**2176-7-19**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2176-7-19**] 11:40AM WBC-28.3* RBC-4.79 HGB-14.7 HCT-42.6 MCV-89 MCH-30.7 MCHC-34.5 RDW-13.2 [**2176-7-19**] 11:40AM PLT COUNT-211 [**2176-7-19**] 11:40AM PT-13.3 PTT-23.3 INR(PT)-1.1 Radiology Report CT HEAD W/O CONTRAST Study Date of [**2176-7-19**] 11:54 AM FINDINGS: There is a large left subgaleal hematoma posterior to the left frontal bone with a small rounded area of higher attenuation within it. There is no intracranial hemorrhage or acute vascular territorial infarct. There is mild cerebral atrophy. There is no evidence of fracture. The paranasal sinuses and mastoid air cells are clear. Incidental note is made of vertebral artery calcifications. IMPRESSION: Large subgaleal hematoma in the posterior to the left frontal bone. No acute infarct or intracranial hemorrhage. Radiology Report CT CHEST W/CONTRAST Study Date of [**2176-7-19**] 11:56 AM Preliminary Addendum ADDENDUM: 1. 4-mm nodule in the middle lobe and 4-mm nodule in the right lower lobe. Rec. f/up at 12 months. 2. Bilateral rib fractures. CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST Clip # FINDINGS: There is a 2-cm hypodensity in the left lobe of the thyroid as well as a more distal 9-mm hypodensity consistent with thyroid nodules. There is no evidence of acute aortic injury. There is a small area of ground glass in the right upper lobe. There is mild bibasilar dependent atelectasis. There is bilateral gynecomastia. The liver, gallbladder, and pancreas are normal. There is a small linear hypoattenuating lesion in the spleen, (best seen on 2,66), without evidence of peri-splenic fluid. It is unlikely a splenic injury; however, a tiny grade 1 laceration cannot be excluded. The adrenals, kidneys, small and large bowel are normal. There is no free air or free fluid. The distal ureters and bladder are normal. There is no free fluid in the pelvis. There are sigmoid diverticula. MUSCULOSKELETAL: There is a nondisplaced fracture of the mid body of the sternum with a small presternal hematoma. There is an old healed posterior fracture of the twelfth rib on the right. At T12 there is a fracture of the inferior articulating facet and lamina on the right (with fracture fragment seen more distally on 2,74). At L1 there is a comminuted fracture of the vertebral body, with some retropulsion of fracture fragments, approximately 8 mm posteriorly, and indentation of the thecal sac. At L3 there is a tiny avulsion fracture of the right transverse process. At L4 there is a fracture of the right transverse process (not L5 as stated in error on the preliminary report). IMPRESSION: 1. Severely comminuted compression fracture of the body of L1 with 8 mm retropulsion of posterior fracture fragment indenting on the thecal sac. 2. T12, L3 and L4 fractures as detailed above. 3. Nondisplaced mid body fracture of the sternum. There is a small presternal hematoma. 4. Small linear hypoattenuation in the spleen which is unlikely to be splenic injury, as there is no perisplenic fluid; however, a tiny grade 1 laceration cannot be entirely excluded. 5. Sigmoid diverticulosis without diverticulitis. 6. Smaller ground glass in the right upper lobe which would be very atypical for contusion, more likely a small micro-aspiration or very early pneumonia. Radiology Report MR L SPINE W/O CONTRAST Study Date of [**2176-7-19**] 8:56 PM FINDINGS: There is an acute fracture of L1 vertebra identified with mild retropulsion indenting the thecal sac with less than 25% narrowing of the canal at this level. The fracture extends through the spinous process and posterior elements as seen on the CT. However, on MRI, no obvious marrow edema is seen in the spinous process. A tiny area of high signal at the posterior margin of the thecal sac at this level represents a fracture cleft within the lamina. There is no obvious disruption of the ligamentous structures identified. Mild increased signal is seen in the intraspinous ligaments at T12-L1 and L1-2 level indicating mild edema. Mild increased signal is seen also in the posterior subcutaneous fat from focal trauma. There is no evidence of marrow edema identified from L2 to L4 vertebral bodies to indicate fracture. The sacrum demonstrates high signal on T1- and T2- weighted images indicative of fatty marrow. This could be due to osteopenia or could be due to prior pelvic radiation. Clinical correlation recommended. The distal spinal cord shows normal signal intensities on T2-weighted sagittal and axial images. Subtle increased signal was suspected on inversion recovery images which could not be confirmed on axial T2-weighted images and therefore appears to be artifactual. The CT demonstrated fractures of the transverse processes of the lumbar vertebrae are not apparent on the MRI. A subtle area of signal abnormality adjacent to the right psoas muscle at L3 level could be due to a small hematoma. Correlation with abdominal CT recommended. IMPRESSION: Fracture of L1 vertebra with minimal retropulsion but without compression of the conus or high-grade thecal sac compression. There is less than 25% narrowing of the spinal canal seen at this level. There is mild increased signal is seen in the interspinous ligament but no obvious disruption of the ligamentous structures identified. No evidence of intraspinal hematoma seen. Other findings as described above. Brief Hospital Course: He was admitted to the Trauma Service and underwent CT imaging which revealed lumbar spine fracture. He was maintained on log roll precautions and was fitted for a TLSO which will need to be worn at all times while out of bed. His pain was initially controlled with IV narcotics and he was later changed to Percocet. A bowel regimen was initiated. He failed a voiding trial and was evaluated by Urology who recommended Flomax 0.4 mg at HS and to leave Foley in place for another week then try another voiding trial at that time. Physical and Occupational therapy evaluated him and have recommended rehab after his acute hospital stay. Medications on Admission: ASA 81mg, Tramazapam, Naproxen Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain: take with food. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: s/p 20 ft Fall L1 burst fracture Right transverse process fracture L3 Urinary retnetion Discharge Condition: Good Discharge Instructions: Wear the TLSO brace at all times when out of bed. Continue to wear the cervical collar at all time until follow up with Neurosurgery. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 363**], Spine Surgery in 2 weeks, call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in [**Hospital 159**] clinic in [**1-31**] weeks, call [**Telephone/Fax (1) 164**] for an appointment. Completed by:[**2176-7-29**]

[ "600.01", "E849.7", "E849.9", "E849.0", "272.0", "518.89", "805.2", "E884.9", "805.06", "289.50", "562.10", "E870.8", "807.2", "805.4", "788.29", "873.0", "996.76" ]

icd9cm

[ [ [] ] ]

[ "57.94", "57.32" ]

icd9pcs

[ [ [] ] ]

7940, 8037

6277, 6915

328, 335

8169, 8176

611, 6254

8359, 8633

575, 592

6996, 7917

8058, 8148

6941, 6973

8200, 8336

274, 290

363, 493

515, 559

21,694

190,366

15844

Discharge summary

report

Admission Date: [**2143-10-6**] Discharge Date: [**2143-10-10**] Date of Birth: [**2082-6-10**] Sex: M Service: ACOVE CHIEF COMPLAINT: Fever and low blood pressure. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of chronic obstructive pulmonary disease with previous exacerbations requiring intubation times one at [**Hospital1 2025**] who was in his usual state of health until four days prior to admission when he felt headache and nausea leading to emesis and diarrhea and this resolved by the day prior to admission. On the day prior to admission he developed increased shortness of breath, thick yellow sputum and fever to 104 degrees at home. He felt some lightheadedness and he felt heavy like he could not lift his head off the pillow. He was taking antibiotics for some skin cyst for a few weeks prior to feeling ill on Thursday. His last chronic obstructive pulmonary disease flare up was in [**2143-10-11**], which required rehab facility placement in [**Location (un) 4628**] after being hospitalized at [**Last Name (un) 4199**]. Two months ago at [**Hospital1 2025**] he was admitted for overnight observation and steroids for chronic obstructive pulmonary disease flare. He is not currently on home oxygen. The patient was taken to [**Hospital1 69**] on the day of admission where he was found to be hypotensive with blood pressures to 80/50. He was given 5 liters of intravenous fluids and his systolic blood pressure came up to the 100s. He was initially 93% on room air and increased to 97% on 2 liters status post nebulizer treatment. He also received a first dose of Levofloxacin, Solu-Medrol intravenous and Albuterol nebulizer treatments. A chest x-ray indicated that there may be some right lower lobe infiltrates. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Chronic obstructive pulmonary disease. 4. Herniated disc. 5. Anxiety. 6. Coronary artery disease status post myocardial infarction and a stent. 7. Glaucoma. 8. "Skin condition" treated with steroid cream. MEDICATIONS: 1. Oxycodone 10 mg q 6 hours. 2. Potassium. 3. Vitamins. 4. Os-Cal. 5. Protonix 40 mg po q day. 6. Lisinopril 5 mg po q day. 7. Lasix 40 mg po q.d. 8. Advair discus. 9. Oxycontin 10 mg a day. 10. Folate 1 mg a day. 11. Remeron 30 mg a day. 12. Valium 5 mg three times a day. 13. Zocor 40 mg a day. 14. Verapamil 240 mg b.i.d. 15. Glyburide 5 mg a day. 16. Methotrexate every week. SOCIAL HISTORY: He volunteers at Community Family Services. He was formerly a certified nursing assistant and shipyard worker. He quit smoking thirty five years ago. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 97.6. Blood pressure 123/80. Heart rate 95. 96% on 2 liters nasal cannula. Generally he is lying in bed with nasal cannula in place not able to speak full sentences initially. HEENT examination revealed mucous membranes are moist and an erythematous blanching wheels on his neck. His lungs revealed prolonged expirations with significant wheezing and crackles at the bases. His cardiovascular examination reveals a regular rate and rhythm without murmurs, rubs or gallops appreciated. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities showed no pedal edema with scaly macular rash on the lower extremities, nonpruritic. His neurological examination his mental status he is alert and oriented to situation. His speech is fluent and comprehensible. Cranial nerves II through XII are intact. His motor examination is limited due to exertional dyspnea. Generally though he was 5 out of 5 strength throughout. His coordination was intact to finger nose finger rapid tapping. His gait examination was deferred. LABORATORY: White blood cell count 12.7, hematocrit 35.9, platelets 374, sodium 141, potassium 4.0, bicarb 22, chloride 108, BUN 18, creatinine 0.9, glucose 241. Urinalysis was negative, calcium 8.0, magnesium 1.7, phosphate 2.5. Arterial blood gas revealed 7.35 with a PO2 of 63, PCO2 41, total CO2 of 24 and a base excess of -2. Legionella antigen was negative. Sputum gram stain and cultures only showed oropharyngeal flora as well as pneumococcus that is sensitive to Penicillin. The blood cultures remained negative as well as urine cultures. HOSPITAL COURSE: 1. Pulmonary: The patient was started on intravenous Solu-Medrol and admitted to the Intensive Care Unit for observation of low blood pressures. He was kept on oxygen and received nebulizer treatments and did well. His blood pressures subsequently came up the next hospital day and was presumptively attributed to concern for sepsis from a possible pneumonia. The patient was continued on Levofloxacin po for presumed pneumonia and did well. He required only meter dose inhalers by hospital day number three. He will continue a steroid taper upon discharge, in addtion to his metered dose inhalers. 2. Cardiovascular: His blood pressure medications were held on the day of admission and restarted on the third hospital day namely Lisinopril. The patient was concerned that his blood pressure would go too low with too many additional blood pressure medications and was only sent home on his Lisinopril. 3. Infectious disease: He was continued on Levofloxacin for a total of ten days and he was discharged on a dose of 500 mg po q.d. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Diabetes. 3. Hypertension. 4. Herniated disc. 5. Anxiety. 6. Coronary artery disease status post myocardial infarction and stent. 7. Glaucoma. 8. Skin condition. DISCHARGE MEDICATIONS: 1. Lisinopril 5 mg po q day. 2. Protonix 40 mg po q day. 3. Advair discus. 4. Folate 1 mg po q day. 5. Remeron 30 mg po q day. 6. Valium 5 mg po t.i.d. 7. Zocor 40 mg po q day. 8. Glyburide 5 mg po q day. 9. Levofloxacin 500 mg po q day. 10. Vitamin D 800 international units po q day. 11. Calcium carbonate 500 mg po t.i.d. 12. Albuterol inhaler. 13. Atrovent inhaler. 14. Salmeterol inhaler. 15. Fluticasone inhaler. 16. Prednisone taper. FOLLOW UP: The patient is to follow up with his primary care physician at [**Name9 (PRE) 2025**] Dr. [**Last Name (STitle) 45544**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Doctor Last Name 24864**] MEDQUIST36 D: [**2143-10-10**] 14:43 T: [**2143-10-11**] 07:31 JOB#: [**Job Number 45545**]

[ "412", "401.9", "491.21", "486", "250.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5409, 5445

5466, 5682

5706, 6175

4339, 5387

6187, 6549

152, 183

212, 1799

1822, 2498

2515, 4321

16,776

143,453

1777

Discharge summary

report

Admission Date: [**2140-11-18**] Discharge Date: [**2140-12-2**] Date of Birth: [**2061-6-14**] Sex: M Service: MEDICINE Allergies: Lasix / Ciprofloxacin / Optiray 300 / Cefepime Attending:[**First Name3 (LF) 317**] Chief Complaint: Transfer from OSH for Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: 79 year old man with history of Afib, CAD s/p CABG x 2, thoracic aortic aneurysm repair x 2 who is transfered from OSH for acute chest pain. He initially present to OSH on [**2140-11-16**] for complains of CP associated with rapid afib. At OSH he was ruled out for MI and had a negative VQ scan and non-contrast CT to eval for pulmonary embolism. His thoracic aortic aneurysm was also noted to be stable on the CT. Patient was rate controlled with IV diltiazem and given increased doses of BB. . On the morning of transfer, he noted acute onset of pounding chest pain that was sharp, located in the center of his chest. He denies radiation to his arm, jaw or back. Was associated with some nausea but denies vomiting of diaphoresis. Pain last for 10min to 1hr and was relieved with morphine. He is currently chest pain free. Patient has shortness of breath at baseline which limits his exercise tolerance. Denies abd pain or change in bowel movements. Has a dry cough at baseline. Also notes increased urinary frequency. He has known prostate enlargement and is followed by urology. Past Medical History: s/p repair of pseudoaneurysm from leaking [**Doctor Last Name 10010**] graft from previous Bentyl operation, coronary artery bypass graft times 3, saphenous vein grafts to left anterior descending artery, obtuse marginal, and posterior descending artery in [**9-24**] s/p Bentall w/[**Doctor Last Name 10010**] modification/mech St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]/CABGx2 ('[**28**]) trach AFib CAD hyperlipidemia HTN hypothyroidism Social History: married, lives with wife, denies current tob use but does have remote history, no EtOH use, denies IVDA Family History: extensive CAD history, father with MI in 60s, brother with MI in 40s and mother with MI and CVA Physical Exam: VITALS: T 99.5, BP in Rt 128/80 in Lt 138/78, P 69, RR 24, 97% on 3L => 95% on 50% trach mask GEN: mild distress, difficulty getting comfortable HEENT: PERRLA, EOMI, OP CLEAR w/ MMM, ecchymosis under left eye, no tenderness to palpation. NECK: JVD to ear, no LAD, well healed trachiostomy CV: mechanical click, RRR no m/r/g LUNGS: diffuse crackles halfway up lung fields ABD: +BS nt/nd soft EXT: 2+ doralis pedis pulses, no peripheral edema Pertinent Results: EKG: atrial flutter with 4:1 block, no acute ST changes . Chest Xray [**11-18**] Worsening bibasilar densities, may be related to pneumonia or CHF . ECHO [**11-17**] normal systolic function, mild septal wall abnormality, biatrial enlargement, mild aortic incompetence, moderate pulmonary hypertension. . Labs from OSH: Glucose 103, BUN 26, Cr 1.6, Na 137, K 5, Cl 103, HCO3 26, Ca 9.3 CK 47, Trop 0.02 WBC 7.3, HCT 35.9, PLT 101 INR 4.2 Brief Hospital Course: 79 year old man with extensive cardiac and surgical history who is transfered from OSH for chest pain . #Aortic Dissection with Rupture- Patient initially transfered from OSH with new chest pain. He was ruled out for a PE before transfer. He was initially ruled out for an MI and MR imaging was obtained to eval for dissection. MRI showed descending aortic dissection. Surgery was consulted and recommended medical management with good heart rate and blood pressure control. While on the floor, he had tearing chest pain to his back. CTA performed which revelaed an aortic dissection with rupture. He was transfered to the CCU and he required 2 units of PRBC. FFP was given to reverse his INR. He was hemodynamically stable while in the unit. A labetalol drip was started to keep SBP from 90 to 100 and HR from 50-60. HR and BP were well controlled in initial 72 hours and hct was stable. Patient did not require any more blood transfusions after the initial 2 units. He was eventually switched to a PO regimen for HR and BP control. Vascular surgery consulted, and the patient was not a candidate for surgery given the rupture was of the descending aorta. After he was stablized on oral meds, he was transfered to the floor. His blood pressure and heart rate were tightly controlled. Per vascular surgery, he will need repeat imaging in the future. . #CAD: Known disease, s/p CABG x 2. He was initially ruled out for an MI. . #Rhythm: In atrial fibrillation/flutter while in house. Initially was difficult to control. Digoxin was stopped and he was tried with amiodarone. Amiodarone was stopped on transfer to the unit. His heart rate was controlled with metoprolol and diliazem. . #Pump: Normal systolic function on recent echo. Throughout hospitalization he was at times noted to be volume overloaded. His home bumex was continued. . #Anticoagulation - He is anticoagulated for his valve and afib. On transfer to the unit, he was initially reversed with FFP. After his HCT was stable, he was bridged with heparin back to coumadin. Patient's anticoagulation goal was decreased to 2.0-2.5 from 2.5 to 3.5. His anticoagulation should be monitored very closely given his comorbidities. . #Renal Failure - Patient has chronic renal failure. Acute renal failure noted in setting of contrast. Returned to baseline before discharge. . #Possible aspiration/Tracheoesophogeal fistula - While in the CCU, there was a concern that the patient was aspirating whlie eating and a concern for a tracheoesophogeal fistula. There did not appear to be a communication on imaging studies. ENT consulted and said that he may benefit from covering stoma while eating. He was maintained on a soft diet with thin liquids. He will need to swallow with his head turned over right shoulder AND chin tucked to chest AND alternate between bites of food & sips of thin liquid. Also needs to swallow with right head turned + chin tuck. . #Hypothryoid - continued synthroid . #HLD - continued statin Medications on Admission: Home Meds: Lopressor 75mg [**Hospital1 **] Digoxin 0.125 every other day synthroid 75mcg daily Bumex Uroxatral every other day lovastatin 10mg daily Coumadin 7.5mg 4 days, 5 mg 3 days multivitamin . Meds on Transfer: Aspirin 81mg daily Colchicine 0.6mg daily digoxin 0.125mg every other day Diltiazem ER 120mg daily Colcae 100mg [**Hospital1 **] Ibuprofen 400mg synthroid 75mcg daily metoprolol 50mg [**Hospital1 **] multivitamin nitropaste 1" q 6 hours omeprazole 20mg once daily simvastatin 5mg daily coumadin 5mg daily Discharge Medications: 1. Lovastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 3. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Bumetanide 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Uroxatral 10 mg Tablet Sustained Release 24 hr [**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO every other day. 6. Amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 9. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY16 (Once Daily at 16). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Ruptured Aortic Aneurysm Atrial Fibrillation Coronary Artery Disease Hypertension Discharge Condition: Stable, blood press and heart rate well controlled. Able to ambulate. Discharge Instructions: You were transfered to the hospital for further evaluation of chest pain. While in the hospital you had imaging studies which showed an aortic dissection. You also had rupture of this aortic dissection. You were followed in the ICU where your blood pressure was tightly controlled. You were also seen by the surgeons who said that you were currently not a surgical candidate. You were medically managed with tight blood pressure and heart rate control. . We changed some of your medications while in the hospital. -We increased the dose of your lopressor, now at 150mg three times daily -We stopped your Digoxin -We added amlodipine for better blood pressure control -We added diltiazem for better heart rate control -Your coumadin dosage is now 2mg . Either call your primary care physician or return to the emergency room if you have chest pain, shortenss of breath, dizziness, confusion, abdominal pain, or other symptoms of concern to you. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10011**] to schedule a follow up appointment for Monday to get your INR checked. . Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10012**] to schedule a follow up appointment in [**12-22**] weeks. Completed by:[**2140-12-3**]

[ "584.5", "427.32", "272.4", "441.01", "292.81", "244.9", "427.31", "E941.1", "V43.3", "V45.81", "403.90", "585.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

7680, 7742

3142, 6145

340, 347

7868, 7941

2680, 3119

8938, 9251

2107, 2204

6718, 7657

7763, 7847

6171, 6370

7965, 8915

2219, 2661

268, 302

375, 1470

1492, 1969

1985, 2091

6388, 6695

52,456

127,173

34895

Discharge summary

report

Admission Date: [**2184-10-15**] Discharge Date: [**2184-10-23**] Date of Birth: [**2117-5-3**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: CC: Headache and vomiting Major Surgical or Invasive Procedure: Right SDH evacuation History of Present Illness: 67M s/p fall from toilet 3 days ago. Pt believes he fell asleep, reportedly woke up right away. No observed seizures as per wife. [**Name (NI) **] post-ictal state. Pt reported had headache that started next day that has gotten progressively worse. Pt reported 1 episode of nausea yesterday. Pt came to OSH this afternoon and found to have 2cm rt SDH. Pt transferred to [**Hospital1 18**] for further eval. Past Medical History: HTN, gout Social History: no smoking hx, drinks 2-3glass wine, few beers daily, no illicit drugs Family History: mother died stroke, father died [**Name (NI) 2481**] dementia Physical Exam: O: T:97.4 BP: 187/92 HR:78 R:16 O2Sats:98%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2 b/l 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 date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 3->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 [**4-19**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT [**10-15**]: CT head 1.8 cm SDH, 1.3cm midline shift CT [**10-17**] Post-operative scan: 1. Status post right pterional craniotomy, with evacuation of right-sided subdural hematoma. Expected postoperative changes are noted including pneumocephalus and extra-axial fluid. There is evidence of decreased mass effect on the right lateral ventricle. 2. Increased mucosal thickening and fluid within the sinuses, likely related to intubated status. [**2184-10-15**] 08:30PM GLUCOSE-142* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 [**2184-10-15**] 08:30PM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-1.9 [**2184-10-15**] 08:30PM WBC-12.7* RBC-3.95* HGB-12.6* HCT-36.3* MCV-92 MCH-31.9 MCHC-34.7 RDW-12.8 [**2184-10-15**] 08:30PM NEUTS-90.5* LYMPHS-7.1* MONOS-2.2 EOS-0.2 BASOS-0.1 [**2184-10-15**] 08:30PM PLT COUNT-320 [**2184-10-15**] 08:30PM PT-12.6 PTT-32.9 INR(PT)-1.1 Brief Hospital Course: The patient is a 67M with a traumatic SDH. Dr. [**First Name (STitle) **] had a discussion with the patient and his wife and recommended surgery. Risks of no surgery were explained, including neurological decline, seizures. The patient understood the risks and opted for observation. Dr. [**First Name (STitle) **] seen felt the patient was cognitively able to make decisions. However, on [**10-17**], the patient developed L facial droop with new pronator drift hence was taken to OR per Dr. [**First Name (STitle) **] for evacuation. There was no operative/peri-operative complications and he was extubated soon after the operation. He had non-focal exam the next day with minimal pain and tolerated food/drinks per mouth. He was transferred out of the ICU on POD#1 and PT/OT was started. He was continued on Keppra for seizure prophylaxis. Physical therapy worked with the patient and felt that he was safe to be discharged home with services. His blood pressure was elevated throughout his hospital course. His atenolol was increased and he was started on lisinopril. This will be addressed further at his PCP's office. On [**10-22**], he was scheduled to be discharged but he was febrile upto Tmax of 101.6 hence he had fever work-up including CXR, CBC and UA. UA showed >25 WBC with many bacteria. Although he denies polyuria/dysuria, given that he was febrile, Bactrim was started for UTI. Culture was sent for sensitivity. On [**10-23**] he was afebrile overnight, and was dishcarged to home with VNA service with a prescription for bactrim for UTI broad coverage pending sensitivity results. Medications on Admission: Atenolol, Allopurinol, antihistamine, ASA 81mg Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on narcotics. Disp:*50 Tablet(s)* Refills:*0* 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 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* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours). Tablet(s) 5. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Right subdural hemorrhage after fall Discharge Condition: Neurologically stable 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 have dissolvable sutures that will self-dissolve over few weeks. Please do not scrub/shampoo the area until sutures are completely dissolved and make sure to pat dry ??????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 prescribed an anti-seizure medicine, take it as prescribed ??????Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please call your PCP to [**Name9 (PRE) 702**] [**Name9 (PRE) 79866**] within 1 week regarding BP control - your BP meds and dose have been adjusted during this admission. ??????You have dissolvable sutures hence you do not need to make an appt to remove your sutures. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment with Dr. [**First Name (STitle) **]. You are also being discharged on a medication to treat your urinary tract infection. Please continue the prescribed antibiotic for a total of 10 days. Completed by:[**2184-10-23**]

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Discharge summary

report

Admission Date: [**2133-7-16**] Discharge Date: [**2133-7-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: MRSA Sepsis Major Surgical or Invasive Procedure: Left IJ removed R IJ inserted (HD catheter) Tunneled catheter placement History of Present Illness: Patient is a 85 y/o M with history of diastolic CHF, complete heart block s/p pacemaker [**6-7**], CKD recently started on HD during last admission who was transferred to [**Hospital1 18**] after having [**4-3**] blood cultures growing gram + cocci as well as hypotension at rehab. He has been at [**Hospital **] [**Hospital **] Hospital since [**2133-7-6**]. He was dialyzed last on [**7-15**] and recieved IV vanco that day. He had cultures drawn on [**7-15**] and cultures back positive at 9:45am on [**7-16**]. The dialysis catheter was removed before he was transferred to [**Hospital1 18**]. Per report he has also been hypotensive with blood pressure fro 88-120 systolic at the rehab. In the ED, his vitals were, T 98.2, HR 70, BP 75/39. RR 22, 98% on RA. BP initially improved with fluid, but IJ placed and BP dropped go 64/32. Levophed was started. He was given Vanco 1gm IV for gram + cocci in blood, levqauin 750mg IV, ceftriazone 1gm IV for PNA. A left IJ was placed. On admission to the MICU, he was afebrile. He denied fevers, chills, lightheadedness, chest pain. He reported shortness of breath, worse on exertion, but not worse than baseline. He was recently admitted from [**Date range (1) 95634**] for A-fib ablation that failed, and had a pacer placed for complete heart block. He was started on amiodarone at that time. He was then admitted from [**Date range (2) 95635**] for pancreatitis. This resolved with bowel rest and hydration. He went into decompensated CHF and was transferred to the ICU for diuresis. He also had a GI bleed. His chronic kidney disease was exacerbated and he was intitiated on HD via a R subclavian tunneled HD cath placed on [**2133-7-2**]. He had been on coumadin for his history of A-fib, but that was stopped in the setting of the GI bleed. Past Medical History: # Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% & severe LVH # Atrial fibrillation previously on Coumadin (until GI bleed [**6-7**]), failed cardioversion # s/p Pacemaker placement [**6-7**] for complete heart block # Peripheral vascular disease s/p right lower extremity bypass # Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**] CT) # Hypertension # Gout # ?Prostate followed by Urology (denies symptoms of BPH) # Chronic Kidney Disease ([**3-7**], Cr 2.2, stage III, est GFR 35) Social History: Patient has an insurance business and worked daily until recent sicknesses. No current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Patient's daughter had "kidney disease" and is now s/p renal transplant. 2 sons and 1 daughter. Physical Exam: Vitals: T: 98.4 BP: 101/66 P: 73 RR: 16 O2Sat: 100 RA Gen: a&ox3, no acute distress HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. 2/6 systolic murmur best heard at lsb LUNGS: decreased breath sound rll, crackles at bases. ABD: distended, tymplanic, non tender positive bowel sounds. EXT: 4+ bl lower extremity edema SKIN: rt left, warm erythema NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-31**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2133-7-21**] 06:00AM BLOOD WBC-9.8 RBC-2.58* Hgb-8.7* Hct-27.2* MCV-105* MCH-33.9* MCHC-32.1 RDW-18.3* Plt Ct-75* [**2133-7-20**] 06:10AM BLOOD WBC-9.4 RBC-2.61* Hgb-8.6* Hct-27.7* MCV-106* MCH-32.8* MCHC-30.9* RDW-18.5* Plt Ct-91* [**2133-7-19**] 05:59AM BLOOD WBC-10.2 RBC-2.44* Hgb-8.4* Hct-25.9* MCV-106* MCH-34.5* MCHC-32.6 RDW-18.6* Plt Ct-91* [**2133-7-18**] 02:56AM BLOOD WBC-11.8* RBC-2.60* Hgb-8.4* Hct-27.7* MCV-107* MCH-32.4* MCHC-30.4* RDW-18.4* Plt Ct-71* [**2133-7-17**] 03:37AM BLOOD WBC-17.4* RBC-2.64* Hgb-8.9* Hct-28.2* MCV-107* MCH-33.7* MCHC-31.6 RDW-19.1* Plt Ct-69*# [**2133-7-16**] 12:27PM BLOOD WBC-17.4*# RBC-2.75* Hgb-9.1* Hct-29.3* MCV-107* MCH-33.0* MCHC-31.0 RDW-19.0* Plt Ct-35*# [**2133-7-21**] 06:00AM BLOOD Neuts-79.4* Bands-0 Lymphs-12.0* Monos-4.0 Eos-4.5* Baso-0.2 [**2133-7-16**] 12:27PM BLOOD Neuts-82* Bands-13* Lymphs-2* Monos-1* Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2133-7-21**] 06:00AM BLOOD PT-15.2* PTT-36.5* INR(PT)-1.3* [**2133-7-20**] 06:10AM BLOOD PT-14.4* PTT-35.9* INR(PT)-1.2* [**2133-7-18**] 02:56AM BLOOD PT-15.2* PTT-32.6 INR(PT)-1.3* [**2133-7-17**] 03:37AM BLOOD PT-14.9* PTT-31.5 INR(PT)-1.3* [**2133-7-16**] 12:27PM BLOOD PT-15.5* PTT-32.1 INR(PT)-1.4* [**2133-7-21**] 06:00AM BLOOD Glucose-93 UreaN-36* Creat-4.5* Na-137 K-4.5 Cl-102 HCO3-27 AnGap-13 [**2133-7-20**] 06:10AM BLOOD Glucose-99 UreaN-29* Creat-3.9*# Na-138 K-5.9* Cl-101 HCO3-27 AnGap-16 [**2133-7-19**] 05:59AM BLOOD Glucose-118* UreaN-45* Creat-5.0* Na-134 K-5.0 Cl-99 HCO3-27 AnGap-13 [**2133-7-18**] 02:56AM BLOOD Glucose-105 UreaN-34* Creat-4.4* Na-135 K-4.8 Cl-98 HCO3-28 AnGap-14 [**2133-7-17**] 03:37AM BLOOD Glucose-111* UreaN-25* Creat-3.8* Na-138 K-4.6 Cl-99 HCO3-30 AnGap-14 [**2133-7-16**] 12:27PM BLOOD Glucose-104 UreaN-20 Creat-3.5*# Na-140 K-4.7 Cl-100 HCO3-31 AnGap-14 [**2133-7-19**] 11:45PM BLOOD ALT-32 AST-29 CK(CPK)-15* [**2133-7-17**] 03:37AM BLOOD ALT-30 AST-28 LD(LDH)-286* AlkPhos-184* Amylase-48 TotBili-1.1 [**2133-7-16**] 12:27PM BLOOD ALT-30 AST-30 LD(LDH)-298* CK(CPK)-31* AlkPhos-186* Amylase-56 TotBili-1.6* [**2133-7-17**] 03:37AM BLOOD Lipase-44 [**2133-7-16**] 12:27PM BLOOD Lipase-38 [**2133-7-16**] 12:27PM BLOOD cTropnT-0.24* [**2133-7-21**] 06:00AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1 [**2133-7-20**] 06:10AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1 [**2133-7-19**] 05:59AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1 [**2133-7-18**] 02:56AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 [**2133-7-17**] 03:37AM BLOOD Albumin-3.6 Calcium-8.9 Phos-2.4* Mg-1.9 [**2133-7-16**] 12:27PM BLOOD Albumin-3.6 Calcium-9.1 Phos-1.8*# Mg-2.0 [**2133-7-21**] 06:00AM BLOOD Vanco-25.3* [**2133-7-20**] 06:10AM BLOOD Genta-3.7* Vanco-27.4* [**2133-7-19**] 05:59AM BLOOD Genta-4.0* Vanco-19.4 [**2133-7-18**] 06:27AM BLOOD Vanco-23.2* [**2133-7-17**] 12:15PM BLOOD Vanco-25.6* [**2133-7-16**] 03:52PM BLOOD Type-[**Last Name (un) **] Rates-/16 O2 Flow-4 pO2-49* pCO2-54* pH-7.39 calTCO2-34* Base XS-5 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**] [**2133-7-17**] 04:23PM BLOOD Lactate-1.4 [**2133-7-16**] 12:34PM BLOOD Lactate-2.0 MICRO: Blood Culture [**2133-7-16**]: Blood Culture, Routine (Final [**2133-7-19**]): STAPH AUREUS COAG +. 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. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2133-7-17**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) 3239**] [**Last Name (NamePattern1) **] ON [**2133-7-17**] AT 955AM. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final [**2133-7-17**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Blood culture [**7-18**]: Blood culture [**7-19**]: Blood culture [**7-21**]: Stool C.diff [**7-18**]:CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2133-7-19**]): REPORTED BY PHONE TO [**Doctor Last Name **],ALEXENDRIA @ 10:05, [**2133-7-19**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Stool C.diff [**7-19**]: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2133-7-19**]): REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] @ 10:05, [**2133-7-19**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Stool C.diff [**7-20**]: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2133-7-21**]): REPORTED BY PHONE TO T. QURIAN @ 2324 ON [**2133-7-20**]. THIS IS A CORRECTED REPORT [**2133-7-21**] 7:39AM. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). IMAGING: ECHO [**2133-7-17**]:The left atrium is markedly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-31**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2133-6-22**], the LV systolic funciton appears slightly less vigorous. No change otherwise. Pacer U/S [**2133-7-16**]: Limited [**Doctor Last Name 352**]-scale evaluation of the left chest wall demonstrates a hypoechoic fluid collection surrounding the pacer leads. This could be postoperative, however, infection within this collection cannot be excluded. A CT with contrast can be performed for further evaluation. Brief Hospital Course: HOSPITAL COURSE BY PROBLEM: MRSA septicemia: The most likely source of infection was thought to be the dialysis catheter placed [**2133-7-2**]. Blood cultures taken at rehab [**7-15**] grew out gram + cocci and cultures were positive for MRSA. Blood cultures taken [**7-16**] in [**Hospital1 18**] also grew out MRSA. At presentation to [**Hospital1 18**], the patient was hypotensive and was started on levophed. The dialysis catheter was removed and the patient was started on IV vancomycin and gentamycin. A new R IJ catheter was placed for temporary use during HD with the plan to place a tunnelled line when the patient was no longer septic. After starting vancomycin, the patient was no longer febrile. Blood cultures taken on [**7-19**], and [**7-21**] showed no growth. Gentamycin was D/Ced on [**7-20**] as vancomycin was thought to be adequate (no other organisms besides MRSA identified). Vancomycin was continued with plans for a total of 14 day course; it was administered after HD and troughs were monitored the morning after HD and titrated accordingly per renal's recommendations. The other possible source of infection considered was pacer pocket infection. The patient had a preliminary ultrasound of the pacer pocket which showed a small fluid collection which was most likely postoperative. TTE showed no evidence of vegetations so further workup was not pursued because the patient was clinically improved with no fevers and no leukocytosis. Pleural Effusions: CXR showed bilateral pleural effusions which were thought to be fluid overload due to his chronic kidney disease and known CHF. These were monitored with plans to tap if he worsened clinically, but as his status improved with antibiotics and HD the effusions were not tapped. Hypotension: Patient was hypotensive to 75/35 at presentation. He had a known low baseline but this was below that baseline and in the setting of sepsis he was placed on levophed. This was supplemented with mitodrine to keep BP at a goal of SBP in the high 80s and MAP > 55. Levophed was weaned as tolerated. He was on levophed from admission on [**7-16**] to the AM of [**7-21**]. Off IV pressors he was hemodynamically stable with BPs in high 80s-100s/50s. Midodrine was continued at 10 mg TID. CKD on HD: Patient was followed by the renal team while in the MICU and dialyzed per their recommendations. He had HD on [**7-19**] with removal of 2.8 L. UF [**7-20**] removed 3.5L. Because his tunnelled HD catheter was thought to be the source of his infection, this was removed at presentation and replaced with a right IJ compatible with HD for use over the short term. The plan was to place a new tunnelled line when the patient was stable off pressors. IR and renal were agreeable with placement of this line and it was placed on [**7-24**] when patient's family agreed to the procedure. The catheter was accessed for HD on [**7-27**]. Patient's electrolytes were monitored daily with the plan to give kayexelate for K > 5.7, renagel for elevated PO4. Medications were renally dosed and he was kept on a fluid restriction of 750cc. Clostridium Difficle Positive stool: Patient was positive for C.diff on 3 separate cultures. He was started on flagyl on [**7-19**] and this was continued until [**7-21**]. On the PM of [**7-20**] he was noted to have a rash over his abdomen and as this coincided with the start of flagyl ~1.5 days prior, and flagyl was D/Ced. He was put on PO vancomycin for the C.diff instead with plan to switch to IV daptomycin if the patient were to have diarrhea or other signs of C.diff active infection. He was d/c'd home with a prescription to complete an additional 8 days of PO vancomycin. Abdominal Rash: Blancing erythematous rash on abdomen was noted on the night of [**7-20**]. This was thought to be most likely a drug rash; the patient had been on vancomycin (for MRSA sepsis) since [**7-16**] and flagyl (for C. diff positive stool) since [**7-19**]. Eosinophils were elevated to 4.5% on the differential which supported the idea of drug rash. Flagyl was D/Ced and the patient was put on PO vancomycin instead. The rash was monitored with the plan that if it did not improve off flagyl (thus possibly a drug rash secondary to vancomycin) that both IV and PO vancomycin would be discontinued and he would instead be put on IV dapsone. At the time of discharge the rash was resolved. Cellulitis: On admission patient was noted to have R lower extremity erythema, possibly consistent with cellulitis. As he was already put on vancomycin for MRSA sepsis, no further antibiotics were added at admission. The leg was carefully monitored with dressing removals and daily checks, and resolved with the vancomycin. Complete Heart Block with pacer: Electrophysiology was notified of the patient's admission. His pacer pocket ultrasound showed small fluid collection as per above, and clinical signs of infection were monitored with the plan that if he worsened he would receive chest CT to further work up pacer pocket infection. This was not necessary as his sepsis resolved with vancomycin. Thrombocytopenia: Patient had a history of thrombocytopenia which had been worked up extensively at previous admission and was thought to be most likely secondary to MDS. Famotadine was D/C for possible H2 blocker toxicity. Platelets were up and down during his stay usually in the 70s-100s. [**7-20**] platelets 91; [**7-21**] platelets 75. He had a standing order for ddAVP. FEN:renal diet, lytes daily. Ppx:heparin sc, no need for PPI, pneumoboots CODE:Full code Access: Tunneled line placed [**7-24**]. Contact: [**Name (NI) **], son [**Name (NI) **] [**Telephone/Fax (1) 95636**] Medications on Admission: Ferrous Sulfate 325 mg Daily Amiodarone 200 mg twice daily Docusate Sodium 100 mg twice daily). Simethicone 80 mg QID as needed Famotidine 20 mg daily Lactulose 15mL as needed for consipation Bisacodyl 10 mg Tablet, as needed Senna 8.6 mg Tablet twice daily Calcium Acetate 667 mg three times a day Acetaminophen 325 mg qHS Acetaminophen 325 mg as needed for insomnia Ondansetron HCl IV? every 8 hours as needed Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: Per HD Intravenous HD PROTOCOL (HD Protochol). 8. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 10. Lactulose 10 gram/15 mL Solution Sig: One (1) PO once a day as needed for constipation. 11. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: HD Line Infection Sepsis Secondary Diagnosis: ESRD on HD Diastolic Congestive Heart Failure Atrial fibrillation Peripheral vascular disease Discharge Condition: Hemodynamically stable. Afebrile. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 750 ccs You were admitted to the hospital for an infection. Your catheter was thought to be the source of your infection. This catheter was removed and a temporary line was placed. You were treated with IV antibiotics and had a new dialysis line placed. You should continue your IV antibiotics until [**8-1**] with your HD. In the hospital you were receiving dialysis on a [**Month/Day (2) 766**], Wednesday, Friday schedule. You should continue your dialysis as scheduled. While you were in the hospital you developed diarrhea caused by Clostridium difficile. You were treated with an antibiotic called vancomycin by mouth. You should complete a total of 14 days of this antibiotic. Please take as directed. During your hospitalization we made several changes to your medications. Your famotidine was stopped because of low platelets counts. You were started on midodrine 10 mg three times daily. Please take your medications as directed and follow up with your primary care physician regarding further management of your medications. Return to the emergency department or contact your primary care physician for fevers, chills, dizziness, fainting, chest pain, shortness of breath, confusion, abdominal pain, diarrhea, weakness, or any other concerning symptoms. You should follow up with your primary care physician one week following discharge from rehab. Please call to schedule an appointment at the time of your discharge from rehab. Followup Instructions: Please follow up with your primary care physician 1 week following your discharge from rehab. Please call [**Telephone/Fax (1) 1579**] to schedule an appointment.

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

18037, 18117

10686, 10686

273, 346

18302, 18338

3720, 10663

19951, 20117

2887, 3065

16911, 18014

18138, 18164

16474, 16888

18362, 19928

3080, 3701

222, 235

10715, 16448

374, 2174

18185, 18281

2196, 2716

2732, 2871

64,055

110,024

37038

Discharge summary

report

Admission Date: [**2189-6-16**] Discharge Date: [**2189-6-24**] Date of Birth: [**2107-4-16**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 618**] Chief Complaint: Transfer from OSH for Pre pontine hemmorhage work up and evaluation Major Surgical or Invasive Procedure: None History of Present Illness: The pt is an 82 year-old woman with a PMH of prior colon CA, mild dementia and chronic pain. She was transferred from an OSH therefore this history is almost entirely from the OSH transfer records. She was reportedly in her USOH yesterday. This morning around 1am she fell and struck her head. She reportedly did not have LOC but it is not clear why she fell. She was taken to an OSH where she was evaluated and noted to have difficulty walking and was "incapacitated with back pain". She was however awake and not noted to be severely confused. She may have had a HA. A head CT was obtained which showed SAH around the brainstem. She was then sent for MRI and MRA. This should a large mass of blood around the brainstem but no clear vessel abnormality. She was then transferred here by [**Location (un) **]. Per verbal report she was given 1 gm of Cerebryx prior to transfer. Per the reports she has a history of a fall and was noted to be too unsteady to walk. It seems that she was "incapacities with back pain". Per [**Location (un) **] she developed hypertension shortly prior to arrival and then on route to the ED here she became rapidly obtunded. In the ED she was noted to be unresponsive and stiff with jerking movements. She was then intubated for airway protection. Her ED course was otherwise remarkable for very labile BP's with alternating SBP's in the 60-190's ROS: UA Past Medical History: Hypertension Colon CA Dementia Social History: Married. Lives w/ husband who also has mild dementia is HCP. [**Name (NI) **] 5 children. Family History: Noncontributory Physical Exam: Vitals: T: 98.6 PR P: 90's R: 16 BP: 60-190/ 30-110's SaO2: 96% on ET General: intubated, sedated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: no carotid bruits appreciated. severe nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+ edema Neurologic: -Mental Status: unresponsive to verbal/nox stim prior to intubation with symmetric jerking movements of all extremities, no gaze deviation CN I: not tested II,III: unable to visualize discs III,IV,V: no dolls, EOMI, no ptosis. No nystagmus V: + corneals bilaterally, nasal tickle on the R VII: face symmetric VIII: UA IX,X: no gag [**Doctor First Name 81**]: UA XII: UA Motor: Normal bulk, increased tone throughout. No myoclonus. Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 0--------------- mute R 0--------------- mute -Sensory: No withdrawal to nox stim -Coordination: UA -Gait: UA On discharge: Pertinent Results: [**2189-6-16**] 08:34PM GLU-315* UREA N-29* CREAT-1.5* SODIUM-139 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-17* ANION GAP-18 CK-MB-23* MB INDX-1.4 cTropnT-0.17*, CK(CPK)-1680*, ALT(SGPT)-16 AST(SGOT)-41* LD(LDH)-285* CK(CPK)-1365* ALK PHOS-52 TOT BILI-0.6, LIPASE-14, ALBUMIN-3.2* CALCIUM-7.2* PHOSPHATE-4.3 MAGNESIUM-1.9, TSH-1.6, PHENYTOIN-8.7*, WBC-19.1* RBC-2.85* HGB-9.1* HCT-27.1* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.9, NEUTS-87.0* LYMPHS-10.6* MONOS-2.2 EOS-0.1 BASOS-0.1, PLT COUNT-142* LPLT-1+, PT-13.2 PTT-28.0 INR(PT)-1.1 [**6-16**] Head CT: 1. Large amount of subarachnoid hemorrhage surrounding the brainstem tracking both superiorly and inferiorly as described above with significant mass effect on the brainstem. Trace amount of intraventricular hemorrhage. The exact etiology/source of bleeding is unclear although either a posterior circulation aneurysm/vascular malformation or hemorrhage from spinal vascular lesion is most likely. When feasible, a dedicated CTA or conventional angiogram would be recommended. An urgent neurosurgical consultation is also recommended given the degree of mass effect on the brainstem. 2. Calcified right frontal meningioma with noncalcified right posterior parietal lesion which depicted uniform enhancement on outside MRI. This may represent a non-calcified meningioma (although somewhat atypical for patient age) with additional lesions such as lymphoma or metastases also within the differential. Continued followup is recommended. Findings were marked as urgent, and posted to the ED dashboard immediately after the exam was completed. Findings were also discussed in person with the consulting neurology resident, Dr. [**Last Name (STitle) **] shortly after image acquisition. [**6-16**] CTA: No obvious aneurysm in the ehad on the source images; however, final read is pending review of 3D reformations. Close follow up wit CT head to assess stability of inracranial hemorrhage. Conventional angio if necessary CT c-spine: 1. No acute fracture or malalignment is seen in the cervical spine. 2. Right occipital bone fracture with overlying soft tissue swelling, nondisplaced, nondepressed. 3. Large amount of blood again seen surrounding the brainstem and extending inferiorly into the upper spinal canal causing mass effect on the brainstem and upper thecal sac. In the mid cervical spine, there is narrowing of the canal due to posterior osteophyte formation at multiple levels, with indentation of the thecal sac anteriorly. If there is concern for cord injury or compression, MRI would be recommended for more sensitive evaluation. NOTE ON ATTENDING REVIEW: While I agree with most of the prelim read give above and soft tissue swelling in the right occipital region, the thin lucency noted in the rt. occipital bone can represent part of the sutureverssu non-displaced fracture, more likely the former. Pl.see the details on CTA report. Extent of mass effect on the cervical cord is difficult to assess on the present study and can be better evaluate dwith MR. The source of hemorrhage is not clear and work up to find the cause in the head/ spine is to be considered. [**6-17**] CT abd: Distraction fracture of L1 vertebral body involving the anterior and middle columns with retroperitoneal hematoma extending into the right retroperitoneal space. In addition, hyperdense material is seen anterior to the spinal cord from T12 through L1 which may represent an extra-axial bleed, which is causing posterior displacement of the cord. Evaluation is limited by artifact from vertebral body fixation hardware, which appears grossly intact. Evaluation of the solid intra-abdominal organs is limited by lack of IV contrast; however, the kidneys, liver, and remaining solid intra-abdominal organs appear intact. Moderate amount of fluid in the abdomen and pelvis, likely simple however, cannot exclude small intra-abdominal bleed from unidentified source. NG tube is not in the stomach. Blood in the distal esophagus. Excreted contrast seen in bilateral proximal ureters indicative of renal dysfunction. [**6-17**] MRI spine: Known oblique transverse type fracture involving the L1 vertebral body with sparing of the superior endplate, which transverses both the anterior and posterior margins and is associated with a large epidural hematoma with anterior and posterior elements which pretty much tracts throughout the lumbar and upper sacral spine. There is a mass effect noted on the exiting cauda equina with the nerve roots centrally clumped. This is most marked at the fracture site spanning from T12-L1 where there is little visualized CSF and less marked mass effect more posteriorly where a rim of CSF is again noted and likely relates to the patient's underlying laminectomy which allows some decompression. Additional regions of scattered subdural and epidural hematoma are noted within the cervical and thoracic spine without any significant cord compression. No cord edema is identified. The known peribrainstem hemorrhage is unchanged and the degree of retroperitoneal hematoma and small bilateral pleural effusions is also stable. [**6-18**] CT abd: No evidence of liver laceration. Stable amount of fluid in abdomen and pelvis. Stable size of retroperitoneal hematoma from L1 fracture. No evidence of renal involvement. Probable stable extra-axial hematoma from T12 to L1 around spinal cord, but again difficult to assess due to large amount of streak artifact. [**6-18**] Angio abd: Aortogram demonstrating pseudoaneurysm of a right L1 lumber artery which was successfully embolized selectively with Gelfoam slurry and coils. [**6-22**] CT Head: Stable w/ expected evolution of the infarct Brief Hospital Course: Admitted from Outside hospital after sustaining a fall, striking her head and undergoing CT imaging which showed a pre pontine hemorrage with a positive traponin leak. She was airlifted to [**Hospital1 18**] for further neurosurgical treatment and evaluation. Neuro ICU course: Neuro: Cervicomedullary junction bleed and SAH: Pt was continued on dilantin for possible seizure. EEG was done but was limited by artifact. No epileptiform activity was seen. Dilantin was discontinued and she had no clinical events suspicious for seizure. She was sedated but off sedation when off sedation she moves all extremities and opened her eyes intermittently. She was not following commands. Her exam remained stable and her prepontine hemorrage was considered stable. No aneurysm was found on CTA. Angio was deferred due to ARF and it was not felt to be likely to change management. L1 fx, epidural bleeding, and cord displacement: Spine consulted and recommended fixation. She was kept of log roll precautions. MRI confirmed these findings. CV: Remained stable. Bedside echo confirmed nl LV fxn. Resp: She remained stably intubated on the vent. Extubated [**6-22**] after the family decided to transition to comfort measures. FEN/GI: Retroperitoneal hemorrhage: On CT abdomen she was found to have retroperitoneal heamorrage without any liver lac or other identified source. Angio was done to identify the source and found aortic L1 branch pseudoaneurysm which was successfully embolized w/ coil and gel foam. Heme: Her hematocrit continued to drop, requiring multiple transfusions due to the intraabdominal bleeding until the coiling procedure. Her hematocrit stabilized. Last transfusion was [**6-18**]. ID: She was treated with ceftriaxone for LLL pnuemonia. Antibiotics were broadened to vanc/cipro/zosyn on [**6-18**]. Renal: Her Cr rose as high as 1.6 due to ARF. Contrast loads were minimized and she was treated with mucomyst. By [**6-22**] her Cr had trended back down to 0.7. Endo: she was treated with insulin sliding scale. Code status: Although she was intubated on arrival she was DNR. Social: Family meeting was held [**6-18**] and then repeat family meeting was held on [**6-22**] when bleeding and ARF were stable but her neurologic status was not improving. The family decided to transition her care to comfort measures and she was extubated on [**6-22**] pm. Medications on Admission: pain medications per report Discharge Disposition: Expired Discharge Diagnosis: Pre Pontine Cerebral Hemorrhage Discharge Condition: Patient passed away Discharge Instructions: Patient comfort measures only Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "E888.9", "902.9", "801.21", "806.4", "V10.05", "276.7", "507.0", "868.04", "584.9", "294.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "39.79", "88.42", "88.47", "96.6" ]

icd9pcs

[ [ [] ] ]

11276, 11285

8795, 11196

360, 367

11361, 11383

3101, 3641

11462, 11562

1964, 1981

11306, 11340

11223, 11253

11407, 11439

1996, 2433

3082, 3082

253, 322

395, 1787

8727, 8772

3650, 8718

2448, 3067

1809, 1841

1857, 1948

77,661

194,451

25797

Discharge summary

report

Admission Date: [**2126-8-15**] Discharge Date: [**2126-8-27**] Date of Birth: [**2049-12-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6088**] Chief Complaint: Abdominal aortic aneurysm Major Surgical or Invasive Procedure: [**2126-8-15**] 1. Open repair of abdominal aortic aneurysm with retroperitoneal approach using the bifurcated aortobifemoral graft. 2. Bilateral groin cutdowns. 3. Left profunda endarterectomy. History of Present Illness: This is a 76-year-old male with a history of coronary artery disease and atrial fibrillation with recent CVA while subtherapeutic on Coumadin, now with demonstrated progression of previously-identified abdominal aortic aneurysm from 5 cm in [**2121**] to 6.5 cm on most recent assessment. The patient was consented for open repair of abdominal aortic aneurysm with retroperitoneal approach. He is not a an EVAR candidate because of inadequate diameter, heavily calcified iliac vessels. Past Medical History: CAD, AFIB, Stroke, PVD, AD, AAA, HTN, Gout, Prostate CA Social History: Independent at home, drives. Supportive wife. [**Name (NI) **] home in [**State 108**]. Family History: N/C Physical Exam: T: 99/5 HR 80 BP 142/62 RR 20 Spo2 99% General: alert and oriented x2, mild confusion at times, oob with assist. CN II-XII intact Cardiac: RRR Lungs: dim bases, no resp distress Abd: soft, NT, ND Wound: Flank staples, LE intact. No cellulitis, erythema. Right groin with edemetous, no signs of infection. Pulses: Fem [**Doctor Last Name **] DP PT [**Name (NI) 2325**]: palp dop dop dop Right: palp palp dop dop Pertinent Results: [**2126-8-27**] 07:08AM BLOOD WBC-12.7* RBC-2.80* Hgb-8.8* Hct-27.2* MCV-97 MCH-31.5 MCHC-32.4 RDW-14.6 Plt Ct-322 [**2126-8-26**] 07:15AM BLOOD WBC-15.8* RBC-3.13* Hgb-9.9* Hct-30.9* MCV-99* MCH-31.5 MCHC-31.9 RDW-14.6 Plt Ct-311 [**2126-8-25**] 03:30AM BLOOD WBC-14.7* RBC-2.92* Hgb-9.5* Hct-27.9* MCV-96 MCH-32.5* MCHC-34.0 RDW-14.7 Plt Ct-280 [**2126-8-27**] 07:08AM BLOOD Plt Ct-322 [**2126-8-27**] 07:08AM BLOOD PT-24.3* PTT-33.2 INR(PT)-2.3* [**2126-8-26**] 07:15AM BLOOD Plt Ct-311 [**2126-8-27**] 07:08AM BLOOD Glucose-103* UreaN-27* Creat-1.2 Na-139 K-4.1 Cl-108 HCO3-24 AnGap-11 [**2126-8-26**] 07:15AM BLOOD Glucose-105* UreaN-33* Creat-1.3* Na-141 K-4.7 Cl-110* HCO3-24 AnGap-12 [**2126-8-24**] 03:06AM BLOOD ALT-159* AST-126* AlkPhos-343* TotBili-2.9* [**2126-8-17**] 03:34AM BLOOD CK-MB-90* MB Indx-0.5 cTropnT-0.01 [**2126-8-27**] 07:08AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.9 [**2126-8-26**] 07:15AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.2 OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) 251**] C. Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 251**] on [**Doctor First Name **] [**2126-8-22**] 9:28 AM Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 64250**] Service: VSU Date: [**2126-8-15**] Date of Birth: [**2049-12-10**] Sex: M Surgeon: [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 41313**] PREOPERATIVE DIAGNOSIS: Asymptomatic 6.5 cm abdominal aortic aneurysm. POSTOPERATIVE DIAGNOSIS: Asymptomatic 6.5 cm abdominal aortic aneurysm. OPERATION: 1. Open repair of abdominal aortic aneurysm with retroperitoneal approach using the bifurcated aortobifemoral graft. 2. Bilateral groin cutdowns. 3. Left profunda endarterectomy. IV FLUIDS: 7000 ml of lactated Ringer's; 700 ml packed red blood cells; 1200 ml Cell [**Doctor Last Name **]; 1065 ml of FFP. URINE OUTPUT: 730 ml. ESTIMATED BLOOD LOSS: [**2115**] ml. COMPLICATIONS: None. ASSISTANT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 64251**], MD [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. PATIENT IDENTIFICATION: This is a 76-year-old male with a history of coronary artery disease and atrial fibrillation with recent CVA while subtherapeutic on Coumadin, now with demonstrated progression of previously-identified abdominal aortic aneurysm from 5 cm in [**2121**] to 6.5 cm on most recent assessment. The patient was consented for open repair of abdominal aortic aneurysm with retroperitoneal approach. He is not a an EVAR candidate because of inadequate diameter, heavily calcified iliac vessels. PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. After administration of both vancomycin and gentamicin IV and application of sequential compression stockings induction of general anesthesia was performed. The patient was positioned in right lateral decubitus position with the pelvis left as flat as reasonably possible and was then shaved, prepped and draped in the usual sterile fashion. Bilateral groin incisions were performed in longitudinal fashion with simultaneous dissection performed at each groin initially utilizing electrocautery through the overlying soft tissues. Utilizing Metzenbaum scissors, the common femoral profunda femoris and superficial femoral arteries were identified. Both proximal and distal control was achieved utilizing encircling vessel loops at each branch vessel. Significant calcification was noted at the left superficial femoral artery consistent with known SFA occlusion with remaining patent left profunda femoris artery, also heavily calcified. Initial dissection under inguinal ligament was also started. Attention was then turned to the left flank/subcostal incision which was performed extending from the 11th rib to the lateral border of the rectus abdominis muscle. Dissection was performed utilizing electrocautery through the soft tissues down to the level of the peritoneum which was then carefully retracted utilizing blunt dissection in a medial-to-lateral and both inferior and superior fashion with careful retraction of the intraperitoneal contents anteriorly. A small rent in the peritoneum was identified and primarily repaired. The left renal artery was carefully identified, as well as the left ureter prior to additional dissection. The tissues overlying the abdominal aortic aneurysm were carefully dissected away with visualization of both the infrarenal abdominal aorta and bifurcation and branch vessels. Distal control was facilitated utilizing vessel loops at the left common iliac arteries. The iliacs were too calcified for clamping so we planned to use distal occlusion balloons. The RCIA was difficult to reach with the aneurysm intact. The infrarenal and pararenal arotic neck were dissected and both were soft. The left renal artery was controlled with a silastic loop. We selectd the proximal clamp location above both renals, below the SMA to allow the proximal anastamosis right at the base of the left renal artery. Prior to heparinization iliac tunnels were created. Heparin was then administered and re-dosed as necessary to keep ACTs>280. A bifurcated Dacron 18x9 graft was then chosen and prepped. Following this, a longitudinal arteriotomy was performed along the length of the aneurysm sac with removal of the intra-aneurysmal contents. Following this removal there was no significant bleeding evident from lumbar vessels. Iliac backbleeding with #7 [**Doctor Last Name 18096**] balloons. Attention was immediately turned to performance of the proximal anastomosis. This was completed in a running fashion utilizing 3-0 Prolene suture in a circumferential manner. Upon completion of the proximal anastomosis, the distal portion of the graft was grasped with subsequent removal of the suprarenal clamp restoring flow to the renal vessels. The graft was then adequately flushed with subsequent clamping at each of the graft bifurcations. The proximal anastomosis was hemostatic upon careful examination. Urine output was slow to resume so IV Manitol was given. Urine output resumed approximately 1/2 hour after removal of the proximal clamp. Common iliac arterys were then adressed and oversewn. This required disconnection from the distal aorta and extensive endarterectomies to the mid CIA bilaterally. The endarterectomized CIAs were closed with a double plegeted, technique. Graft limbs were tunnelled to the groins. Attention was then turned to the left limb of the bifurcated graft which was passed in a proximal to distal fashion into the previously-dissected left groin. The left common femoral, superficial femoral and profunda femoris arteries were then crossclamped using atraumatic vascular clamps and an arteriotomy was performed at the left profunda femoris artery. Left distal anastomosis was then performed in running fashion utilizing a running 5-0 Prolene in end-to-side fashion. Prior to completion of the anastomosis, adequate antegrade and retrograde flushing was performed from the common femoral and profunda femoris arteries with flushing utilizing heparinized saline. The right limb of the bifurcated graft was passed to the groin and flusched to check adequate flow. The right common femoral, profunda femoris and superficial femoral arteries were crossclamped using atraumatic vascular clamps and a longitudinal arteriotomy was performed in the right common femoral artery down onto the proximal SFA. Anastomosis was performed utilizing running 5-0 Prolene sutures in end-to-side fashion. Prior to completion again, the arteries were flushed in both antegrade, retrograde fashion with flushing utilizing heparinized saline. Upon completion of the anastomosis, the atraumatic vascular clamps were completely removed. Assessment performed utilizing continuous Doppler demonstrated adequate flow at the right common femoral, profunda femoris and superficial femoral arteries. Assessment of the left groin, however, demonstrated minmal antegrade flow at the left profunda femoris artery. The SFA was known to be chronically occluded. It was, therefore, felt that the anastomosis should be taken down and re-done. This was done on the lateral side, leaving the heel and toe of the dacon graft in place. We found an occlusive calcified plaque that had lifted in the PFA. Endarterectomy of this area was performed with a clean endpoint. Backbleeding from the PFA was excellent after doing this. Additional posterior tacking sutures were used. An additional bovine pericardial patch was utilized for closure of the profunda femoris artery, effectively extending the patch 2.5cm onto the PFA. The anastomosis was completed and after both antegrade and retrograde flushing of the vessels with subsequent removal of the replaced vascular clamps. This resulted in widely-patent flow by continuous Doppler through the profunda femoris artery. Attention was then turned back to the retroperitoneal abdominal aorta where meticulous hemostasis was obtained. AAA sac was closed over the graft with 2-0 PDS. The flank incision was then closed utilizing a #1 PDS looped suture closing the fascial layers at the transversus abdominis and internal oblique. A #1 looped PDS was then utilized to close a second layer of external oblique and anterior rectus fascia. The skin was then closed utilizing skin staples. Attention was then turned to the groin incisions which were closed respectively with multiple layers of interrupted 3-0 Vicryl sutures, first closing the overlying femoral sheath, the subcutaneous tissues and subdermal layers. The skin was then closed with staples as well. The patient given significant volume resuscitation required during the open aortic procedure, remained intubated and was transferred stable and in good condition to the intensive care unit postoperatively. The right DP was palpable and the left PT was dopplerable as they were preoperatively. [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD was present for the entire procedure. [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 41315**] ART DUP EXT LO UNI;F/U LEFT Clip # [**Clip Number (Radiology) 64252**] Reason: S/P AROTO [**Hospital1 **] FEM AND LEFT PROFUNDA ART ENDART, ASSESS LT LEG [**Hospital 93**] MEDICAL CONDITION: 76 year old man s/p open AAA repair now with changing distal pulse exam. Pt has known occluded R SFA, s/p L profunda endarterectomy REASON FOR THIS EXAMINATION: LLE vascular supply, occlusion/dvt Final Report HISTORY: 76-year-old gentleman status post aortobifemoral bypass with known occluded right superficial femoral artery. Presenting with changing distal pulses. TECHNIQUE: Evaluation of the femoral arteries in the left groin was performed with B-mode, color and spectral Doppler ultrasound. FINDINGS: The distal end of the bypass graft is patent with monophasic Doppler waveforms and peak systolic velocities ranging between 57 and 76 cm/sec. A peak systolic velocity of 67 cm/sec was seen at the graft-to-artery anastomosis. In the native common femoral artery a peak systolic velocity of 152 cm/sec was noticed with monophasic Doppler waveforms. The flow was not visualized in the left superficial femoral artery due to known occlusion. Monophasic Doppler waveforms and peak systolic velocities ranging between 78 and 127 cm/sec were seen in the left profunda femoral artery. COMPARISON: None available. IMPRESSION: Patent distal bypass graft to the left lower extremity. Patent left common femoral and profunda femoral arteries with monophasic Doppler waveforms. Final Report CHEST RADIOGRAPH INDICATION: AAA repair. COMPARISON: [**2126-8-22**]. FINDINGS: As compared to the previous radiograph, there is improvement with increased ventilation of the retrocardiac lung areas and near total resolution of the pre-existing retrocardiac atelectasis. No pleural effusions. No pulmonary edema. No pneumonia. The nasogastric tube and the right central venous access line have been removed in the interval. Borderline size of the cardiac silhouette with enlargement of the left ventricle. [**Last Name (LF) **],[**First Name3 (LF) 251**] C. VSURG CSRU [**2126-8-21**] 12:49 PM LIVER OR GALLBLADDER US (SINGL Clip # [**Clip Number (Radiology) 64253**] Reason: eval for flow to liver/gall bladder in pt w abdominal pain [**Hospital 93**] MEDICAL CONDITION: 76 year old man s/p AAA repair REASON FOR THIS EXAMINATION: eval for flow to liver/gall bladder in pt w abdominal pain Provisional Findings Impression: AGLc WED [**2126-8-21**] 5:09 PM PFI: Main portal vein is widely patent with normal hepatopetal flow. Aorta not well assessed. Final Report HISTORY: 76-year-old male status post AAA repair. Patient with abdominal pain. Per son[**Name (NI) 930**] discussion with Dr. [**First Name8 (NamePattern2) 3692**] [**Last Name (NamePattern1) **], patient is here to assess for evidence of main portal vein thrombosis. COMPARISON: MRA runoff from [**2122-8-17**], and abdominal ultrasound from [**2122-8-17**]. ABDOMINAL ULTRASOUND: The current study, performed portably, is technically limited. Allowing for this, the liver appears normal in echotexture and architecture, with no focal liver lesion seen. The main portal vein is patent with normal wall-to-wall flow. No intra- or extra-hepatic bile duct dilation is seen, with the common duct measuring 5 mm. The gallbladder appears normal, without evidence of stones. Visualization of the pancreas is limited due to bowel gas; however, the visualized portions of the pancreatic head and neck show no focal abnormality. The spleen is not enlarged, measuring 10.6 cm. No ascites is seen in the visualized four quadrants of the abdomen. The aorta is not well assessed due to bowel gas. A single image shows a small area of central color flow (with diameter measuring approximately 1.5 cm), with no flow seen in the periphery of the mid abdominal aorta. This is compatible with flow within the AAA graft and thrombosis in the aneurysm sac, but imaging is extremely limited. The visualized intrahepatic IVC is unremarkable. The kidneys measure 10.1 cm on the right and 10.7 cm on the left. There is limited visualization of the left kidney, however, 6-mm nonobstructing calculi in the interpolar and lower pole of the left kidney are unchanged from [**2122-8-17**]. 3.6-cm partially exophytic upper pole left renal cyst is as previously seen. Previously seen interpolar left renal cyst is not visualized. No hydronephrosis is seen in the kidneys. IMPRESSIONS: 1. Main portal vein is widely patent with normal hepatopetal flow. 2. Aorta not well assessed due to overlying bowel gas. 3. Left renal calculi (nonobstructing) and cyst, unchanged. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: On [**2126-8-15**] The patient was taken to the OR for open AAA via a retroperitoneal approach. He did well intraoperatively. Post operatively he was intubated and sedated in the ICU on a pressers (phenylephrine). He received multiple units of blood for surgical blood loss. Incisions stable and intact without active bleeding. On POD #1 on physical exam the left calf was noted to be tight and there was concern of compartment syndrome. CK's were monitored and trended. Tmx 102. Orthopedic consult for possible compartment syndrome, continued to monitor for changes hourly in ICU. Patient was kept intubated in the ICU for several days. Left leg compartment pressures and CK's slowly trended down. On [**2126-8-18**] the patient received 2 additional units of blood. Extubated attempted successfully. Pain under adequate management. CXR did show bilateral basilar atelectasis with pleural effusions. Levo started for PNA, (+ Ecoi culture). Continued diuresis daily with lasix and diamox as needed. On [**2126-8-19**] the patient continued to improve slowly. He had a bedside swallow evaluation which he failed, kept NPO including oral medications. On [**2126-8-21**] a Dobbhoff was placed. All medication including Coumadin were restarted. Pulmonary toilet encouraged, the patient got OOB with Physical therapy. On [**2126-8-21**] the patient was transferred to the Vascular floor. PICC placed for access/blood draw. Continued on tube feeding and Levaquin. Repeat speech exam passed on [**2126-8-22**] for thin liquids and ground solids. Rehab screening. Patient continues to have some mild confusion, working with PT daily. Discharged to Rehab on [**2126-8-27**]. PICC and Dobbhoff had been removed. Levaquin course was complete prior to transfer. Will follow up with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: Allopurinal 100, Amlodipine 10, Atenolol 50'', Atorvastatin 20, Lisinopril 40, Tamsulosin 0.4, Coumadin 2.5, Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-24**] Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: goal INR [**12-26**] (AFIB). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: AAA PMH: Coronary artery disease AFIB Stroke Peripheral Vascular Disease Hypertension Gout Prostate CA 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 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 [**4-30**] 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 [**12-26**] 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 Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2126-9-4**] 10:00 Completed by:[**2126-8-27**]

[ "272.4", "V12.54", "728.88", "458.29", "V58.61", "V10.46", "782.4", "788.5", "482.82", "441.4", "274.9", "401.9", "414.01", "440.20", "276.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "00.40", "38.44", "96.6", "38.18", "00.44", "38.48" ]

icd9pcs

[ [ [] ] ]

19752, 19930

16858, 18676

341, 546

20077, 20077

1827, 12295

22945, 23118

1263, 1268

18835, 19729

14419, 14450

19951, 20056

18702, 18812

20228, 22492

22518, 22922

1283, 1808

276, 303

14482, 16835

574, 1063

20092, 20204

1085, 1142

1158, 1247

65,760

170,683

8828+55980

Discharge summary

report+addendum

Admission Date: [**2158-12-21**] Discharge Date: [**2158-12-29**] Date of Birth: [**2102-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Right shoulder and abdominal pain Major Surgical or Invasive Procedure: [**2158-12-26**]: Inferior vena cava gram and left iliac venogram. with Placement of Bard G2 inferior vena cava filter by left femoral vein approach. History of Present Illness: 56M, otherwise healthy, describes onset of right shoulder and then ruQ right sides abdominal pain a little over 48 hours ago. Denies any history of trauma. Pain is sharp, constant all along his right side, worse with some movements. Never had symptoms like this before ROS: Denies any n/v/f/c/d/c/cp/sob. Past Medical History: GERD Physical Exam: PE: 101.4 115 170/80 18 98%RA NAD AOx3 CTAB RRR soft, mild-mod distended, somewhat tender mid abdomen and RUQ, no murphys no rebound or guarding no c/c/e guiac neg no masses Labs: PT: 14.0 PTT: 26.0 INR: 1.2 Lactate:1.1 134 97 7 123 3.9 27 1.0 ALT: 84 AP: 61 Tbili: 0.4 Alb: AST: 42 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 19 11.0 D 8.1 D 219 hct22.9 D N:77.9 L: CT: High density abdominal fluid especially around liver consistent with hemorrhage. Most likely source is hepatic adenoma Pertinent Results: [**2158-12-29**] 06:50AM BLOOD WBC-9.8 RBC-3.53* Hgb-11.2* Hct-33.3* MCV-94 MCH-31.6 MCHC-33.5 RDW-15.0 Plt Ct-592* [**2158-12-27**] 05:20AM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3* [**2158-12-27**] 05:20AM BLOOD Glucose-99 UreaN-10 Creat-0.9 Na-135 K-3.7 Cl-99 HCO3-26 AnGap-14 [**2158-12-27**] 05:20AM BLOOD ALT-98* AST-93* AlkPhos-126* TotBili-1.4 [**2158-12-26**] 05:25AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 [**2158-12-27**] 05:20AM BLOOD AFP-1.6 Brief Hospital Course: He was admitted to the SICU and transfused with PRBC for a hematocrit of 22. Hct increased to 25 and he was given 2 more units of PRBC. On [**12-21**], ABD CT demonstrated perihepatic hematoma with hemoperitoneum. Given the apparent lack of trauma, the most likely cause was an underlying parenchymal lesion in the liver dome such as adenoma. An angio was performed on [**12-22**] with no bleeding source identified. He required further transfusion with prbc then hct stabilized at 29. He spiked fevers and was pan-cultured. WBC ranged between 9.5 and 11. IV Vanco and Zosyn were given for 4 days. These were switched to po cipro and flagyl. Stools were negative for c.difficile. He continued to have fevers of 101 daily likely due to the peri-hepatic hematoma. AFP was 1.6. On [**12-25**], repeat CT was done showing no abscess, no significant interval change in the appearance of the perihepatic hematoma and hemoperitoneum since the prior exam. There were hypoattenuating liver lesions not fully characterized. There was incidental finding of non-occlusive right common iliac vein thrombosis. An IVC filter was placed by vascular surgery on [**12-26**]. Anti-coagulation was not started due to the previous hepatic bleeding. An outpatient hypercoagulable workup was recommended. He also developed a superficial phlebitis on the dorsum of his left hand and antecubital site. Both sites were improved at time of discharge. Medications on Admission: none Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Perihepatic hematoma with hemoperitoneum Acute deep venous thrombosis in the right common femoral vein Discharge Condition: Stable/good Discharge Instructions: Please call Dr [**Last Name (STitle) 9411**] office at [**Telephone/Fax (1) 673**] for increased abdominal pain, fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down food, fluid or medications or any other concerning symptoms. If you have sudden or acute abdominal pain you should proceed to the nearest emergency room for evaluation Please follow up with your primary care physician as well as Dr [**First Name (STitle) **] for continued evaluation No heavy lifting or strenuous physical activity Paperwork for employment claim has been filled out Followup Instructions: Please follow up with your primary care physician Dr [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] within the next 2 weeks ([**Telephone/Fax (1) 1300**] Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Date/Time [**2159-1-5**] 2:30 PM Completed by:[**2159-1-2**] Name: [**Known lastname 5387**],[**Known firstname 5388**] Unit No: [**Numeric Identifier 5389**] Admission Date: [**2158-12-21**] Discharge Date: [**2158-12-29**] Date of Birth: [**2102-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2800**] Addendum: On [**12-26**], a CT of the chest revealed two pulmonary nodules in the right and left upper lobes, respectively. A followup CT scan in three months was recommended to ensure stability of these findings. Discharge Disposition: Home [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2159-1-2**]

[ "573.8", "211.5", "453.41", "568.81", "451.82", "518.89" ]

icd9cm

[ [ [] ] ]

[ "88.47", "99.04", "38.7", "38.91" ]

icd9pcs

[ [ [] ] ]

5376, 5540

1890, 3318

349, 506

3789, 3803

1420, 1867

4427, 5353

3373, 3613

3663, 3768

3344, 3350

3827, 4404

884, 1401

276, 311

534, 841

863, 869

32,131

171,517

48974

Discharge summary

report

Admission Date: [**2163-4-20**] Discharge Date: [**2163-4-22**] Date of Birth: [**2087-2-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 76F with severe R sided CHF, pulm HTN, 3+TR, ILD [**12-25**] amio toxicity on 3L home O2, afib presents with SOB and rising creatinine. Of note, the patient was only discharged from [**Hospital1 18**] yesterday after she was treated from [**4-8**] to [**4-19**] for progressive dyspnea [**12-25**] pulm HTN and R heart failure. She was evaluated by the pulmonary consult service who pursued a trial of sildenafil which the patient did not tolerate due to orthostatic hypotension. She found the BiPAP mask uncomfortable. Digoxin was added to her medication regimen with what was felt to be a good effect. Her hospital course was remarkable for tenuous oxygenation status requiring repositioning bed to improve sats, low blood pressures with SBP in 80s - 90s, and low urine output. UOP was noted to be 200 cc/day with a creatinine that remained stable at baseline of 0.5-0.7 until the day of discharge when it was noted to be 1.7, the plan was to monitor this closely at the rehab. At rehab, the creatinine was noted to be rising and the pt developed SOB. She returned to the ED for further evaluation and treatment. In the ED, initial vitals were t 97.5 p 64 bp 117/76, rr 16 99 on NRB. She was given vanc, zosyn to treat a possible PNA. CXR showed increasing bilateral effusions, no evidence of acute CHF or PNA. There was no fever or leukocytosis. Creatinine was noted to be up to 2.7. ABG was 7.33/69/87. She was infused 700 cc NS. She was admitted to MICU team for further management. . Past Medical History: 1. Atrial fibrillation, on coumadin and Sotalol 2. Interstitial lung disease, thought to be due to amiodarone toxicity 3. Basal cell carcinoma of the right face status pos surgical excision 4. Squamous cell carcinoma of the left eyelid 5. Hiatal Hernia 6. Right knee surgery 7. Left knee arthroscopic surgery 8. Status post cholecystectomy [**2113**] 9. Status post hysterectomy 10. Acute lumbar disc herniation, with multilevel cervical and lumbosacral radiculopathy.(chronic L5-S1 radiculopathy bilaterally, acute L4 radiculopathy) Social History: Social History: Lives with her husband. [**Name (NI) 4084**] smoked, does not drink alcohol. Family History: Family History: Parents died of intracranial hemorrage. Daughter with breast cancer. Brother and sister died from "enlarged heart" Physical Exam: VS: T 97.3, BP 89/40, HR 64, rr 26 SpO2 96-100% on NRB Gen: awake, alert, A+Ox3, mild resp distress HEENT: clear OP, MMM Neck: supple, no JVD to angle of jaw CV: RRR, systolic murmur LLSB Resp: dry crackles throughout Abd: soft nt/nd, +BS Ext: wwp, trace edema Pertinent Results: [**2163-4-19**] 07:15AM WBC-9.1 RBC-4.55 HGB-13.9 HCT-42.8 MCV-94 MCH-30.5 MCHC-32.5 RDW-16.2* [**2163-4-19**] 07:15AM PLT COUNT-180 [**2163-4-19**] 07:15AM GLUCOSE-101 UREA N-27* CREAT-1.7* SODIUM-138 POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-35* ANION GAP-17 [**2163-4-19**] 07:15AM PHOSPHATE-5.9* MAGNESIUM-2.0 [**2163-4-20**] 06:30PM NEUTS-77.0* LYMPHS-14.7* MONOS-7.2 EOS-0.4 BASOS-0.6 [**2163-4-20**] 06:30PM NEUTS-77.0* LYMPHS-14.7* MONOS-7.2 EOS-0.4 BASOS-0.6 [**2163-4-20**] 06:30PM WBC-10.0 RBC-4.26 HGB-13.6 HCT-39.7 MCV-93 MCH-32.0 MCHC-34.3 RDW-16.6* [**2163-4-20**] 06:30PM ALT(SGPT)-1004* AST(SGOT)-1353* LD(LDH)-1104* ALK PHOS-92 TOT BILI-1.1 [**2163-4-20**] 06:30PM GLUCOSE-151* UREA N-49* CREAT-2.7* SODIUM-132* POTASSIUM-5.3* CHLORIDE-89* TOTAL CO2-32 ANION GAP-16 [**2163-4-20**] 06:42PM GLUCOSE-146* LACTATE-2.4* NA+-133* K+-5.2 CL--86* Brief Hospital Course: 76F with severe R sided CHF, pulm HTN, 3+TR, ILD [**12-25**] amio toxicity on 3L home O2, afib presents with SOB and rising creatinine. She had baseline severe pulm HTN with RV failure, 3+TR. There was an attmpt to optimize renal status. She likely had poor renal perfusion from severe RV failure/pulm HTN leading to poor LV preload. Urine sediment appeared c/w ATN. She was also noted to have transaminitis likely [**12-25**] congestive hepatopathy. Had hep serologies last admission which were negative. RUQ ultrasound [**2163-4-9**] showed no significant pathology. Unfortunately, during her admission, her respiratory status could not be stabilized and her creatininte continued to rise. Her family decided to tranistion her to comfort measures and she passed away on [**2163-4-22**]. Medications on Admission: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp<90, hr<60. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**] Drops Ophthalmic PRN (as needed). 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) be treatment Inhalation Q4H (every 4 hours) as needed for wheezing or shortness of breath. 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety, shortness of breath. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-24**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-24**] Sprays Nasal QID (4 times a day) as needed. 13. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal TID (3 times a day) as needed. 14. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: to be adjusted based on INR. 15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient passed away. Discharge Condition: Discharge Instructions: Followup Instructions: [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "E942.0", "V10.83", "584.5", "515", "785.50", "276.51", "553.3", "397.0", "790.4", "V58.61", "416.8", "427.31", "428.0", "518.81", "V45.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6283, 6292

3857, 4648

318, 324

6358, 6358

2960, 3834

6438, 6504

2546, 2663

6255, 6260

6313, 6335

4674, 6232

6384, 6384

2678, 2941

275, 280

352, 1845

1867, 2403

2435, 2514

57,678

102,554

54279

Discharge summary

report

Admission Date: [**2182-6-13**] Discharge Date: [**2182-6-22**] Date of Birth: [**2114-2-15**] Sex: M Service: NEUROLOGY Allergies: Bactrim Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: aphasia, rightside plegia Major Surgical or Invasive Procedure: none History of Present Illness: Professor [**Known lastname 111203**] is a 64-year-old gentleman with a history of atrial fibrillation last INR 1.2, who was last seen normal at 11:30 to 12 am who presents with new onset aphasia and right hemiplegia. Patient had spent the day playing with his grandchildren. He then was watching the Red Sox game on TV and it is unclear when he went to bed. The son was [**Location (un) 1131**] a book and thinks he heard him around midnight. At some point in the night he woke up and went down stairs. The wife also went down stairs and noted his speech was garbled. The daughter came home a little after 2 and noted he had a right facial droop and called 911. His wife observed that his right arm and leg were becoming weak. EMS was called at 2:45 for slurred speach, he was found to be aphasic with right sided weakness and a facial droop. He went to [**Hospital3 **] where a CT had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] left MCA sigh, loss of [**Doctor Last Name 352**] weight differentiation. An MRI was done which showed some restricted diffusion in the left insula and a cut off of the M1. The [**Hospital3 **] medical staff considered that he was past the time window for iv TPA and thought that he was not a candidate. He was then transferred to [**Hospital1 18**] for possible intervention with the mechanical clot retrieval device. Of note his INR was 1.2 at the OSH. Wife states he is inconsistent with taking his medications and sometimes forgets. On general review of systems, the pt denies recently had some diarrhea from his return from Barcelona this past week. But no recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: -Atrial fibrillation. -Noninsulin dependent diabetes mellitus. -Hypertension. -Hyperlipidemia. -CAD w stents -Depression Social History: Minimal EtOH, Former smoker. Lives at home with his wife. [**Name (NI) **] is a [**University/College 5130**] professor of business. He has 4 children. Family History: no history of strokes Physical Exam: Vitals: T:98.4 P:82-103 R:18-24 BP:96-140/45-74 SaO2:94-99% RA to 2LNC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, Global aphasia -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF III, IV, VI: EOMI V: sensation intact VII: right facial droop VIII: appears intact IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: RUE: no movement. plegic, flaccid RLE: toes wiggle, but unable to move in plane of gravity or antigravity Full spontaneous movement of left upper and lower extremity. -Sensory: Grimaces to noxious stimuli in RUE, withdraws on RLE as well as left side -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor on left and extensor on the right. Pertinent Results: Laboratory: ADMISSION LABS [**2182-6-13**] 05:44AM BLOOD WBC-8.6 RBC-4.24* Hgb-14.1 Hct-41.5 MCV-98 MCH-33.2* MCHC-33.9 RDW-13.8 Plt Ct-163 [**2182-6-17**] 10:10PM BLOOD Neuts-82.0* Lymphs-10.9* Monos-4.7 Eos-2.2 Baso-0.2 [**2182-6-13**] 05:44AM BLOOD PT-14.5* PTT-25.3 INR(PT)-1.3* [**2182-6-13**] 05:44AM BLOOD Glucose-263* UreaN-28* Creat-1.1 Na-140 K-4.8 Cl-104 HCO3-28 AnGap-13 [**2182-6-13**] 09:39AM BLOOD ALT-22 AST-27 LD(LDH)-224 CK(CPK)-131 AlkPhos-56 . RISK FACTORS [**2182-6-13**] 09:39AM BLOOD CK-MB-5 [**2182-6-13**] 09:39AM BLOOD cTropnT-<0.01 [**2182-6-13**] 11:39PM BLOOD CK-MB-5 [**2182-6-17**] 10:10PM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9 Iron-19* Cholest-131 [**2182-6-13**] 09:39AM BLOOD Albumin-3.7 Cholest-129 [**2182-6-17**] 10:10PM BLOOD Triglyc-81 HDL-56 CHOL/HD-2.3 LDLcalc-59 [**2182-6-13**] 09:39AM BLOOD %HbA1c-6.4* eAG-137* [**2182-6-17**] 10:10PM BLOOD calTIBC-295 TRF-227 [**2182-6-13**] 09:39AM BLOOD TSH-2.9 [**2182-6-13**] 09:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG. . Discharge labs: DISCHARGE LABS [**2182-6-22**] 07:10AM BLOOD WBC-7.5 RBC-3.78* Hgb-12.5* Hct-36.0* MCV-95 MCH-33.0* MCHC-34.6 RDW-13.9 Plt Ct-260 [**2182-6-22**] 07:10AM BLOOD PT-27.6* PTT-37.8* INR(PT)-2.6* [**2182-6-22**] 07:10AM BLOOD Glucose-255* UreaN-24* Creat-0.7 Na-138 K-4.6 Cl-97 HCO3-32 AnGap-14 [**2182-6-22**] 07:10AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 . . Urine: [**2182-6-13**] 05:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025 [**2182-6-13**] 05:42PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2182-6-13**] 05:42PM URINE RBC-56* WBC-9* Bacteri-FEW Yeast-NONE Epi-0 [**2182-6-13**] 05:42PM URINE Mucous-RARE [**2182-6-13**] 05:42PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . IMAGING Cardiology Report ECG [**2182-6-13**]: IMPRESSION: Atrial fibrillation, average ventricular rate 91. There appears to be aberrant conduction during short coupled beats. No previous tracing available for comparison. . ED STROKE CTA HEAD & NECK WITH PERFUSION [**2182-6-13**]: IMPRESSION: 1. Hyperdense left MCA, with absent filling on angiography indicative of occlusion. 2. Large area of increased MTT in left MCA distribution with smaller area of low blood volume indicating area of ischemia to be larger than infarct. . CHEST (PORTABLE AP) Study Date of [**2182-6-13**]: IMPRESSION: There is mild cardiomegaly. There are low lung volumes. There are bibasilar atelectasis. No evidence of aspiration. There is no pneumothorax or pleural effusion. . CHEST (PORTABLE AP) Study Date of [**2182-6-14**]: IMPRESSION: Mild cardiomegaly is stable, but pulmonary vascular engorgement suggests early cardiac decompensation or volume overload. Pleural effusion is minimal if any. No pneumothorax. . MR HEAD W/O CONTRAST [**2182-6-14**]: IMPRESSION: Thrombus is visualized in the left cavernous and petrous portion of the internal carotid artery with infarction visualized in the left frontal lobe, caudate, and putamen. Areas of microhemorrhage are visualized in the left caudate and putamen with no evidence of macrohemorrhage. . CHEST (PORTABLE AP) [**2182-6-15**]: Study was centered in the thoracoabdominal region. NG tube tip is in the stomach. Evaluation of the chest is very limited due to technique and projection. The visualized lungs and cardiomediastinum are unchanged. . CHEST (PA & LAT) [**2182-6-17**]: Low lung volumes with incresed vascular congestion suggesting cardiac decompensation or volume overload. Bilateral pleural effusions if any appear minimal. . CHEST (PORTABLE AP) [**2182-6-19**]: In comparison with study of [**6-17**], the tip of the nasogastric tube extends well into the stomach. Continued enlargement of the cardiac silhouette with pulmonary edema. The possibility of a supervening consolidation at one or both bases cannot be definitely excluded. . CHEST (PORTABLE AP) [**2182-6-21**]: Tip of Dobbhoff in the stomach, but the end of the weight portion is near the GE junction. Recommend advancing 4 to 5 cm to ensure proper position. . . Cardiology: PORTABLE TTE [**2182-6-14**]: IMPRESSION: The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect.RV with normal free wall contractility. 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. The mitral valve leaflets are elongated. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . ECG Study Date of [**2182-6-13**] 6:05:22 AM Atrial fibrillation, average ventricular rate 91. There appears to be aberrant conduction during short coupled beats. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 91 0 88 [**Telephone/Fax (2) 111204**]3 Brief Hospital Course: Primary diagnoses: Left middle cerebral artery stroke secondary to atrial fibrillation with subtherapeutic INR . Secondary diagnosis: Hypertension Diabetes Possible sleep apnea . . . Mr. [**Known lastname 111203**] is a 64 year old Professor [**First Name (Titles) **] [**Last Name (Titles) 111205**] at [**University/College 5130**] with h/o AF (poorly compliant with therapy as last INR 1.2) who presented with new onset aphasia and right hemiplegia with R facial droop. Symptoms were of a stuttering infarct suggestive of cardioembolic disease. . . # Left MCA infarct: He initially presented to [**Hospital3 **] where head CT showed a dense left MCA sign, loss of [**Doctor Last Name 352**] weight differentiation. Patient did not receive TPA. An initial MRI at OSH showed restricted diffusion in the left insula and a cut off of the M1. The [**Hospital3 **] medical staff determined that he was outside of the window for giving iv TPA. He was then transferred to [**Hospital1 18**] for the possibility of intervention with a mechanical clot retrieval device. Upon arrival to [**Hospital1 18**] he had an NIHSS of 21, he was alert, aphasic, right hemianopia, right facial droop, plegic right upper, and paretic right lower extremity. A follow up CTA demonstrated ~50% narrowing of L internal carotid artery just after the bifurcation and CTP demonstrated increased MTT throughout MCA distribution. Given extensive infarction the decision was made that given the extended time window and already decreased CBV in a sizeable area of the brain, the decision against intervention was made for fear of high-risk for hemorrhagic complications. Patient was transferred to the Neuro ICU and started on a heparin gtt in hopes of stabilizing the clot. Repeat MRI here showed infarction in the left frontal lobe as well as the left caudate and putamen and MRA showing thrombus in the left cavernous and petrous portion of the internal carotid artery with areas of microhemorrhage in the left caudate and putamen with no evidence of macrohemorrhage. Warfarin was restarted on [**6-16**]. Additional Stroke Risk factors were addressed with HbA1c 6.4%, cholesterol 131 and LDL 59 TSH 2.9. Echo showed no cardiac cause for his stroke with no VSD/ASD or PFO noted and normal LV systolic function with EF>55%. In addition, there was moderate-severe biatrial dilatation. Patient received PT and OT. Patient initially failed swallow assessment and an NG tube was inserted. As his clinical picture improved, his swallow improved and did well with assessment on [**6-21**] with coughing afterwards ? representing aspiration. Advice was that he should have a Dobbhoff tube placed with repeat evaluation later in the week. He has evidence of improvement and would likely not require PEG tube. As with speech, he neurologically improved, especially speech - at the time of discharge he was slightly antigravity at hip flexion. IV heparin was transitioned to enoxaparin and INR was 2.6 on discharge and LMWH was stopped and warfarin dose reduced to 5mg. We continued pravastatin 40mg daily. Patient was transferred to rehab on [**2182-6-21**] and has neurology follow-up on [**2182-8-13**]. # Cardiovascular: Patient has a history of AF but admission INR was subtherapeutic at 1.2. Echo showed no cardiac cause for his stroke with no VSD/ASD or PFO noted and normal LV systolic function with EF>55%. In addition, there was moderate-severe biatrial dilatation. Patient was rate controlled initially with IV metoprolol PRN and we continued dofetilide. Given that patient is on dofetilide, we monitored patient with daily Chem 7 and repleted electrolytes of K to 4 and Mg to 2. Patient had mild HTN and we added half dose lisinopril [**6-21**]. We continued pravastatin 40mg daily. metoprolol should be restarted at rehabiliation and his lisinopril increased as tolerated back to his home dose. # Diabetes: Patient has a history of T2DM on glipizide and pioglitazone. BGLc was well controlled in house with an ISS and oral diabetic medications were held. HbA1c 6.4%. Oral medications should be restarted at rehab. # Pulmonary: Patient had difficulty with secretions while on the ICI and likely had some problems with mucus plugging. He required regular suctioning and once on the floor he greatly improved and suctioning frequency had greatly diminished. He remains at risk for aspiration and should be seen by speech therapy as above for repeat swallow evaluation. In addition, the patient likely has sleep apnea as sats were seen to drop when he falls asleep. His wife confirmed a history of snoring and respiratory changes in sleep. We did not pursue CPAP given risks for aspiration. PCP should consider [**Name Initial (PRE) **]/p eval for sleep apnea work up on d/c. # FEN: NG tube was inserted in ICU and Dobbhoff placed on [**6-21**] and in correct place on CXR. Currently receiving NG feed but signs of fluid overload should be assessed and of the patient appears to have congestion, a more concentrated feed can be considered. #Precautions: Falls and aspiration # CODE: FULL CODE # Contact: home: Wife [**Name (NI) **] [**Telephone/Fax (1) 111206**] Children: [**Location (un) **]: [**Telephone/Fax (1) 111207**] [**Doctor First Name **]: [**Telephone/Fax (1) 111208**] [**Doctor First Name **]: [**Telephone/Fax (1) 111209**] [**Female First Name (un) **]: [**Telephone/Fax (1) 111210**] Medications on Admission: Tikosyn 500 mcg p.o. b.i.d. Coumadin 4 mg p.o. daily. Prastatin 40 mg p.o. daily. Lopressor 25 mg p.o. b.i.d. Glipizide XL 20 mg p.o. daily. Actos 45 mg p.o. daily. Lisinopril 20 mg p.o. daily. Paroxetine 20 mg p.o. daily. Folic Acid and Vitamin D Discharge Medications: 1. dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. paroxetine HCl 10 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 9. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain, fever. 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): while NG Tube in place. 11. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 15. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 16. glipizide 10 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO once a day. 17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: Left middle cerebral artery stroke secondary to atrial fibrillation with subtherapeutic INR . Secondary diagnosis: Possible sleep apnea Discharge Condition: Mental Status: Patient understands questions but is significantly aphasic, can follow simple commands Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurologic: No movement of the right arm, proximal>distal weakness of the right leg. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented following sudden onset right-sided weakness and speech problems. [**Name (NI) **] had a CT scan in the ED which showed evidence of a stroke involving he left side of the brain which accounts for your symptoms. You were transferred to the ICU for closer monitoring. Your stroke affected your swallowing and an NG tube was placed. The likely cause for your stroke was due to your atrial fibrillation which in light of an indaequate warfarin level (INR) meaning that the blood was not sufficiently thin, predisposes to clot formation in the heart which can then travel to the brain and cause a stroke. For your atrial fibrillation, you were started initially on an IV form of heparin, to thin your blood until another blood thinner called warfarin is at an appropriate level. As you are now on warfarin you must be careful regarding any falls as you will bleed more and especially if you were to hit your head as this can cause bleeding in the brain. If you fall, you should seek medical attention. You had a new feeding tube placed on [**6-21**] prior to transferring to rehab. And you will need continued swallowing evaluation to determine when it will be safe to take food and medications by mouth. Your oxygen level was noted to fall when you went to sleep and this suggests that you have sleep apnea. Your PCP should arrange [**Name9 (PRE) 8019**] for this. You were transferred to a rehab facility to continue your stroke rehabilitation. You have neurology follow-up as below. Medication changes: We INCREASED warfarin to 5mg daily We DECREASED lisinopril to 10mg daily We STARTED albuterol and ipratropium nebulisers as required for your breathing difficulties We STARTED laxatives Please continue your other medications as prescribed Followup Instructions: You should follow-up with your PCP [**Name Initial (PRE) 176**] 1 week after discharge from rehab. [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 26774**] You also have the following neurology follow-up appointment. Department: NEUROLOGY When: TUESDAY [**2182-8-13**] at 1 PM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2182-6-22**]

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Discharge summary

report+addendum

Admission Date: [**2111-4-12**] Discharge Date: [**2111-4-21**] Date of Birth: [**2033-8-17**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2111-4-14**] Aortic valve replacement (21mm porcine), Tricuspid Valve repair (30mm ring) [**2111-4-13**] Cardiac cath History of Present Illness: 77 year old female who presented on [**2110-12-20**] with sudden onset of left sided weakness, slurred speech, and headache with right-sided frontal hypodensity on NCHCT at [**Hospital3 **] in setting of sub-therapeutic INR and subsequently transferred to [**Hospital1 18**] for further management. On admission to [**Hospital1 18**], she was treated for a stroke but was outside the window for interventions such as tPA or interventional clot retieval. An echo was performed on [**2110-12-22**] showing severe aortic valve stenosis, mild-moderate MR, moderate PAH. She has known aortic stenosis and has been followed by her primary care doctor/cardiologist, Dr. [**Last Name (STitle) **]. Presents for surgical work-up and aortic valve replacement. Past Medical History: Aortic Stenosis, Tricuspid Regurgitation s/p Aortic valve replacement, Tricuspid valve repair Past medical history: Atrial fibrillation Rheumatic heart disease Hypertension Lyme disease Osteoarthritis s/p CVA [**12/2110**] w/residual L and numbness/weakness h/o L breast CA s/p lumpectomy/axilary node disection/radiation h/o ovarian CA s/p hysterectomy-no chemo needed per patient renal hypodensities on CT scan likely infarcts 5mm LLL lung nodule dx [**12/2110**] rec 6 mo f/u s/p Laminectomies L3-L4 and L4-L5 and foraminotomies ([**2105**]) s/p Bilateral total hip replacements s/p Hysterectomy s/p L breast lumpectomy Social History: Last Dental Exam:1-2 weeks ago-recent extractions Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] ([**Telephone/Fax (1) 67335**] Lives with:[**Hospital3 **] Contact:Daughter [**Name2 (NI) **] Phone #([**Telephone/Fax (1) 67336**] Occupation: Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-10**] drinks/week [] >8 drinks/week [] Illicit drug use Family History: No premature coronary artery disease Physical Exam: Pulse:71 Resp:16 O2 sat: 94 on RA B/P Right:134/86 Left: Height: Weight:77.7 General: Skin: Dry [x] [**Month/Day (3) 5235**] [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Heart: RRR [] Irregular [x] Murmur [x] grade [**5-10**] harsh systolic murmur radiates to carotid_____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _trace bilateral____ Varicosities: bilateral R>L Neuro:awake, alert, oriented to person, place, date, situation with some cueing. Unable to recall details of recent past events(i.e. when she stopped coumadin, when she saw the dentist last), unable to remember interviewer's name or recall 3 objects after 15 minutes. PERRL, EOMI, tongue midline, Moves all extremities, R grip strength 5/5, L grip strength 4/5, R plantar/dorsiflexion [**5-9**], L plantar/dorsiflexion [**4-9**] Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit murmur radiates to bilateral carotids Pertinent Results: [**2111-4-13**] Cardiac cath: 1. Selective coronary angiography of this right dominant coronary system demonstrated no angiographically significant coronary disease. The LMCA, LAD, LCX, and RCA were all patent. 2. Limited resting hemodynamics revealed systemic systolic arterial hypertension. . [**2111-4-14**] Echo: Pre-CPB: Mild spontaneous echo contrast is present in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic [**Month/Day/Year 5236**]. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. The tricuspid annulus measures 4.8 cm. There is no pericardial effusion. Post Bypass: The patient is AV-Paced, on an epinephrine infusion. There is a ring on the tricuspid annulus with no leak and no TR. RV systolic fxn is mildly depressed. There is a tissue valve in the aortic position with a tiny leak at the right cusp with could not be seen with later views. Residual mean gradient is 6 mmHg. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. . [**2111-4-20**] 05:35AM BLOOD WBC-6.6 RBC-3.51* Hgb-10.0* Hct-32.3* MCV-92 MCH-28.6 MCHC-31.1 RDW-12.8 Plt Ct-214 [**2111-4-19**] 09:09AM BLOOD WBC-7.3 RBC-3.63* Hgb-10.9* Hct-34.8* MCV-96 MCH-30.0 MCHC-31.3 RDW-12.8 Plt Ct-221 [**2111-4-20**] 05:35AM BLOOD PT-19.7* INR(PT)-1.9* [**2111-4-19**] 09:09AM BLOOD PT-17.9* INR(PT)-1.7* [**2111-4-18**] 06:50AM BLOOD PT-17.3* PTT-25.7 INR(PT)-1.6* [**2111-4-17**] 12:45PM BLOOD PT-16.7* INR(PT)-1.6* [**2111-4-16**] 09:20PM BLOOD PT-15.2* INR(PT)-1.4* [**2111-4-16**] 05:02AM BLOOD PT-14.6* INR(PT)-1.4* [**2111-4-14**] 12:46PM BLOOD PT-15.1* PTT-26.1 INR(PT)-1.4* [**2111-4-20**] 05:35AM BLOOD Glucose-98 UreaN-16 Creat-0.7 Na-138 K-4.2 Cl-98 HCO3-33* AnGap-11 [**2111-4-19**] 09:09AM BLOOD Glucose-128* UreaN-20 Creat-0.7 Na-137 K-4.1 Cl-98 HCO3-28 AnGap-15 Brief Hospital Course: Ms. [**Known lastname **] was admitted prior to surgery for Heparin and surgical work-up, including cardiac cath. She was treated with Cipro for a pre-op Klebsiella UTI. She underwent a cardiac cath on [**4-13**] which revealed no coronary artery disease. She was brought to the operating room on [**4-14**] and underwent a aortic valve replacement. Please see operative note for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically at her baseline (short-term memory loss) and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Coumadin was resumed for chronic atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Blood culture did grow GPC, however, this was believed to be a contaminant and Vancomycin was stopped. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital6 **] in [**Location (un) 246**] in good condition with appropriate follow up instructions. Medications on Admission: acetominophen 650mg daily at 8am ascorbic acid 500mg twice daily lisinopril 5 mg daily atenolol 100mg daily oxybutynin 1 patch every sunday and wednesday quetiapine 5mg at bedtime tramadol 50 mg every 12 hours coumadin 4mg daily LD Tuesday [**4-7**] Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: dose for goal INR 2-2.5, dx: afib. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Aortic Stenosis, Tricuspid Regurgitation s/p Aortic valve replacement, Tricuspid valve repair Past medical history: Atrial fibrillation Rheumatic heart disease Hypertension Lyme disease Osteoarthritis s/p CVA [**12/2110**] w/residual L and numbness/weakness h/o L breast CA s/p lumpectomy/axilary node disection/radiation h/o ovarian CA s/p hysterectomy-no chemo needed per patient renal hypodensities on CT scan likely infarcts 5mm LLL lung nodule dx [**12/2110**] rec 6 mo f/u s/p Laminectomies L3-L4 and L4-L5 and foraminotomies ([**2105**]) s/p Bilateral total hip replacements s/p Hysterectomy s/p L breast lumpectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Motrin and Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2111-5-20**] 1:45 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] PCP/Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8725**] [**2111-5-15**] at 2:00p **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication AFib Goal INR 2-2.5 First draw [**2111-4-22**] Completed by:[**2111-4-21**] Name: [**Known lastname 1985**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 11664**] Admission Date: [**2111-4-12**] Discharge Date: [**2111-4-21**] Date of Birth: [**2033-8-17**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Percocet Attending:[**First Name3 (LF) 741**] Addendum: Ms. [**Known lastname **] was discharged to [**Hospital **] Rehab and Lopressor was increased. See below. Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: dose for goal INR 2-2.5, dx: afib. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2111-4-21**]

[ "780.93", "396.2", "041.3", "401.9", "V10.43", "729.89", "427.31", "287.5", "793.11", "599.0", "416.8", "397.0", "V10.3", "715.90", "438.89" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.14", "88.56", "35.21", "37.22" ]

icd9pcs

[ [ [] ] ]

13323, 13541

5761, 7258

305, 428

9674, 9908

3566, 5738

10831, 11951

2353, 2391

11974, 13300

9028, 9122

7284, 7535

9932, 10808

2406, 3547

246, 267

456, 1207

9144, 9653

1869, 2337

74,816

135,703

44378

Discharge summary

report

Admission Date: [**2145-12-1**] Discharge Date: [**2145-12-2**] Date of Birth: [**2072-1-10**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12657**] Chief Complaint: Bleeding from throat, subraglottic mass Major Surgical or Invasive Procedure: Fiberoptic endoscopic exam revealed subraglottic mass History of Present Illness: HPI: 73 yo M started to spit blood from his mouth after lunch. No bleeding noted from his nose, no pain, no change in swallowing, no shortness of breath. He has a history of tonsillar cancer s/p neck dissection, Chemo/XRT in [**2140**], now being followed by Dr. [**First Name (STitle) 3311**] of [**Hospital1 112**] for his H&N cancer. Dr. [**First Name (STitle) 3311**] saw patient in [**Month (only) **] and performed an endoscopic exam which was negative. He is not anticoagulated except for baby aspirin, and generally feels well. Past Medical History: Past Medical History: DM HTN (in the past) Tonsillar cancer s/p neck dissection, Chemo/XRT [**2140**]/[**2141**]. s/p appendectomy ruptured feeding tube dysphagia hematuria Social History: Social History: -approximately 15 pack-year history of smoking and stopped 20 years ago. -previously was a heavy alcohol user, drinking a fifth per day of hard liquor. He stopped drinking alcohol ~[**2138**]. -retired security person for [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **], lives with sister Physical Exam: PE (at ED yesterday): AVSS except for high BP of SBP~200 GEN: NAD, pleasant, hoarse voice (but normal for him), spitting up blood and occasionally. After gargling with Afrin x3, bleeding stopped EARS: nl canal & TM Nose: Slight blood tinged mucosa on right turbinates, but no active bleeding Nasopharynx: Slight blood tinged mucosa, no active bleeding. OC: after rinsing with water, no active bleeding. Oropharynx/hypopharyx: blood stained mucosa, no active bleeding site. Glottic area: Scoped x3, initially copious amount of blood pooling around glottic structure. After nasal suctioning at the same time as scoping, cleared area for better exam. There is a supraglottic mass obscuring the airway. Epiglottis is of normal size and shape. After overnight observation: -No stridor, voice stable, no discomfort, had coughed up small clots x2, no active bleeding -OC/OP: clear, no sighn of bleeding or blood/clots Brief Hospital Course: Mr. [**Known lastname **] presented to the ED [**2145-12-1**] evening with hemoptysis/bleeding from the mouth. Bleeding was stopped by patient gargling with Afrin. Fiberoptic exam and CT showed a supraglottic mass and there was no further active bleeding. He was then observed overnight for airway observation and stability regarding his bleeding. He only had small clots that he coughed up x2, no active bleeding. Discussions with Dr. [**Last Name (STitle) 3878**] (attending at the [**Hospital1 **]) resulted in plan to let him go home, and return to the ED (at [**Hospital1 112**] where his Head & Neck surgeon is) if he should bleed. He has an appointment to see Dr. [**First Name (STitle) 3311**] at [**Hospital1 112**] tomorrow (Friday), and will go to surgery on Monday. Medications on Admission: Medications: Aspirin (baby), Humulin insulin, Prilosec, ?statin, multivitamins Discharge Medications: NO Aspirin. Humulin insulin, Prilosec, ?statin, multivitamins Please gargle with Afrin if bleeding starts Discharge Disposition: Home Discharge Diagnosis: hypopharyngeal/supraglottic bleeding due to supraglottic mass Discharge Condition: Stable, no bleeding overnight Discharge Instructions: - Liquids and soft foods only. - Please do not take Aspirin - If you should bleed, gargle with Afrin and go to emergency room at [**Hospital6 1708**] where you head and neck surgeon Dr. [**First Name (STitle) 3311**] attends. - if you have any difficulty swallowing, breathing, voice change, or any other concerns, please go to [**Hospital6 13185**] emergency room. - You have an appointment with Dr. [**First Name (STitle) 3311**] tomorrow (Friday). Please call his office to confirm the time. - You will have surgery on Monday to biopsy the mass in your airway. Please do not have anything by mouth after midnight Sunday night (the night before your surgery). Confirm and get instructions regarding surgery on Monday. Followup Instructions: Please see Dr. [**First Name (STitle) 3311**] in his office tomorrow (Friday). Please call his office to confirm the time.

[ "V15.82", "250.00", "V11.3", "V58.67", "V10.02", "V87.41", "786.3", "784.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3529, 3535

2481, 3266

362, 417

3640, 3671

4439, 4564

3397, 3506

3556, 3619

3292, 3374

3695, 4416

1541, 2458

283, 324

445, 985

1029, 1182

1214, 1526

63,245

164,657

39370

Discharge summary

report

Admission Date: [**2142-10-5**] Discharge Date: [**2142-10-14**] Date of Birth: [**2066-11-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2142-10-5**] Bentall Procedure(27mm [**Company 1543**] Freestyle) with Replacement of Hemiarch(32mm Gelweave Graft) History of Present Illness: This 75 year old man has a history of atrial fibrillation, hypertension, diverticulitis and diverticulosis. He was evaluated on [**2142-9-8**] for complaints of left lower quadrant pain. It was felt that the patient had diverticulitis and he was started on Avelox 400mg daily and clear liquids. Because of continued abdominal pain, he underwent a CT scan of his abdomen on [**2142-9-11**]. This revealed a dilated ascending aorta up to 6cm. Prior to surgical intervention, patient underwent cardiac catheterization which showed an LVEF of 70% and clean coronary arteries, with moderate aortic insufficiency. Past Medical History: Atrial fibrillation s/p DC cardioversion - not on Coumadin, Premature Ventricular Contractions's, Ascending aortic aneurysm, Benign Prostatic Hypertrophy, Hx of prostatitis/sepsis, Diverticulitis/Diverticulosis, Dejenerative Joint Disease of the lumbosacral spine, Dejenerative Joint Disease of knees- tentatively scheduled for knee replacement in [**Month (only) 359**] shingles involving right side of chest, Actinic keratoses Multinodular goiter, Glaucoma, Decreased hearing s/p vasectomy s/p Right thigh abscess s/p I&D [**11-29**] s/p Right inguinal hernia repair s/p Cholecystectomy s/p Appendectomy Social History: Lives with: [**Name (NI) **] [**Name (NI) 53133**] (wife): [**Telephone/Fax (1) 87030**], married 3 children Occupation: retired, worked as an account manager/sales. Wife is [**Name Initial (MD) **] retired RN. Tobacco: 4 cigars per week ETOH: One or two drinks per day No recreational drug use Family History: Mother had a stroke in her 60's. She died of heart failure at age 74. Father died at 87yo. Physical Exam: Pulse: 74 Resp: 18 O2 sat: 99%-RA B/P Right: 135/77 Left: Height: 5 feet 10 inches Weight: 195 pounds General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] MMM, no lesions, no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-soft systolic Abdomen:Soft[x] non-distended[x] non-tender[x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: mild bilat Neuro: Grossly intact, non-focal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit none Right: 2+ Left:2+ Pertinent Results: [**2142-10-5**] Intraop TEE: PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The interatrial septum is aneurysmal. A PFO is not clearly seen but can not be comp-letely ruled out. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is effacement of the sino-tubular junction. The ascending aorta is moderately dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS There is normal biventricular systolic function. There is a stentless bioprosthesis in the aortic position. It appears well seated and the leaflets can be seen to be moving normally. There is trace central valvular regurgitation. The maximum pressure gradient through the valve is 22 mmHg with a mean pressure of 9 mmHg at a cardiac output of 4.8 l/m. There is now moderate tricuspid regurgitation in comparison to trace in the pre-bypass exam. The reason for this change can not be ascertained. The ascending aortic graft can not be well seen. The aortic arch and descending thoracic aorta appear intact after decannulation. No other significant changes from the pre-bypass exam. Brief Hospital Course: The patient was brought to the operating room on [**2142-10-5**] where the patient underwent Bentall procedure (including 27mm aortic tissue valve) with hemiarch replacement. 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, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He did develop thrombocytopenia with platelet count of 63,000. Heparin dependent antibody screen would return negative. He did develop post-operative atrial fibrillation and this was managed with amiodarone and coumadin as well as titration of beta blocker and calcium channel blocker as tolerated for optimal rate control. EP was consulted and recommended acceptable resting heart rate of less than 120. 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. INR was supratherapeutic at 4.0 and discharge to rehab was held one day. By the time of discharge on POD 9, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital 38**] rehab in good condition with appropriate follow up instructions. INR should be checked Monday, [**2142-10-15**]. Medications on Admission: Lumigan - 0.03 %-1 drop to both eyes at night Metoprolol - 25 mg every morning Diovan - 160 mg every morning Aspirin - 325 mg every morning Vitamin D - 1,000 unit daily Glucosamine, Multivitamin Proscar 5mg qd Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. finasteride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 1 week,then 400mg daily x 1 week, then 200mg daily until further instructed. 15. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 16. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane QID (4 times a day) as needed for sore throat. 18. warfarin 1 mg Tablet Sig: MD to dose daily Tablet PO DAILY (Daily). 19. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 21. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Aortic Insufficiency, Ascending Aortic Aneurysm s/p Bentall Atrial Fibrillation Hypertension History of Diverticulitis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- 1+ 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) **] [**2142-10-25**] @ 130 PM Cards/Primary Care Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] [**2142-11-14**] 10am **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for a-fib Goal INR 2-2.5 First draw Monday, [**2142-10-15**] Completed by:[**2142-10-14**]

[ "285.9", "424.1", "511.9", "427.31", "702.0", "241.1", "305.1", "V70.7", "600.00", "715.36", "401.9", "441.2", "287.5", "562.10" ]

icd9cm

[ [ [] ] ]

[ "38.45", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8667, 8764

4746, 6458

338, 459

8927, 9142

2879, 4723

9982, 10489

2059, 2152

6719, 8644

8785, 8906

6484, 6696

9166, 9959

2167, 2860

284, 300

487, 1098

1120, 1729

1745, 2043

83,429

171,097

37599

Discharge summary

report

Admission Date: [**2168-1-18**] Discharge Date: [**2168-1-19**] Date of Birth: [**2087-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3948**] Chief Complaint: Bleeding from Tracheostomy Major Surgical or Invasive Procedure: [**2168-1-18**] Rigid bronchoscopy, exploratory trach site for bleeding History of Present Illness: 80 yo F with hx of MI without intervention in [**10/2167**] resulting in respiratory distress and prolonged intubation requiring tracheostomy. Pt was discharged to vented rehab ([**Hospital 5503**] Rehab) and had been doing well until trach site began to bleed on [**2168-1-18**]. She was taken to [**Hospital6 **] where she was observed to bleed 200-300cc from trach site. Her trach was changed to a 6 cuffed tube with decreased bleeding after inflation of the cuff. Because of tachycardia the OSH gave the patient 2u pRBCs, her post transfusion crit at the OSH was 32.5 up from 25.8 on [**2168-1-17**]. Her INR was 1.1. She was diaphoretic and unresponsive during this episode and placed on ventilatory support. She did have an EKG that did not show any signs of acute myocardial ischemia. She was then transferred to [**Hospital1 18**] for bronchoscopy and identification and control of the bleeding source. On arrival in the [**Hospital1 18**] ED she denied c/p, sob or n/v she was awake and alert following commands. There was blood staining on her clothes and on the trach ties althouth there was not active bleeding coming from around the trach. She did have blood tinged sputum on suctioning of the trach. Arrangements were made to take her urgently to the OR for evaluation and treatment of the tracheal site bleeding. Past Medical History: DM II COPD Obesity Hypercholesterolemia HTN CAD s/p MI Recent Cellulitis of right leg Osteoporosis Social History: Pt currently lives at nursing facility ([**Hospital 5503**] Rehab). Her son is closely involved with her care and was present the date of admission. Not a current smoker Family History: non-contributory Physical Exam: VS: T: 98.8 HR: 83 SR BP: 147/51 Sats: 100% .5 RR: 24-33 General: no apparent distress HEENT: normal cephalic Neck: trach in place no ooz Card: RRR normal S1, S2 Resp: decreased breath sounds otherwise clear GI: obese, G-tube in place GU: foley in place Skin: RLL venous stasis changes skin intact Neuro: awake, alert, moves all extremities Pertinent Results: [**2168-1-19**] Hct-28.6* [**2168-1-18**] WBC-9.6 RBC-3.38* Hgb-9.6* Hct-28.4*# MCV-84 MCH-28.3 MCHC-33.6 RDW-17.0* Plt Ct-226 [**2168-1-18**] WBC-14.7* RBC-4.49 Hgb-12.2 Hct-38.7 MCV-86 MCH-27.1 MCHC-31.5 RDW-17.3* Plt Ct-318 [**2168-1-18**] Glucose-118* UreaN-42* Creat-0.9 Na-142 K-4.9 Cl-102 HCO3-37* AnGap-8 [**2168-1-18**] UreaN-38* Creat-0.9 K-4.8 [**2168-1-18**] Glucose-244* UreaN-37* Creat-0.9 Na-143 K-5.4* Cl-98 HCO3-33* AnGap-17 [**2168-1-19**] Type-ART pO2-117* pCO2-54* pH-7.35 calTCO2-31* Base XS-3 [**2168-1-19**] Type-ART pO2-108* pCO2-45 pH-7.40 calTCO2-29 Base XS-1 [**2168-1-18**] Type-ART pO2-92 pCO2-59* pH-7.36 calTCO2-35* Base XS-5 [**2168-1-18**] Type-ART pO2-436* pCO2-45 pH-7.50* calTCO2-36* Base XS-10 CXR: [**2168-1-18**] PORTABLE UPRIGHT AP VIEW OF THE CHEST: Tracheostomy tube is noted with tip in satisfactory position, terminating approximately 3.1 cm from the carina. Low inspiratory lung volumes are noted, and there is elevation of the right hemidiaphragm. Cardiac silhouette appears normal in size. The aorta is tortuous with mural calcifications noted. Crowding of the pulmonary vascularity is seen as a result of low inspiratory volumes, but no overt pulmonary edema is visualized. Blunting of the costophrenic sulci bilaterally suggests small bilateral pleural effusions. Additionally, bibasilar opacities are seen, which could represent atelectasis, but infection is not excluded. No pneumothorax is visualized. No acute skeletal abnormalities are visualized. IMPRESSION: Low inspiratory lung volumes which limits assessment of the lung bases. Elevation of the right hemidiaphragm. Small bilateral pleural effusions. Bibasilar opacities may represent atelectasis, but infection is not excluded. Brief Hospital Course: Mrs. [**Known lastname 19649**] was transferred from [**Hospital 5503**] Rehab Hospital for hemoptysis. She was taken to the operating room for flexible and rigid bronchoscopy which showed granulation tissue proximal to the trach with mild oozing from the from the right lateral wall which subsided with saline flushing. No active bleeding in the stoma, trachea istal to trach stoma, right bronchial tree or left bronchial tree. Clot was seen throughout the distal airway and therapeutic aspiration was perormed in both bronchial trees. She transferred to the SICU and remained on the vent over night CMV 0.4/400/20/5. Oxygen saturation 100%. Slight ooz from trach site otherwise clear. Trach #7 Portex Cuff inflated. Respiratory: POD1 she wean to 50% trach mask. RR: [**12-16**] Sats: 98%-100% ABG on trach mask: [**2168-1-19**] Type-ART pO2-117* pCO2-54* pH-7.35 calTCO2-31* Base XS-3 Serial ABGs [**2168-1-19**] Type-ART pO2-108* pCO2-45 pH-7.40 calTCO2-29 Base XS-1 [**2168-1-18**] Type-ART pO2-92 pCO2-59* pH-7.36 calTCO2-35* Base XS-5 [**2168-1-18**] Type-ART pO2-436* pCO2-45 pH-7.50* calTCO2-36* Base XS-10 Cardiac: Cardiac enzymes negative x 2. HR 85-100 SR, BP 100-150. Her beta-blocker was restarted. ECG NSR GI: obese, benign. Tube feeds were restarted via G-tube Replete with fiber Goal 50 mL/hr. Renal: foley in place good urine output. BUN 42 mild elevation likely for hemoptysis. CRE 0.9 stable. Skin: buttocks site clean intact mild [**Location (un) 84369**]. Right lower extremity discoloration ankle to mid-calf. Heme: serial HCT were done 28 x 2 stable Endocrine: fingerstick blood sugars were [**Medical Record Number 84370**] requiring no coverage. Neuro: awake, alert, responds to commands Disposition: she was transferred back to [**Hospital 5503**] Rehab Hospital. She will follow-up with her PCP and pulmonologist as previous. Medications on Admission: Insulin Sliding Scale, albuterol 5mg/mL 0.5%"", Diltiazem 30"', fragmin 5000u', guifenesin 200"", lisinopril 5', metoprolol 37.5"', mirtazapine 15', nitro patch 0.4 qday, protonix 40", seroquel 12.5"', simethicone 80"', simvastatin 40', xenaderm topical to buttocks, lorazepam 0.5"'prn anxiety, morphine 2mg prn pain, viokase 1tabprn, zofran 2mg prn nausea Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) injection Subcutaneous once a day. 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours. 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 8. Insulin Sliding Scale continue previous Humalog insulin sliding scale 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 0.5 mL Inhalation four times a day as needed for shortness of breath or wheezing. 11. Guaifenesin 100 mg/5 mL Liquid Sig: Ten (10) mL PO four times a day. 12. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Transdermal once a day. 13. Pantoprazole 40 mg Susp,Delayed Release for Recon Sig: One (1) package PO twice a day: dilute with Apple juice. 14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 15. Viokase 8 468 mg (30,[**Telephone/Fax (1) 83321**]-30K unit) Tablet Sig: One (1) Tablet PO three times a day as needed. 16. Sodium Bicarbonate 325 mg Tablet Sig: One (1) Tablet PO three times a day: give with Viokase let sit in G-tube 15 mins before flushing. 17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 18. Morphine 2 mg/mL Syringe Sig: One (1) Injection every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 54351**] - [**Location (un) 5503**] Discharge Diagnosis: Tracheal site bleed DM II COPD Obesity Hypercholesterolemia HTN CAD s/p MI Recent Cellulitis of right leg Osteoporosis Discharge Condition: Awake, alert, trached. Discharge Instructions: Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 9674**] Followup Instructions: Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Completed by:[**2168-1-20**]

[ "496", "733.00", "278.00", "412", "519.09", "250.00", "E878.3", "272.0", "786.3", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "97.23", "33.21" ]

icd9pcs

[ [ [] ] ]

8216, 8291

4251, 6126

330, 404

8454, 8479

2486, 4228

8641, 8756

2089, 2107

6534, 8193

8312, 8433

6152, 6511

8503, 8618

2122, 2467

264, 292

432, 1762

1784, 1885

1901, 2073

65,180

194,713

40031

Discharge summary

report

Admission Date: [**2114-11-7**] Discharge Date: [**2114-12-12**] Date of Birth: [**2036-9-18**] Sex: M Service: SURGERY Allergies: adhesive tape Attending:[**First Name3 (LF) 158**] Chief Complaint: abdominal pain, sepsis Major Surgical or Invasive Procedure: [**2114-10-22**]: Subtotal colectomy [**2114-10-30**]: exploratory laparotomy with end ileostomy [**2114-11-8**]: Exploratory laparotomy and drainage [**2114-11-19**]: Open abdomen and VAC change [**2114-11-20**]: Tracheostomy [**2114-11-22**]: Open abdomen and VAC change [**2114-11-24**]: Open abdomen and VAC change [**2114-11-28**]: Open abdomen and VAC change [**2114-12-1**]: Open abdomen and VAC change [**2114-12-4**]: Open abdomen and VAC change (spider vac changed to regular VAC) 12 [**2114-12-6**]: Open abdomen and VAC change [**2114-12-9**]: Open abdomen and VAC change [**2114-12-11**]: Open abdomen and VAC change History of Present Illness: Mr. [**Known lastname **] is a pleasant 78 year-old gentleman with a distant history of diverticulitis and a reversed Hartmann's pouch 30 years prior, who recently experienced intractable lower gastroitestinal bleeding at [**Hospital3 4107**] on [**2114-10-22**] with subtotal colectomy with ileo-sigmoid anastomosis. This was complicated by several episodes of bleeding per rectum about 3 weeks prior to this admission. He then underwent a total colectomy and ileo-rectal anastomosis, which was complicated by anastomotic leak. The anastomosis was resected and an end-ileostomy was created on [**2024-10-29**]. At the outside hospital he was experiencing severe abdominal pain, he began experiencing hematochezia from his ileostomy. He demonstrated a persistent leukocytosis and was treated with Vancomycin, Ceftazidime, and Flagyl. He was transferred to [**Hospital1 18**] for further management on [**2114-11-7**]. In the [**Hospital1 18**] ER he complained of moderate right-sided abdominal pain, but denied nausea or vomiting. He denied fever or chills. Past Medical History: Hypertension, hyperlipidemia, COPD, diverticulitis, obesity, chronic constipation Social History: Quit smoking 42 years ago, rare alcohol use, no recreational drugs. Family History: Diabetes and Alzheimer's in the family. Physical Exam: ON ADMISSION: VITALS: T 98, HR 98, BP 142/66, RR 22, O2sat 96% RA. GEN: NAD. A&Ox3. HEENT: Anicteric. Dry mucosal membranes. NECK: No JVD. No LAD. No TM. CVS: RRR. RESP: CTAB. ABD: Obese, soft, tender to palpation on R, nontender on L. Ileostomy at right abdomen is necrotic with scant melanotic discharge. DRE: Deferred EXTR: Warm and well perfused. 2+ peripheral edema ON DISCHARGE: Pertinent Results: [**2114-11-8**] 12:15AM BLOOD WBC-23.3* RBC-3.42* Hgb-9.7* Hct-29.6* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.4 Plt Ct-452* [**2114-11-8**] 12:15AM BLOOD Neuts-87* Bands-1 Lymphs-2* Monos-9 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2114-11-8**] 03:50AM BLOOD PT-18.9* PTT-31.6 INR(PT)-1.7* [**2114-11-8**] 12:15AM BLOOD Glucose-120* UreaN-39* Creat-1.9* Na-143 K-4.0 Cl-108 HCO3-26 AnGap-13 [**2114-11-8**] 12:15AM BLOOD ALT-17 AST-18 AlkPhos-61 Amylase-71 TotBili-0.6 [**2114-11-8**] 12:15AM BLOOD Albumin-2.0* Calcium-7.1* Phos-4.2 Mg-1.6 [**2114-11-10**] 08:51AM BLOOD Vanco-20.1* [**2114-11-8**] 12:17PM BLOOD Type-ART pO2-177* pCO2-52* pH-7.32* calTCO2-28 Base XS-0 [**2114-11-8**] 12:17PM BLOOD Glucose-112* Lactate-1.1 Na-138 K-3.6 Cl-106 [**2114-11-8**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST: High-density area with locules of gas in the rectus abdominis on the right just superior to the ileostomy most likely represents a hematoma; however, infection cannot be excluded. A leak also cannot be excluded given the high-density material. Small, unsuitable for drainage, fluid collection, simple in attenuation and without a well defined wall, abutting this rectus abdominis hyperdense area. Superinfection not excluded. No extraluminal contrast at the anastomotic site in the pelvis. Free air in the abdomen may be related to postop status. Moderate bilateral pleural effusions with adjacent relaxation atelectasis. Ascites. [**2114-11-21**] UNILAT UP EXT VEINS US LEFT PO: No evidence of DVT. [**2114-11-27**] CXR In comparison with the study of [**11-25**], the tracheostomy and nasogastric tubes remain in place. Bilateral pleural effusions with compressive atelectasis, most prominent at the left base. There is substantial pulmonary vascular congestion. Overall, there is little change. [**2114-12-12**] 04:06AM BLOOD WBC-7.0 RBC-2.89* Hgb-8.8* Hct-27.0* MCV-94 MCH-30.3 MCHC-32.4 RDW-17.4* Plt Ct-182 [**2114-12-12**] 04:06AM BLOOD Glucose-104* UreaN-61* Creat-1.6* Na-138 K-4.3 Cl-106 HCO3-24 AnGap-12 [**2114-12-12**] 04:06AM BLOOD Albumin-2.5* Calcium-8.5 Phos-2.9 Mg-1.9 [**2114-12-12**] 04:06AM BLOOD VitB12-499 [**2114-12-12**] 04:06AM BLOOD TSH-1.9 Brief Hospital Course: NEURO/PAIN: The patient remained intubated after his operative procedure on [**2114-11-8**] at [**Hospital1 18**] and was maintained on Fentanyl gtt for sedation and pain control. This was transitioned to Dilaudid IV by HOD#23. The patient had been following some commands off sedation and was received intermittent Ativan, Zyprexa and clonidine for agitation. CARDIOVASCULAR: The patient had a relatively stable hemodynamic course. On [**11-13**] he experienced some episodic hypotension which resolved with Q6 hour albumen 5% (12.5/500 mL) colloid resuscitation. Levophed was initiated in the post-op period and was continued until [**11-13**] and was weaned appropriately when his pressures responded. He was transfused 1 U PRBC on [**11-13**] for the hypotension and a tapering hematocrit. On [**11-14**] another unit of PRBC was transfused with adequate response. Lopressor and hydralazine were administered as needed for control of hypertension which occurred in the following hospital days. RESPIRATORY: The patient remained intubated following the procedure. By [**11-13**] bilateral pleural effusions were noted with cardiomegaly and pulmonary edema. These effusion continued into [**11-24**] but remained stable and had not progressed. A Lasix gtt was initiated on [**11-11**] to attempt aggresive diuresis for the effusion with some success. The Lasix gtt was discontinued on [**11-14**]. Moreover, the patient had been on CMV and weaned to MMV on [**11-10**]. Despite no identifiable pulmonary process other than effusions, PSV was not tolerated initially. On [**11-18**] he was self-extubated and subsequently re-intubated. He began tolerating CPAP/PSV during the day with nighttime CMV by [**11-19**], but was unable to tolerate weaning from the ventilation device. On [**11-20**] a percutaneous tracheostomy was placed without complication. Over the course of the next week he continued CPAP/PSV during the day but required CMV overnight. A bronchoscopy and BAL were sent on [**11-24**] given an increased in tracheal and respiratory secretions which were empirically treated with Vancomycin and Zosyn. The BAL washing demonstrated an E.coli strain for which he was treated. By HOD#21 he had begun tolerating longer periods of trach mask without ventilatory support. Pt tolerated PMV trials prior to discharge. FEN/GI: After admission the patient was brought to the operating room on [**2114-11-8**] after several previous surgeries at an outside hospital, most recently for an anastomotic leak. He had an end-ileostomy created during a prior surgery. He was transferred to our institution with an elevated white count to 20,000, bandemia, and a necrotic-appearing stoma. A CT scan showed air and extensive fluid in the abdomen, as well as likely intestinal perforation, as there was significant air and fluid around the ileum prior to insertion into the fascia. Exploratory laparotomy and resection of the stoma and revision of stoma was performed on [**2114-11-8**]. The ileum was clearly dead below the level of the fascia on intra-op inspection. Unfortunately, the abdomen was essentially frozen as well. It was not possible to isolate any single loop of bowel without great risk of an enterotomy--it was simply not possible to isolate any loop of bowel. It was decided that drainage would be more appropriate and a 24-French Foley catheter was passed retrograde into the viable part of the ileum through the stoma. Drains were placed surrounding the stoma, and it was not possible to close the abdomen, and a [**Location (un) 5701**] bag-type setup was used with toweling and Ioban. This open abdominal wound remained as such and was treated with frequent vacuum-dressing changes, first utilizing a Spider VAC abdominal device and then this was downgraded to a white sponge VAC dressing on [**12-4**]. During this time the patient had been maintained NPO with IV fluid hydration as required. The patient was started on TPN on [**11-19**] and continued on such during his hospitalization. The patient was continued on subcuanteous octreotide since admission given his necrotic abdomen, in order to slow ostomy output and promote bowel quiescence. Protonix was given daily for GI prophylaxis. A left and right upper quadrant [**Location (un) 1661**]-[**Location (un) 1662**] bulb with drain was draning necrotic-feculent material and bilious output. These were discontinued once output tapered appropriately. The patient also had a Sump drain placed intra-op which was dislodged upon turning the patient on [**11-29**]. The patient's open abdominal wound was showing signs of contracture by HOD#25. The ostomy continued to appear necrotic with the Foley catheter digitalized through the stoma which terminated at the level of the suspected healthy bowel with the balloon inflated. His ostomy output ranged between 100-200 mL of green-liquid stool by HOD#20-25. The VAC output appeared ot be bilious-type contents and ranged between 400-500 mL of fluid daily over HOD#10-36 with regular VAC dressing changes demonstrating granulation tissue and stable fistula orifice. HEME/ID: Upon presentation the patient had a WBC of 20K, blood cultures grew no organism, and remained afebrile. A stoma/ostomy wound swab on [**11-8**] grew 4+ GPCs, 3+ yeast and 2+ GPC finalized as mixed bacterial types. A urine culture from [**11-8**] grew 10K yeast and a BAL washing from [**11-24**] grew the E.coli strain mentioned above. Blood cultures had remained negative during his hospitalization. As noted he was started on Vancomycin and Zosyn on [**11-8**] and these were discontinued on [**2114-12-4**] after an adeqaute course was completed. The patient had remained afebrile since admission. His leukocytosis on admission was 23.3 and had steadily trended down to WBC 11 by [**12-5**]. His hematocrit ranged from 26 to 29% since admission and was relatively stable. He only required 2U PRBC transfusion on [**11-13**]-8 when hypotension and fluid resuscitation was required. On day of discharge, WBC was 7 and he remained afebrile. ENDOCRINE: The patient was maintained on a sliding insulin scale with glucose monitoring during his hospital stay. His insulin was included in his TPN orders. RENAL: The patient had a Foley catheter placed intra-operatively. He was noted to have yeast growing in his urine as noted above which was covered by the antibiotics started on admission. On [**11-23**] he was noted to have some hematuria and had some intermittent decreases in output. His Foley was changed on [**11-23**]. The patient was aggresively diuresed with a Lasix gtt as mentioned above, which was discontinued on [**11-14**]. His fluid balance since admission noted that he was significantly third-spacing fluid given his intra-abdominal issues and was over 20L positive since admission by HOD#25. His I/Os were monitored closely during his stay. By HOD#15, the goal was to keep his fluid balance even to maintain his pressures but avoid volume overload. LOS fluid balance was down to +15L. Intermittent albumen 5% (12.5/500 mL) colloid resuscitation was continued through [**11-28**] as needed to maintain intravascular volume. Creatinine on discharge was 1.6 with continued adequate urine output. PROPHYLAXIS: The patient was maintained on heparin subcutaneously for DVT/PE prophylaxis. The patient was encouraged to get out of bed with PT support with an abdominal binder in place by POD#27. Pneumatic compression boots were maintained during his hospitalization. Protonix IV was given for GI prophylaxis. Medications on Admission: Percocet PRN, Flagyl 500 PO TID, Lopressor 25 PO BID, Albuterol PRN, Pantoprazole 40 PO QD, Ceftazidime 2g IV daily, Vancomycin 1500 mg IV Q24, RISS, Heparin 5000 units SQ TID Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for wheezing. 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast, rash. 4. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. clonidine 0.1 mg/24 hr Patch Weekly Sig: 0.1 mg/24 hr Patch Weekly Transdermal QSUN (every Sunday). 6. levothyroxine 200 mcg Recon Soln Sig: Fifty (50) mcg in Recon Soln Injection DAILY (Daily). 7. octreotide acetate 100 mcg/mL Solution Sig: One Hundred (100) mcg SC Injection Q8H (every 8 hours). 8. pantoprazole 40 mg Recon Soln Sig: Forty (40) mg in Recon Soln Intravenous Q24H (every 24 hours). 9. metoprolol tartrate 5 mg/5 mL Solution Sig: Five (5) mg IV Intravenous Q4H (every 4 hours): hold for SBP <110 or HR <60. 10. fentanyl 75 mcg/hr Patch 72 hr Sig: Seventy Five (75) mcg/hr Patch 72 hr Transdermal Q72H (every 72 hours). 11. acetaminophen 650 mg Suppository Sig: Six [**Age over 90 1230**]y (650) mg PR Suppository Rectal Q6H (every 6 hours). 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) UNIT SC Injection TID (3 times a day). 13. hydralazine 20 mg/mL Solution Sig: Ten (10) mg IV Injection PRN (as needed) as needed for SBP >160. 14. lorazepam 2 mg/mL Syringe Sig: 1-2 mg IV Injection Q4H (every 4 hours) as needed for anxiety. 15. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day). 16. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5-1 mg IV Injection Q4H (every 4 hours) as needed for pain. 17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for irritation. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: LGIB Anastomotic Leak Peritonitis Acute Renal Failure Respiratory Failure Pneumonia Open abdominal wound Discharge Condition: Mental Status: Confused - sometimes, following some commands. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge to Extended Care Facility Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you Followup Instructions: Please call [**Telephone/Fax (1) 15106**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] upon discharge from Extended Care Facility. Completed by:[**2114-12-12**]

[ "401.9", "276.3", "276.0", "569.83", "038.42", "V45.72", "V85.41", "496", "511.9", "486", "997.4", "112.2", "276.69", "557.0", "263.9", "278.01", "E878.2", "995.92", "286.7", "518.5", "569.69", "584.5", "567.9", "568.0", "569.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "31.1", "99.15", "54.12" ]

icd9pcs

[ [ [] ] ]

14784, 14858

4892, 12416

296, 928

15007, 15007

2690, 4869

16202, 16391

2226, 2267

12643, 14761

14879, 14986

12442, 12620

15163, 16179

2282, 2282

2671, 2671

234, 258

956, 2018

2297, 2655

15022, 15139

2040, 2124

2140, 2210

29,408

176,852

32023

Discharge summary

report

Admission Date: [**2123-8-19**] Discharge Date: [**2123-8-25**] Date of Birth: [**2044-3-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: fatigue & weakness Major Surgical or Invasive Procedure: None History of Present Illness: 79yo M with hx of HTN and gout, who presented to [**Hospital1 18**] [**Location (un) 620**] on [**2123-8-19**] with fatigue & generalized weakness over the past week. Pt reports having a gout flare about 2wks ago (affecting L foot) was started on colchicine. Pain persisted and pt began taking exra colchicine, hoping it would help relieve his pain. He took an unclear amount (approx 20pills) over a few days. Foot pain improved. However, he developed nausea & diarrhea with some abd discomfort, which radiated to his chest. Saw his PCP, [**Name10 (NameIs) 1023**] started prilosec w/ little improvement. Pt began to feel progressively more weak. He also notes trouble w/ his balance & feeling "shaky." No HA or vision changes. No CP/palpitations. + SOB at baseline. Pt con't to have diarrhea, no blood noted in stool. Noted decreased UOP ~1wk. . OSH course: Cr 12.2, K 6.7, bicarb 11. Pt got bicarb, kayexylate (60), insulin and D5. Transferred to [**Hospital1 18**] for possible urgent HD. Past Medical History: HTN for at least 20yr Gout Glaucoma Obesity . Social History: Widowed. Lives alone. Supportive son & dtr in area. History of alcohol abuse (over [**11-24**] pint of vodka for over 30 years); Quit 12yrs ago. 90+ pack year history, quit >25yr ago Family History: No family history of renal disease Physical Exam: VS: Temp: 96.9 BP: 125/50 HR: 72 RR: 13 O2sat: 97% on RA general: obese, pleasant, conversant in mild distress comfortable, NAD HEENT: PERLLA, EOMI, anicteric, injected sclera, no sinus tenderness, MMM, op without lesions, jvd not seen, no carotid bruits lungs: CTAb/l, though decreased air movement at bases heart: distant hrt sounds, RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: protuberant, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: 1+ dependent edema skin/nails: no rashes/no jaundice/no splinters neuro: AAOx3. Cn II-XII intact. No asterixis. 5/5 strength throughout. No sensory deficits to light touch appreciated Pertinent Results: Admission Labs: [**2123-8-19**] 10:36PM BLOOD WBC-6.7 RBC-3.34* Hgb-10.9* Hct-31.8* MCV-95 MCH-32.7* MCHC-34.5 RDW-13.7 Plt Ct-279 [**2123-8-19**] 10:36PM BLOOD PT-11.8 INR(PT)-1.0 [**2123-8-19**] 10:36PM BLOOD Plt Ct-279 [**2123-8-19**] 10:36PM BLOOD Glucose-106* UreaN-150* Creat-12.6* Na-131* K-5.3* Cl-98 HCO3-11* AnGap-27* [**2123-8-19**] 10:36PM BLOOD ALT-12 AST-5 LD(LDH)-192 CK(CPK)-143 AlkPhos-79 Amylase-100 TotBili-0.2 [**2123-8-19**] 10:36PM BLOOD CK-MB-8 [**2123-8-19**] 10:36PM BLOOD cTropnT-0.04* [**2123-8-19**] 10:36PM BLOOD Albumin-3.6 Calcium-8.5 Phos-12.2* Mg-3.8* UricAcd-9.4* Iron-156 [**2123-8-19**] 10:36PM BLOOD Ferritn-456* [**2123-8-19**] 11:34PM BLOOD Type-ART pO2-87 pCO2-34* pH-7.10* calTCO2-11* Base XS--18 Intubat-NOT INTUBA [**2123-8-19**] 11:34PM BLOOD Glucose-101 Lactate-0.8 Na-127* K-5.0 Cl-102 [**2123-8-19**] 11:34PM BLOOD freeCa-1.16 CHEST X-RAY ([**2123-8-19**]) No acute cardiopulmonary process ECG: ([**2123-8-19**]) Sinus rhythm. First degree atrio-ventricular conduction delay. Borderline left axis deviation. Non-specific QRS widening. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. Renal ultrasound 1) Markedly limited examination. 2) No hydronephrosis in either kidney. 3) Bilateral hypoechoic renal lesions cannot be adequately characterized due to technical limitations, although they may represent cysts. 4) Patent renal arteries and veins bilaterally. Limited Doppler examination due to technical difficulties. ECG: ([**2123-8-21**]) Sinus bradycardia. Intraventricular conduction defect. Compared to prior tracing of [**2123-8-19**] no change. ULTRASOUND OF LEFT LOWER EXTREMITY ([**2123-8-25**]) FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and popliteal veins were performed. Normal flow, compressibility, and augmentation were seen. There was no evidence of intraluminal thrombus. IMPRESSION: No evidence for deep vein thrombosis in the left leg. Brief Hospital Course: MICU Course On arrival here, his Cr was 12.6 and K 5.3. Admitted to the ICU and treated with a bicarb gtt, kayexylate, insuin and D5. Renal consult was obtained and it was decided to hold off on dialysis and to treat him medically. He is continued on a bicarb gtt and started sevelamer. He had a renal ultrasound which was normal. Patient transfered to regular wards on [**2123-8-22**]. # ARF with hyperphosphatemia: Continued to improve with medical therapy. Suspect failure was due to combination of chronic renal failure, dehydration, ace inhibitor and overdose of colchicine. We continued IV hydration during period of post ATN diuresis and were able to medically manage elctrolytes with phosphate binders and potassium replacement. Nephrology team continued to follow patient and believe he will not require dialysis. Primary care physician was [**Name (NI) 653**], he will continue to follow patient and VNA will check electrolytes with results faxed to his office. Patient will need nephrology follow up locally; will defer this to PCP. . # EKG changes: TWI in precordial noticed shortly after transfer to wards. These however were not accompanied by increase in cardiac troponins in spite of renal failure. Changes are most likley secondary to metabolic disturabance from renal failure and were attenuated at the time of discharge. . # HTN: Once euvolemic, patient became slightly hypertensive but responded well to Norvasc 5mg po daily. We held lisinopril, HCTZ and aspirin as these could further worsen renal function in the acute setting. . # Lower extremity edema: Patient developed pitting edema of lower extremities in a mildly asymetric fashion. Lower extremitly dopplers were obtained and preliminary read revealed no thrombus. . # anemia: was anemic on admission with unremarkable iron panel. Would defer further management to primary care physician. . # Gout: Patient did not have any more signs of gout flare. Did not require steroids; would avoid NSAIDS or colchicine in light of ARF. . # Glaucoma: Continue Brimonidine and Lumigan for bilateral glaucoma. . # FEN: Tolerated a renal diet . # prophylaxis: DVT ppx with heparin SC and pneumoboots. . # Code: Patient requested to code status be DNR/DNI, which was maintained during entire hospitalization. Medications on Admission: colchicine 0.6mg daily lisinopril 40mg daily triamteren/hctz 25/50 [**Hospital1 **] lipitor 80mg daily Prilosec OTC 20mg daily ASA 81mg daily Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H (every 12 hours). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* 5. Ipratropium Bromide 0.02 % Solution Sig: Two (2) PUFFS Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: PRIMARY 1. ACUTE RENAL FAILURE SECONDARY 1. GOUT 2. HYPERTENSION Discharge Condition: Stable, normotensive with improving renal function. Discharge Instructions: You were admitted to the hospital because your kidneys began to fail after you took more gout medicine than what was recommended. In the hospital, we stopped the medications that could worsen this situation, began to give you fluids and corrected the imbalances in the salts of your blood that were caused by renal failure. You slowly began to improve and now are showing signs of recovery. Please do not take any anti-inflammatory medicines (Advil, Motrin, Aspirin, ect) or any more of your gout medicine, Colchicine, until you see your primary care doctor. Please take all medications as prescribed and keep all doctors [**Name5 (PTitle) 4314**]. If you experience any chest pain, shortness of breath, nausea, vomiting or diarrhea, stop making urine, feel confused or develop any other symptom that concerns you, please seek medical attenditon immediately. Followup Instructions: You have a follow up appointment with your primary care provider, [**Name10 (NameIs) **] [**Last Name (STitle) 36568**] ([**Telephone/Fax (1) 75007**] on Tuesday, [**8-31**] at 10am [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "403.90", "274.0", "584.9", "585.9", "276.7", "285.9", "276.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7418, 7477

4431, 6710

333, 340

7587, 7641

2382, 2382

8550, 8856

1648, 1684

6903, 7395

7498, 7566

6736, 6880

7665, 8527

1699, 2363

275, 295

368, 1362

2399, 4408

1384, 1432

1448, 1632

79,586

178,710

47238

Discharge summary

report

Admission Date: [**2188-5-20**] Discharge Date: [**2188-6-3**] Date of Birth: [**2123-7-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 603**] Chief Complaint: Felt Bad Major Surgical or Invasive Procedure: Right Sided Subclavian CVL History of Present Illness: 64YoM with history of HTN, GERD, HEP C, polysubstance abuse, brought from friends house because he was confused and did not know where he was, generally "feeling terrible." Per his report, this has been an acute change. He also stated that for the past day or so, he has had worsening low back pain radiating to his buttocks, which is new. In the ED, he gave a history of possible syncopal episode following heroin use. He is not complaining of any abdominal pain, nausea, changes in bowel habits, dysuria, chest pain, SOB, headache, neck pain/stiffness. He apparently gets all of his care at [**Hospital1 2177**]. . In ED, initial vitals were 97.6 91 185/132 14 94%. He was c/o epigastric pain and had 2 episodes of bloody to [**Last Name (un) 30212**]-colored emesis. He was started on octreotide and pantoprozole gtt. Hct was 48.8. Utox positive for opiates; he states he has not used in months . GI was consulted and recommended EGD. . On the floor, patient is hypertensive to SBPs 170s-180s. He is not oriented to place or time, and also denies any recent drug use. NG lavage done by GI was negative. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: GERD HTN Hep C Heroin abuse Gunshot wound to abdomen s/p ex-lap 20 years ago Social History: He is homeless and has been living at shelter. History of heroin use. - Tobacco: 1 ppd for about 30 years - Alcohol: Denies any recent alcohol use; "does not like it" - Illicits: IV Heroin last use: "months ago" Family History: NC Physical Exam: Admission: General: Alert, not oriented to place or time, NAD HEENT: Sclera anicteric, Dry MMM, conjunctiva injected Neck: supple, JVP 7-8 cm, no LAD Lungs: Dry bibasilar crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: protuberant, soft, normoactive bowel sounds, no shifting dullness to percussion, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, PERRLA, no asterexis, no focal motor deficits, tender ness to palpation over right lower paraspinal musculature Discharge: Gen: Pleasant, middle aged male in NAD. AAOx3 HEENT: NCAT. Sclera anicteric. Left eye clouded without vision. EOMI. MMM, OP benign. No sinus tenderness to palpation Neck: Supple, full ROM. No visible JVP. No cervical lymphadenopathy. CV: RRR with normal S1, S2. No M/R/G. No S3 or S4. Chest: Respiration unlabored. Mild crackles at RLL base, otherwise CTAB without crackles, wheezes or rhonchi. Abd: Bowel sounds present. Soft, protuberant, NT/ND. No organomegaly or masses appreciated Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, PT 2+. Skin: No rashes, ulcers, or other lesions noted. Neuro: CN II-XII grossly intact. Normal speech. Pertinent Results: ADMISSION LABS: ================= [**2188-5-20**] 06:00PM WBC-18.2* RBC-4.58* HGB-14.0 HCT-40.0 MCV-87 MCH-30.5 MCHC-34.9 RDW-14.7 [**2188-5-20**] 06:00PM NEUTS-85.5* LYMPHS-9.3* MONOS-4.0 EOS-0.8 BASOS-0.3 [**2188-5-20**] 06:00PM PLT COUNT-179 [**2188-5-20**] 05:20PM URINE HOURS-RANDOM UREA N-299 CREAT-166 SODIUM-43 POTASSIUM-71 CHLORIDE-22 [**2188-5-20**] 05:20PM URINE HOURS-RANDOM [**2188-5-20**] 05:20PM URINE GR HOLD-HOLD [**2188-5-20**] 02:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2188-5-20**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2188-5-20**] 02:00PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-<1 [**2188-5-20**] 02:00PM URINE HYALINE-4* [**2188-5-20**] 02:00PM URINE MUCOUS-RARE [**2188-5-20**] 12:52PM LACTATE-2.0 K+-3.3* [**2188-5-20**] 11:33AM PT-12.9 PTT-24.3 INR(PT)-1.1 [**2188-5-20**] 11:28AM AMMONIA-20 [**2188-5-20**] 11:04AM GLUCOSE-127* UREA N-50* CREAT-5.2* SODIUM-148* POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-24 ANION GAP-22* [**2188-5-20**] 11:04AM estGFR-Using this [**2188-5-20**] 11:04AM ALT(SGPT)-119* AST(SGOT)-168* CK(CPK)-[**Numeric Identifier 100019**]* ALK PHOS-63 TOT BILI-0.7 [**2188-5-20**] 11:04AM LIPASE-58 [**2188-5-20**] 11:04AM cTropnT-0.05* [**2188-5-20**] 11:04AM CK-MB-67* MB INDX-0.5 [**2188-5-20**] 11:04AM ALBUMIN-4.3 [**2188-5-20**] 11:04AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2188-5-20**] 11:04AM WBC-20.0* RBC-5.46 HGB-16.3 HCT-48.2 MCV-88 MCH-29.9 MCHC-33.8 RDW-14.7 [**2188-5-20**] 11:04AM NEUTS-88.4* LYMPHS-7.2* MONOS-3.7 EOS-0.5 BASOS-0.3 [**2188-5-20**] 11:04AM PLT COUNT-196 [**2188-5-20**] 12:00AM URINE HOURS-RANDOM [**2188-5-20**] 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG DISCHARGE LABS: ================== [**2188-6-3**] 05:55AM BLOOD WBC-9.8 RBC-3.72* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.6 MCHC-33.3 RDW-14.2 Plt Ct-358 [**2188-6-3**] 05:55AM BLOOD Plt Ct-358 [**2188-6-3**] 05:55AM BLOOD Glucose-100 UreaN-16 Creat-1.7* Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 [**2188-5-31**] 08:35AM BLOOD ALT-22 AST-28 CK(CPK)-132 AlkPhos-50 TotBili-1.0 [**2188-5-29**] 06:35AM BLOOD Lipase-21 [**2188-6-3**] 05:55AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0 [**2188-5-27**] 05:14AM BLOOD HIV Ab-NEGATIVE [**2188-5-26**] 05:33AM BLOOD Free T4-1.4 [**2188-5-26**] 05:33AM BLOOD Triglyc-115 CT Abdomen [**2188-5-26**] COMPARISON: [**2188-5-25**] CT abdomen and pelvis and chest radiograph of [**5-26**], [**2187**]. TECHNIQUE: MDCT axial images were obtained through the chest without IV contrast. Coronal and sagittal reformats were displayed. FINDINGS: The imaged thyroid gland is normal. There is no axillary, mediastinal, or hilar adenopathy meeting CT criteria for pathologic enlargement. A left-sided central venous line follows a normal course terminating at the junction of the brachiocephalic vein with the SVC. The heart is enlarged with trace pericardial fluid. Small hiatal hernia is present. There is a new right-sided pigtail catheter terminating at the base of the right lung. Loculated pleural effusion is slightly increased compared to the prior study. For example, a collection of fluid at the base measures 2.6 cm in maximal width compared to 2.1 cm previously. Gas within the pleural fluid is presumably secondary to placement of the pigtail catheter. A loculated component of fluid anteriorly measures 5.6 x 11.2 cm. A third component of fluid along the right lateral chest measures approximately 4.4 x 2.1 cm. A small collection of gas within a consolidation at the right lung base adjacent to the effusion is similar to prior and concerning for pneumonia or necrotizing pneumonia. There is peribronchial thickening. A 5-mm nodule in the right lower lobe is not appreciably changed from the prior study (2:26). A second nodule measuring 3 mm is seen at the right lung base (2:33). There is a small left pleural effusion. In the visualized upper abdomen, the gallbladder is distended up to 4.5 cm with sludge. a fat-containing abdominal wall hernia is incompletely evaluated. Hypodensity in the upper pole of the left kidney is better evaluated on the prior CT abdomen. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified. IMPRESSION: 1. Interval placement of a right-sided pigtail catheter with slight increase in the loculated pleural effusion which could reprsent empyema. Persistent area of loculated gas surrounded by lung parenchyma could represent pulmonary abscess or necrotizing pneumonia. 2. Gallbladder distension up to 4.5 cm with sludge. Recommend right upper quadrant ultrasound for further evalaution. 3. Small left-sided pleural effusion. 4. Small pulmonary nodules measuring up to 5 mm on the right. The study and the report were reviewed by the staff radiologist. RUQ/Liver US [**2188-5-28**] FINDINGS: Normal liver echotexture without focal liver lesion. No intrahepatic biliary dilatation. The common bile duct measures 3 mm. Incidental 3-mm polyp noted within the gallbladder. The gallbladder wall measures 3 mm. Gallbladder is only mildly distended. There is a trace of peri-cholecystic fluid. The patient was son[**Name (NI) 5326**] [**Name2 (NI) 6416**]. No son[**Name (NI) 493**] features of acute cholecystitis. Findings in the gallbladder are likely related to underlying liver disease and third spacing from renal failure and low albumin. The main portal vein is patent and demonstrates hepatopetal flow. Pancreas is partially visualized in the midline, the distal tail is not seen in its entirety. The visualized IVC is unremarkable. The spleen measures 12cm. There is a non-obstructing 6-mm calculus in the interpolar region of the right kidney. This is stable. No evidence for ascites in the visualised upper abdomen. IMPRESSION: 1. Minimally distended gallbladder with mild gallbladder wall edema and pericholecystic fluid. No gallstones seen. The patient was son[**Name (NI) 5326**] non-tender. Findings most likely represent sequelae of liver disease and third spacing from acute renal failure and low albumin. 2. Incidental 3-mm gallbladder wall polyp. 3. Stable non-obstructing 6-mm right renal calculus. CXR [**2188-6-1**] CLINICAL HISTORY: Hypertensive HCV status post VATS. CHEST: Since the prior chest x-ray, the left chest tube has been removed. There is no evidence of a pneumothorax. Atelectasis of the left lower lobe is present. Left effusion is seen. Upper zone redistribution to the right side is present though not to the left, third degree of failure is probably present. IMPRESSION: Chest tubes removed. No pneumothorax. Brief Hospital Course: The patient is a 64 year old male with a history of HCV infection, GERD, HTN, and polysubstance abuse admitted for UGIB and [**Last Name (un) **] from rhabdomyolysis, while hypertensive to 170s-180s systolic. He was admitted to the MICU and later transfered to the floor. On the floor he had no subsequent upper GI bleeding, and his acute kidney injury and rhabdomyolysis slowly resolved. While on the floor, he was found to have a RLL necrotizing PNA/empyema, which was treated with IV antibiotics and a VATS decortication. Active issues: # Upper GI Bleed On presentation, the patient complained of epigastric pain and had two episodes of bloody to [**Last Name (un) 30212**]-colored emesis. He was started on Octreotide and Pantoprozole gtt. Hct was 48.8. GI was consulted and recommended EGD. He was admitted to the MICU after his maroon-colored emesis in the ED while hypertensive to 170s-180s systolic. In the MICU, he remained hemodynamically stable overnight. He had negative NG lavage, and his hematocrit was stable. He received IVFs and maintained good urine output. RUQ ultrasound with doppler showed a normal appearing liver without a nodular appearance, not suggestive of cirrhosis. The patient was transfered to the general medicine floor where he had no further episodes of emesis. He had an EGD which was negative for any source of bleeding, but positive for gastritis, as well as esophagitis and duodenitis. Subsequent H. Pylori testing was positive. On discharge, the patient was started on PPI with instructions to follow-up with his PCP for treatment of the H. Pylori once he finished his course of antibiotics begun in-hospital. # [**Last Name (un) **] / Rhabdomyolysis: On presentation, the patient had been brought in by his friends who did not know how long he had spent unconsious, raising suspicion of rhabdomyolysis. On admission, his Cr was 5.2 with baseline 1.4 based on [**Hospital1 2177**] discharge summary in [**2185**]. CK elevated to [**Numeric Identifier 100019**] on admission, likely secondary to rhabdomyolysis as a major contributor. Renal ultrasound demonstrated no obstructive cause for the [**Last Name (un) **]. Over the course of his admission, the patient received regular IVF treatment, and his CK trended downward to 132 at his final measurement before discharge. Although his Cr also downtrended steadily with the length of his admission, he had a brief bump in his Cr. After he received IV lasix, his urine output steadily improved, and his Cr at discharge remained at 1.7 its nadir for this admission. He was not continued on Lasix due to his continued urine output. While in the hospital, every possible effort was made to renally dose medications and avoid nephrotoxins. # Necrotizing Pneumonia/Empyema Shortly after the patient was transfered from the MICU to the floor, the patient began to report some discomfort at the right upper quadrant/lower right costal margin. At this time, he had a few brief fluctuations in mental status. The discomfort increased over two days, and began radiating to his back. Given the finding of a non-obstructing kidney stone on his initial ultrasound, and a mild pancreatitis, a CT abdomen was ordered (both kidney and RUQ U/S were recently negative for obstruction). The patient was found to have a loculated effusion in the RLL, which was initially tapped by interventional pulmonology. The patient was started on IV Vanc/Zosyn. Thoracic surgery performed a right VATS decortication on [**2188-5-28**]. Subsequent to the surgery, the patient ran a low temperature on several nights, likely due to atelectasis (cultures sent during these spikes were negative), which quickly resolved. During this period, the patient received aggressive chest PT, and had a progressive decrease in his requirement of supplemental O2. Due to the low suspicion for MRSA, the patient's antibiotics were changed to levofloxacin and clindamycin, and his improvement was sufficient that ID recommended that he could be switched to PO antibiotics for his remaining course, which will end on [**2188-6-16**]. Chronic Issues: # Hypertension: The patient was initially 170s-180s systolic on arrival to the ED. His SBP continued to remain high in the MICU and was in the 160-180s just prior to transfer to the floor. On the floor, he received labetalol, hydralazine, and amlodipine, where his pressures generally remained within the 120-140 range. On discharge, he was prescribed once daily metoprolol and amlodipine in order to increase compliance. # Drug Abuse: The patient initially denied recent drug use in several months, but had UTox positive for opiates in the ED. He has smoked 1 PPD for many years. In the hospital, the patient received a prn nicotine patch. Given his history of IVDU, an HIV test was performed which was negative. Social work also consulted, and confirmed that the patient had been off drugs for one year, with occasional lapses and was now living independently after years of struggling to get housing. The patient was kept in contact with his social supports in order to help him maintain his progress as an outpatient and to ensure that he remains connected to social services. Transitional Issues: - Follow up H. Pylori treatment - Follow up L inf renal mass with outpatient u/s Medications on Admission: HCTZ -- patient unsure of dose Diltiazem -- patient unsure of dose Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 13 days: end date [**6-18**]. Disp:*15 Tablet(s)* Refills:*0* 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Outpatient Lab Work Please draw chemistry panel (CHEM 7) 2 days after discharge to assess renal function 5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 13 days: end date [**6-18**]. Disp:*52 Capsule(s)* Refills:*0* 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Upper GI bleed Acute Kidney Injury due to Rhabdomyolysis Right Lower Lobe Pneumonia complicated by empyema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital because you were found unconscious. When you were admitted, you were vomiting blood and you had a severe injury to your kidneys. You were placed in the medical intensive care unit (MICU) in order to be monitored very carefully. . When your condition improved, you were transferred to the general medicine [**Hospital1 **]. However, when you were on the general medicine [**Hospital1 **], it was discovered that you had an infection in your right lung. A CT scan was performed which showed that the infection was so severe that it had to be treated with surgery. You had surgery on [**2188-5-27**], after which two tubes were placed in your chest to drain fluid and to keep your lung inflated. These tubes were removed a few days after the surgery and your respiratory status was monitored carefully. You were started on oral antibiotics with a plan to complete a 4 week course. During your stay, you were also found to have an infection with an organism called H. Pylori. It is important for you to follow up with your primary care doctor in order to treat H. Pylori once you finish your treatment for pneumonia. The following changes were made to your medications: To treat infection: * START taking Levofloxacin 750mg tablets. Take one tablet every 48 hours for 13 days * START taking Clindamycin 300mg tablets. Take one tablet four times daily. . For your stomach: * Start Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Take One (1) Tablet, Delayed Release (E.C.) by mouth twice a day . To treat your high blood pressure: * START taking METOPROLOL XL 200mg tablet. Take one tablet daily. * Start Amlodipine 10 mg Tablet Take One (1) Tablet by mouth daily. . Again it was pleasure taking care of you. *** Again it is of the utmost importance to abstain from drinking and drug use **** Followup Instructions: You will need to follow-up with thoracic surgery department; they will plan on contacting you; if you don't hear from them please call [**Telephone/Fax (1) 3020**] for an appt. . You will plan to follow-up with your PCP at [**Hospital3 9947**] or the at the VA. You will need to schedule an appt for 1-2 weeks. . Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2188-7-1**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Completed by:[**2188-6-10**]

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icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "34.52", "96.34", "34.91" ]

icd9pcs

[ [ [] ] ]

16829, 16886

10441, 10967

311, 339

17037, 17037

3695, 3695

19073, 20071

2301, 2305

15850, 16806

16907, 17016

15758, 15827

17188, 19050

5593, 10418

2320, 3676

15650, 15732

1503, 1951

263, 273

10982, 14526

367, 1484

3711, 5577

17052, 17164

14543, 15629

1973, 2052

2068, 2285

71,021

145,689

35407

Discharge summary

report

Admission Date: [**2201-1-23**] Discharge Date: [**2201-1-28**] Date of Birth: [**2125-6-28**] Sex: F Service: MEDICINE Allergies: Midazolam Attending:[**First Name3 (LF) 2297**] Chief Complaint: ventilator dependent patient with ?trach leak Major Surgical or Invasive Procedure: Bronchscopy Tracheostomy tube replacement PICC line placement History of Present Illness: Ms. [**Known lastname 116**] is a 75F with COPD, pulmonary HTN, atrial fibrillation, and chronic respiratory failure who is ventilator dependent who is transferred from an OSH for IP evaluation of a possible tracheostomy leak. The current trach has been in place for 1 year. Of note, the patient has had been admitted continuously since [**2200-5-1**] for failure to wean from ventilator. On the morning of admission, the patient had desaturations and required ventilation with an ambu bag. A bronchoscopy was preformed revealing a patent trachea a the tube was replaced with a shiley # 8 89 mm in length to 15 mm above the carina. The patient was then placed on assist control 450/12/O peep and FiO2 of 40%. She had consistently low tidal volumes ranging from 250-280, but in no distress. In addtion, on the day of admission the patient had a CBC/diff with 5% bans. The patient was currently treated with Zyvox which was d/c'd and broadened to Zosyn/flagyl for concern of possible aspiration. The team from the OSH also had concern for C diff, but labs are still pending at time of transfer. Past Medical History: Cardiopulmonary arrest [**2198**] Chronic respiratory failure s/p tracheostomy : Shiley #8 ?????? 89mm CHF Atrial fibrillation COPD LUL resection [**2-2**] cyst-no CA found Pulmonary hypertension Epilepsy GERD h/o shingles with post herpetic neuralgia Thrombocytosis Anemia Hypothyroidism Right upper extremity brachioplexopathy Social History: Divorced, lives alone. No current tobacco use, though used for many years ago. No EtOH use. Repetitively hospitalized since [**2199-9-30**]. Daughter is HCP. Family History: Non-contributory Physical Exam: Admission Physical Exam Vitals T 98.3 HR 81 BP 145/74 RR 12 98% on vent 450x12/6/50% General: Awake, A/O x 3, follows commands, no acute distress HEENT: NCAT, PERRL, tracheostomy Neck: Supple Pulm: L lung with rhonchi CV: RRR Abd: soft, protuberant, nontender, +BS, some ecchymosis from injection sites, G tube in LUQ Extrem: RUQ with claw deformity-unable to make fist, Generalized weakness, worse in legs and RUE-[**3-5**]. LUE 4-/5. Neuro: CN intact, normal sensation, follows commands and moves all extremities. Discharge Physical Exam Tmax: 37.5 ??????C (99.5 ??????F) HR: 98 bpm BP: 143/76 RR: 16 SpO2: 100% General: Awake, A/O x 3, follows commands, uncomfortable appearing HEENT: NCAT, PERRL, tracheostomy with audible leak, improved from prior Neck: Supple Pulm: L lung with rhonchi and wheezes CV: S1 & S2 regular, fast and without murmur Abd: soft, protuberant, nontender, +BS, some ecchymosis from injection sites, G tube in LUQ Extrem: RUE with claw deformity-unable to make fist, Generalized weakness, worse in legs and RUE-[**3-5**]. LUE 4-/5. Neuro: CN intact, normal sensation, follows commands Pertinent Results: Discharge labs: [**2201-1-28**] 02:36AM BLOOD WBC-12.8*# RBC-2.75*# Hgb-8.7*# Hct-26.5* MCV-96# MCH-31.7 MCHC-32.9# RDW-13.9 Plt Ct-437 [**2201-1-27**] 03:49PM BLOOD PT-14.5* PTT-34.1 INR(PT)-1.3* [**2201-1-28**] 02:36AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-140 K-4.3 Cl-111* HCO3-23 AnGap-10 [**2201-1-28**] 02:36AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2 [**2201-1-27**] 03:49PM BLOOD Hapto-303* [**2201-1-28**] 03:05AM BLOOD Type-CENTRAL VE Temp-36.3 pO2-44* pCO2-51* pH-7.24* calTCO2-23 Base XS--5 Microbiology: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2201-1-28**]): Feces negative [**2201-1-25**] 11:50 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2201-1-25**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): ? OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. SPARSE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. ? OF THREE COLONIAL MORPHOLOGIES. GRAM STAIN (Final [**2201-1-24**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2201-1-26**]): SPARSE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF FOUR COLONIAL MORPHOLOGIES. Relevant Imaging: CT Chest [**1-24**] 1. Severe scarring and traction bronchiectasis more prominent in both upper lobes, could be due to old granulomatous exposure such as tuberculosis, less likely sarcoid. 2. Multifocal peribronchial and bronchiolar opacities on the right, likely due to aspiration. Left lower lobe secretions with newly develped atelectasis could also be due to aspiration. Note that it is impossible to rule out a spiculated lesion from this extensive scarring given the absence of prior study for comparison. Followup in three months is recommended. 3. Marked volume loss on the left with shift of the mediastinum. The left upper lobe bronchus is not identified, could be obstructed or due to prior left upper lobectomy. 4. Mild emphysema. 5. Signs of pulmonary hypertension. 6. Moderate hiatal hernia. Gallstones. 7. Pectus excavatum. 8. Hyperinflated tracheostomy cuff. Torso CT [**1-27**] IMPRESSION: 1. No evidence of retroperitoneal or intrathoracic hemorrhage. 2. Slightly worsened peribronchiolar and dependent opacities in the right lower lobe, suspicious for aspiration. 3. Unchanged severe bronchiectasis and scarring in the upper lobes bilaterally, which [**Known lastname **] be due to prior granulomatous disease. 4. Persistently over-inflated tracheostomy tube cuff as well as termination of the left PICC in the right brachiocephalic vein. 5. Moderate hiatal hernia. 6. Gallstones. CXR [**1-28**] Improving L lung aeration Brief Hospital Course: A 75 year old lady transferred from [**Hospital1 **] for Interventional Pulmonary evaluation of persistent tracheostomy leak. Her tracheostomy tube was changed after bronchoscopy. She was found to have a developing Pneumonia on transfer for which she will be treated with Doripenem & Vancomycin until [**2201-2-9**]. 1. Ventilator dependent respiratory failure: Ms. [**Known lastname 116**] was transferred for evaluation of her persistent tracheostomy leak. She was evaluated at bedside by interventional pulmonology (IP), underwent bronchoscopy via tracheostomy tube which showed copious purulent secretions which were aspirated. The tracheostomy tube was changed and replaced at the bedside. The leak persisted, but the patient tolerates CMV with tidal volume set at 600 (breathing ~ 350). The was clearly an anxiety component to her complaints of dyspnea because while she was sleeping or sedated, her tidal volumes improved. She had transient episodes of desaturation which improved with suction. She was treated with morphine to resolve symptoms of air hunger. A fentanyl patch 25mcg was applied daily to relieve pain/anxiety which also improved her respiratory status. It is recommended that she remain on AC/CMV for transport to be re-evaluated by her primary team at [**Hospital1 **]. Our IP team has no further mechanical interventions to offer at this time. 2. Pneumonia: Gram stain of sputum and bronchoalveolar lavage was significant for Gram negative rods and Gram positive cocci. She has been started on Doripenem and Vancomycin to be administered via placed PICC line for a 2 week course to end [**2201-2-9**]. 3. Tachycardia: The patient was found to be in sinus tachycardia from 95-130 while admitted despite a history of atrial fibrillation. This was determined to be secondary to anxiety, work of breathing, and pneumonia. As we achieved therapeutic success with antibiotics her tachcardia improved. The patient was continued on all other medications on which she was transfered. Medications on Admission: Flagyl 500 mg per G tube Q 8 hours Zosyn 3.75 grams IV Q 6 H Synthroid 75 mcg daily Zyvox 600 mg PO BID from [**Date range (1) 2820**] Neurontin 200 mg Q 8 H Seroquel 12.5 mg per G tube QD, 25 mg QHS Seroquel 12.5 mg Q 8 H: PRN aggitation Cymbalta 30 mg QD Albuterol Neb Q 2 H PRN Klonopin 0.25 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Senokot 10 ml QHS Fleet enema PRN Lidoderm patch to back QD Darvocet ? Q 6 H PRN MV QD Sarna lotion QD Desenex powder Zinc 220 PO QD Compazine 5 mg IV Q6H PRN nausea OS-cal with Vita D 500 mg PO QD Flovent 2 puffs [**Hospital1 **] Hep 5000 SQ [**Hospital1 **] ASA 81 mg QD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO 0900, 1700 (). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q2H (every 2 hours) as needed for SOB. 15. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for Aggitation. 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 19. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for Pain. 20. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 21. Doripenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 14 days: Last day [**2201-2-9**]. 22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 23. Vancomycin 750 mg IV Q 12H Start [**2201-1-27**] 24. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for air hunger. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: 1. Ventilator dependence 2. Pneumonia 3. Chronic Obstructive Pulmonary disorder Discharge Condition: Vital signs stable on Ventilator AC Mode. Discharge Instructions: You have been admitted to the [**Hospital1 18**] MICU to have our Interventional Pulmonology Service evaluate your tracheostomy tube. They found that you had a persistent leak around the cuff of the tracheostomy and replaced your breathing tube. Unfortunately, there are no further interventions that our Pulmonologists can offer at this time. While you were here you developed a pneumonia which we have been treating with appropriate antibiotics. Followup Instructions: 1. Continue Doripax & Vancomycin for 2 weeks ending [**2201-2-9**] pending clinical improvement. 2. Follow with your Pulmonologist as scheduled. Our Interventional Pulmonology Service has no other interventions to offer at this time.

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12317

Discharge summary

report

Admission Date: [**2187-5-22**] Discharge Date: [**2187-5-29**] Service: KURLIN-MED IDENTIFYING DATA: [**Age over 90 **] year old female admitted to the Medical Intensive Care Unit with mental status changes, hypoxia, bradycardia and now called out to the Medical Floor. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old Cantonese speaking only female immigrated to the United States in [**2164**] with a past medical history significant for end-stage renal disease on hemodialysis, history of seizure disorder since [**2187-1-19**], and recent pneumonia, who initially presented from hemodialysis unresponsive, bradycardic and short of breath, and admitted to the Medical Intensive Care Unit. At the Medical Intensive Care Unit the patient was hypotensive and unresponsive to fluid boluses and started on Dopamine, now off since [**5-23**], a.m. Heart rate stable in the 40s to 50s, no Telemetry events. Started on Ceftriaxone and Azithromycin for a possible Pulmonary process. Chest x-ray was clear. Lumbar puncture was negative. Change in mental status improved to more alert. Stools showed positive C. difficile and Flagyl was started. A right upper quadrant ultrasound was negative and was done secondary to an increase in GGT and alkaline phosphatase. The patient was started on Vancomycin secondary to one out of four bottles Gram positive cocci, possibly secondary to a central line infection with central line now discontinued. The oxygen by nasal cannula was being weaned to off. Chest CT scan on [**5-23**] revealed possible reactivation tuberculosis with right apex opacities and now on respiratory precautions. The patient was now stable for call out to the Medical Floor. PAST MEDICAL HISTORY: 1. Hypertension. 2. End-stage renal disease on hemodialysis. 3. History of recent pneumonia in [**2187-4-18**]. 4. Low back pain. 5. Upper gastrointestinal bleed in [**2187-1-19**] secondary to ibuprofen. 6. Seizure disorder; first diagnosed with a seizure during hemodialysis in [**2187-1-19**]. 7. History of appendectomy. 8. Status post colon perforation during colonoscopy with resection and temporary ostomy. ALLERGIES: No known drug allergies. MEDICATIONS: (On transfer) 1. Flagyl 500 intravenous three times a day. 2. Vancomycin 1 gram intravenously. 3. Ceftriaxone one gram intravenously. 4. Azithromycin 250 mg intravenously. 5. Dilantin 100 mg intravenously twice a day. 6. Subcutaneous heparin. 7. Protonix 40 intravenously. 8. Calcium carbonate. 9. Nephrocaps. 10. Renagel. SOCIAL HISTORY: Immigrated to the United States in [**2164**]; [**Hospital 2670**] nursing home. No smoking or alcohol use. Son is [**Name (NI) 38412**] [**Name (NI) 38413**], [**Telephone/Fax (1) 38414**]. PHYSICAL EXAMINATION: (On transfer) Vital signs are temperature 99.1 F., maximum temperature 100.4 F.; blood pressure 132/68; heart rate 51; respiratory rate 14; O2 saturation 100% on two liters. General appearance: In no acute distress. Somewhat alert and awake. Makes eye contact. Responds to verbal stimuli; mumbles. HEENT: No jugular venous distention, normocephalic, atraumatic. Supple neck; oropharynx clear. Moist mucous membranes, minimally reactive pupils bilaterally, small. Cardiovascular: Regular rhythm, bradycardic. Normal S1 and S2. II/VI systolic murmur throughout. Lungs clear anteriorly and laterally. Abdomen soft, nontender, nondistended with hypoactive bowel sounds. Extremities: No signs of clubbing or cyanosis. No edema bilaterally. Lower extremities with good pulses. Neurologic: Nonfocal. Cranial nerves II through XII intact with slightly decreased alertness. LABORATORY DATA: White blood cell count 13.6, hematocrit 32.9, platelets 189. Chem-7 remarkable for a BUN of 38 and a creatinine of 4.4 (the patient on hemodialysis with end-stage renal disease). Glucose of 118. Blood cultures one out of four grew Gram positive cocci, in pairs and clusters which grew out to be Vancomycin resistant enterococcus. All other blood cultures were negative to date. Lumbar puncture was negative. Cerebrospinal fluid culture: No growth to date. CK MB and troponin negative. Dilantin level 4.9. Central line tip culture with no significant growth. Urine cultures negative to date. Stool cultures C. difficile positive. Fecal culture and Campylobacter culture negative to date. Chest CT scan on [**5-23**], showed previous granuloma infection with cluster of calcified granulomas at the left apex and right apex, opacities at the right lung apex, suspicious for reactivation tuberculosis; no other studies documenting stability. Small bilateral pleural effusions, esophageal nodular thickening questionable for neoplasm. Atrophic kidneys with two cysts, hepatic cysts and bilateral anterior rib fractures. SUMMARY OF HOSPITAL COURSE: The patient is a [**Age over 90 **] year old female with a past medical history of end-stage renal disease, hypertension, recent pneumonia, and seizure disorder, presenting initially to the Medical Intensive Care Unit with mental status changes, hypoxia, bradycardia, hypotension, and uremia, with hyperkalemia, now stabilized and improved for transfer to medical floor. 1. Neurologic: The patient's mental status changes were thought to be secondary to toxic metabolic (uremia) and possibly infection. The family now reports that the patient's mental status is back to baseline when patient was transferred to Medical Floor. Infectious causes were worked up and antibiotics were given empirically which were now discontinued upon transfer to the floor. The patient was continued on Dilantin for a history of seizure disorder with Dilantin level in the low end of therapeutic. The patient, for the remainder of her hospital stay, was stable neurologically. 2. Infectious Disease: The patient had some fevers since admission but was afebrile for the remainder of her hospital stay with a decreasing white blood cell count. The patient had initially been covered empirically with Ceftriaxone and Azithromycin with possible pulmonary process which has since then been discontinued with a clear chest x-ray and a chest CT scan clear of infiltrates. The patient had a negative lumbar puncture as well as negative urinalysis and urine culture. The chest CT scan did reveal concern for possible reactivation TB and the patient was placed in respiratory isolation upon transfer to the floor. Three AFB smears were obtained and were all negative. The patient did not have any active cough. The patient did have Gram positive cocci that grew out from her right femoral line blood culture, one out of two bottles. Peripheral cultures were negative. Vancomycin had initially been started but then discontinued with surveillance cultures showing no growth to date. Femoral line was discontinued in the Medical Intensive Care Unit and the culture was tipped which showed no significant growth. The patient did have stool that was positive for Clostridium difficile and was treated with Flagyl 500 mg p.o. twice a day renal dosed, and will continue for a total of 14 day treatment. While on the floor, the patient remained stable from an Infectious Disease standpoint. 3. Pulmonary: The patient initially was found to be hypoxic while in the Medical Intensive Care Unit. Eventually this was thought to be secondary to fluid overload and improved with dialysis upon admission to the Medical Intensive Care Unit. While on the Floor, the patient was on nasal cannula at two liters saturating 98 to 100% and eventually was weaned to room air. The patient remained in respiratory isolation until ruled out for tuberculosis times three and negative AFB smears. Chest CT scan as above. While on the floor, the patient remained in stable respiratory condition. 4. Renal: The patient received dialysis on her regular scheduled Tuesday, Thursday and Saturday, while in the hospital. Renal Service was following throughout. The patient continued on her Nephrocaps, Renagel and TUMS. Her initial uremia was resolved while in the Medical Intensive Care Unit. No other acute renal issues during hospital stay. 5. Cardiovascular: The patient was hemodynamically stable upon transfer to the floor, off Dopamine since the morning of [**5-23**]. The patient had stable bradycardia during the Medical Intensive Care Unit stay and during hospital stay which eventually returned to [**Location 213**] sinus rhythm. The patient had initially been on 100 of Atenolol per day, which was discontinued on admission. No significant Telemetry events were noted during hospital stay. The patient has a history of hypertension and was eventually restarted back on her Norvasc and a lower dose of Lopressor as well as Captopril for good blood pressure control. 6. Gastrointestinal: The patient was treated and continued on Flagyl for a total course of 14 days for positive C. difficile in her stool. The patient reportedly had guaiac positive stool initially during the Medical Intensive Care Unit stay, but her hematocrits have remained stable. The patient's right upper quadrant ultrasound was negative after being obtained secondary to an increase in GGT and alkaline phosphatase which, since then, have trended down. No other gastrointestinal issues were encountered while on the Medical Floor. 7. Hematology: The patient's hematocrit remained stable throughout her stay on the medical floor. 8. Musculoskeletal: The patient has a history of lower back pain since [**Month (only) 404**] of [**Month (only) 956**] of this year. The patient will be empirically treated with a Pox II inhibitor upon discharge. No further studies were obtained. 9. Fluids, Electrolytes and Nutrition: The patient's diet was slowly advanced after a Speech and Swallow evaluation was obtained which showed that the patient was swallowing adequately. Aspiration precautions were used initially until the patient's alertness returned to baseline. Upon discharge, the patient was eating well. 10. Code Status: The patient remained a full code during hospital stay. DISPOSITION: The patient will return [**Hospital1 2670**] Facility. DISCHARGE INSTRUCTIONS: 1. Physical Therapy and Occupational Therapy will evaluate patient and the patient was safely discharged back to nursing facility. 2. The patient will follow-up with her primary care doctor as needed. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To [**Hospital1 2670**] Nursing facility. DISCHARGE DIAGNOSES: 1. End-stage renal disease on hemodialysis. 2. Hypertension. 3. Low back pain. 4. Seizure disorder. 5. Clostridium difficile positive stool on Flagyl. DISCHARGE MEDICATIONS: 1. Captopril 12.5 mg p.o. three times a day. 2. Lopressor 25 mg p.o. twice a day. 3. Norvasc 10 mg p.o. q. day. 4. Dilantin 100 mg p.o. twice a day. 5. Protonix 40 mg p.o. q. day. 6. Flagyl 500 mg p.o. twice a day until [**2187-6-5**]. 7. Calcium carbonate 1000 mg p.o. three times a day. 8. Colace 100 mg p.o. twice a day. 9. Sevelamer 800 mg p.o. three times a day. 10. Nephrocaps one capsule p.o. q. day. 11. Vioxx 12.5 mg p.o. q. day. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2187-5-29**] 13:48 T: [**2187-5-29**] 14:33 JOB#: [**Job Number 10187**]

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icd9cm

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12822

Discharge summary

report

Admission Date: [**2145-2-20**] Discharge Date: [**2145-2-26**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Clarithromycin / Vioxx / Ultram Attending:[**First Name3 (LF) 1881**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: MICU [**Location (un) **] ADMIT NOTE . CC:[**CC Contact Info 39484**]. HPI: 84 yo F with h/o afib on coumadin, MVR, COPD, HTN who was admitted to [**Hospital1 18**] today with SOB thought to be secondary to CHF and PNA. She was transfered to the MICU after becoming hypoxic, diaphoretic, and hypotensive requiring intubation and a levophed gtt. . During the code, patient was found to have be in respiratoy distress using accessory muscles to breath after eating dinner. BP was unable to be obtained with dopplers. She had strong b/l femoral pulses. A right IJ was unsuccessful; a right fem line was placed. She was started on a levophed gtt, intubated, and transfered to the MICU. . As per the chart, she presented to the ED with progressive SOB, intermittent right sided chest pain, and an occasional productive cough. She denied fevers/chills. Pt reported orthopnea, DOE, and LE swelling worse than baseline. At baseline she ambulates with a walker. . In the ED patient received CTX/Azithro, Solumedrol 125 IV, Dilt 10 IV, ASA 325. She was noted to be in aflutter at a rate of 140s, that improved with dilt 10 IV x1. She received an additional 2 doses of lasix 20 mg IV. . PMH: 1. GERD 2. PAF 3. Mechanical MVR [**2135**] (at [**Hospital1 2025**] for MR) - on coumadin 4. COPD 5. AAA repair [**5-11**] 6. h/o DVT 8. HTN 9. h/o PNA 10. h/o gastritis 11. DJD 12. OA 13. diverticulosis 14. chronic pain 15. spinal stenosis 16. S/p fall and rib fracture in [**11-11**] 17. Piaget's disease . Meds at home: HCTZ 25 qd Quinine 325 qd Calcium carbonate 500 tid Desipramine 10 HS Lactulose 30 q8 prn Salmeterol 50 mcg [**Hospital1 **] Trazodone 50 hs prn Fluticasone 100 mg [**Hospital1 **] Ipratroprium QID Coumadin 2 mg HS Pantoprazole 40 qd Albuterol MDI Klonopin 1 HS PRN Vicodin (not taking) Dilaudid (not taking) Senna Colace . All: Sulfa - rash, PCN - hives, Vioxx - n/v, Clarithro - unknown, Ultram - lightheadedness, Fosamax -- unknwon . SHx: Per primary evaluation in ED, patient lives by herself independently. >50 pack-year smoking hx with current use of [**2-8**] pack per day. Denies Etoh or drugs. Daughter helps her at home. There was a recent question of diversion of patient's home pain meds in OMR -- missing several doses when VNA saw her. . FHx: NC . PE: Tc 96.5 HR 68 BP 119/69 RR 25 O2Sat 100% Vent: AC 400/16(actual 22)/PEEP 5/FiO2 50% GEN: frail elderly female, intubated/sedated HEENT: pupils ~2 mm and equal, dry mmm NECK: unable to assess CV: RRR, nl S1S2, valve click LUNG: coarse rhoncherous breath sounds throughout anteriorly, no wheezes ABD: soft, nt, bs+ EXT: cool, minimal peripheral edema, strong DP/PT pulses bilaterally . Labs: . . . . . . . . . . Past Medical History: GERD chronic paroxysmal a-fib MVR [**2135**] AAA repair [**5-11**] COPD hx DVT HTN TAH [**2134**] Paget's disease of LLE hx gastritis hx RML pna DJD OA Diverticulsosi Chronic pain spinal stenosis . Family History: Not compliant with taking FH Pertinent Results: ABG during code: pH 7.44 pCO2 28 pO2 426 HCO3 20 on ambu bag Na:138 K:5.0 Cl:105 Hgb:10.0 HCT:30 Glu:406 freeCa:1.53 Lactate: 10.6 10.2-> INR 7.0 CK 68, trop 0.02 LDH 550, Hapto <20, . Studies: RLE U/S [**2145-2-20**]: no DVT . CXR [**2145-2-20**]: Mild CHF, b/l pleural effusions R>L, RLL consolidation, flattened diaphragms . EKG: aflutter 150, no st/t changes . Echo [**2143-2-18**]: Overall left ventricular systolic function is normal (LVEF>55%). A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mitral regurgitation is present but cannot be quantified (likely normal for this prosthetic valve). There is mild pulmonary artery systolic hypertension. . . Brief Hospital Course: A/P: 84 yo F with AF, MVR on coumadin, COPD with acute respiratory distress and hypotension requiring intubation and levophed. . # Hypoxic Respiratory distress. After evaluation and triage in the ED, she arrived on the inpatient floor without respiratory distress satting well on 2LNC. Approximately three hours later she developed acute respiratory distress, the differential included aspiration event, but later was demonstrated to have low risk for aspiration by speech and swallow, a flash pulmonary edema from ischemia or tachycardia (ECG with new symmetric lateral TWI's), CAP (RLL consolidation with effusion), PE (however this seems unlikely given INR of 10; and negative LE dopplers) stroke. In the unit she was started on vancomycin. She was kept on ventilator and on levophed in the unit for one day only. She has responded well to antibiotics, lasix prn, and has remained afebrile with good O2 sats on 2LNC. Repeat CXR showed bilateral infiltrates. A cardiac echocardiagram indicated that she did have a decreased LVEF of 30-35%, which may have contributed to her shortness of breath. She was stabilized and transferred back to the floors, she was treated with levaquin, for a community acquired pneumonia, a viral nasal aspirate was negative for influenzae, urine legionella was also negative. Her oxygen requirements were slowly tapered and she required 2L of oxygen at time of discharge to rehabiliation. She was to finish a 10 day course of antibiotics for presumed pneumonia. . # Hypotension. On transfer to the floor she developed acute hypotension, the differential included sepsis, cardiogenic shock from ischemia, and adrenal insufficiency a code was called and she was transferred to the MICU. She was pancultured without growth, an echocardiagram indicated wall motion abnormalities, and a decreased LVEF, her cardiac enzymes were cycled with a slight elevation of troponins at 0.03. She was not anticoagulated as her INR was 10 and there was concern for DIC. She was initially maintained on levophed, but weaned off without difficulty, her blood pressures remained stable for the rest of her hospital course. She was initially treated with diltiazem while in the ICU but she was changed to metoprolol for blood pressure control and rate control as she was shown to have a decreased EF. Her heart rate increased to the 120s on metoprolol and her blood pressures could not tolerate increase of metoprolol with SBP in the 110s, thus diltiazem was reapplied and titrated upwards while tapering off the metoprolol. There may be indication at rehab to attempt to add an ace inhibitor and continue the diltiazem for rate control, as this was suspect in her acute hypotensive decompensation. . # Coagulopathy. Her INR was elevated on admission with an INR of 10. This was thought to be associated with compliance as she has had multiple admission with elevated INRs. She was given FFP and vitamin K to reverse the coagulopathy. After stabilization of her hypotension and return to the floor, she was restarted on heparin for MVR prophylaxis, and her outpatient coumadin was restarted for a goal of INR [**3-12**]. Her INR was 1.1 at time of discharge with instructions to titrate coumadin for a goal of INR [**3-12**]. She was to be maintained on a heparin sliding scale until her coumadin was therapeutic . # CKK- Her creatine remained at her baseline during this dmission. . # AFib- She has a history of atrial fibrillation, which during the course of hypotensive code and transfer to the unit evolved to atrial flutter. She was rhythm controlled with diltiazem and she remained atrial fibrillation, her cardiac medications were converted from diltiazem to metoprolol to better address her CHF but her heart rate increased and thus she was titrated back to diltiazem. . # Mechanical MV. Initially her INR of 10, she was given FFP and vitamin K, and her INR normalized. She was restarted on heparin, and her coumadin was restarted, please see coagulopathy for further detail . # COPD. This likely contributed to respiratory distress, she was symptomatically controlled with atrovent. . # Anemia. Her hematocrit remained at baseline levels, She did not require transfusions. . # FEN. A speech and swallow evaluation demonstrated she had only low risk for aspiration, she was maintained on thin liquids, and a soft dysphagia diet. Medications on Admission: HCTZ 25 qd Quinine 325 qd Calcium carbonate 500 tid Desipramine 10 HS Lactulose 30 q8 prn Salmeterol 50 mcg [**Hospital1 **] Trazodone 50 hs prn Fluticasone 100 mg [**Hospital1 **] Ipratroprium QID Coumadin 2 mg HS Pantoprazole 40 qd Albuterol MDI Klonopin 1 HS PRN Discharge Medications: 1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 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* 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 7. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*5 units* Refills:*0* 11. 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* 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 days. Disp:*2 Tablet(s)* Refills:*0* 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:*5 units* Refills:*2* 16. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 unit* Refills:*0* 17. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 18. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please titrate on heparin sliding scale. Disp:*1 qs* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Pneumonia CHF Discharge Condition: Stable Discharge Instructions: Please take your medications as instructed If you experience increased shortness of breath, chest pain, or other concerning symptoms please call your doctor Please follow up with the doctors listed below. Followup Instructions: Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2145-3-2**] 6:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2145-4-27**] 3:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2145-3-16**] 4:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]

[ "428.0", "V58.61", "530.81", "276.51", "496", "401.9", "427.32", "731.0", "584.9", "518.81", "486", "V43.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "96.71", "99.07" ]

icd9pcs

[ [ [] ] ]

11097, 11176

4102, 8481

296, 303

11234, 11243

3314, 4079

11498, 12077

3265, 3295

8797, 11074

11197, 11213

8507, 8774

11267, 11475

237, 258

331, 3027

3049, 3249

15,181

156,172

30185

Discharge summary

report

Admission Date: [**2102-3-22**] Discharge Date: [**2102-3-27**] Date of Birth: [**2067-5-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Pt is 34 yo f w/ HTN who presented last PM to OSH with CP radiating to back/arms. CP was sternal, burning, occurred at rest, and radiated to back and both arms. Pain worsened with exertion. The CP was associated with SOB, nausea, and dry heaves. At the OSH, she had T-wave inversions in leads V1-V3, with negative cardiac enzymes x 1, and was found to have K 2.5. She received ASA and was placed on a nitro gtt. She reports viral URI 1 wk ago. Pt was then transferred to [**Hospital1 18**]. In the [**Name (NI) **], pt had chest CTA, which was negative for PE or dissection. EKG showed unchanged TWI (not dynamic). She ruled in for MI with trop 0.51, CK 153, MB 20. She had a stat TTE, which showed normal wall motion. She was placed on IV heparin and given plavix 600mg. She had recurrent CP, and was re-started on nitro gtt. She also was given potassium 40meq and Anzemet. Pt was then taken to cardiac cath. . Pt now presents s/p cath, and denies CP/SOB. She c/o mild headache and feeling "wiped out." Past Medical History: HTN Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Father has thalassemia trait. Physical Exam: VS: T 97.7 BP 171/104 HR 93 RR 20 O2 100% RA Gen: WDWN female in NAD, lying flat. 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 flat JVP CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, [**1-10**] sys murmur @ RUSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R groin site intact. No hematoma. 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: REPORTS: . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2102-3-22**] 7:54 AM: IMPRESSION: 1. No evidence of pulmonary embolism or thoracic aortic dissection. 2. 6-mm right thyroid nodule, further evaluation with ultrasound is recommended. 3. Trace left pleural effusion. A reports place in the ED dashboard at completion of examination. . Cardiac cath: 1. Selective coronary angiography of this right dominant system did not reveal any significant disease. The LMCA, LAD, and RCA were all widely patent. The LCx had a smooth 60% lesion in the OM3 branch. 2. Limited resting hemodynamics revealed moderately elevated left heart filling pressures (LVEDP of 24mmHg) in the setting of systemic arterial hypertension with an aortic blood pressure of 180/114mmHg. 3. Left ventriculography revealed a calculated LVEF of 56% with no regional wall motion abnormalities. There was no mitral regurgitation. FINAL DIAGNOSIS: 1. Coronary arteries are free of angiographically significant disease. 2. Moderate diastolic left ventricular dysfunction. . [**2102-3-22**] TTE: The left atrium is elongated. 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%). 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 appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. There is a small anterior space which most likely represents a fat pad. . [**2102-3-25**] TTE: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal severe hypokinesis of the mid/distal inferolateral wall, though with preservation of the very distal segment. The remaining segments also contract well. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2102-3-22**], the regional left ventricular systolic dysfunction is new and c/w interim ischemia. . MRA KIDNEY W&W/O CONTRAST [**2102-3-23**] 2:11 PM: IMPRESSION: 1. No evidence of renal artery stenosis. 2. No evidence of retroperitoneal mass suspicious for pheochromocytoma. . CT HEAD W/O CONTRAST [**2102-3-24**] 10:15 AM FINDINGS: There is no sign for the presence of an intracranial hemorrhage, visible mass lesion, minor or major vascular territorial infarction. The density values of the brain parenchyma are normal. Surrounding osseous and soft tissue structures are unremarkable, aside from rather bulbous appearance of both internal auditory canals. This finding may merely represent a congenital variant. However, if there is any clinical suspicion for the possibility of bilateral intracanalicular masses, which can be seen in the rather unusual condition of neurofibromatosis II, supplemental MR scanning with gadolinium enhancement of the internal auditory canals would be helpful. There is slight prominence of the visualized posterior superior nasopharyngeal soft tissues. This finding could be within normal limits for a patient of this age. . LABS: . [**2102-3-27**] 05:00AM BLOOD WBC-6.6 RBC-4.60 Hgb-10.4* Hct-32.8* MCV-71* MCH-22.6* MCHC-31.6 RDW-18.2* Plt Ct-356 [**2102-3-26**] 06:31AM BLOOD WBC-6.2 RBC-4.42 Hgb-10.4* Hct-31.3* MCV-71* MCH-23.6* MCHC-33.3 RDW-18.1* Plt Ct-351 [**2102-3-25**] 07:00AM BLOOD WBC-5.0 RBC-4.39 Hgb-9.9* Hct-31.2* MCV-71* MCH-22.6* MCHC-31.8 RDW-17.9* Plt Ct-332 [**2102-3-24**] 05:40AM BLOOD WBC-7.0 RBC-4.49 Hgb-10.1* Hct-32.0* MCV-71* MCH-22.6* MCHC-31.7 RDW-17.7* Plt Ct-352 [**2102-3-23**] 06:48AM BLOOD WBC-6.2 RBC-4.48 Hgb-10.1* Hct-31.9* MCV-71* MCH-22.5* MCHC-31.7 RDW-17.9* Plt Ct-327 [**2102-3-22**] 06:20AM BLOOD WBC-6.0 RBC-4.50 Hgb-10.1* Hct-32.0* MCV-71* MCH-22.4* MCHC-31.6 RDW-17.8* Plt Ct-340 [**2102-3-25**] 07:00AM BLOOD Neuts-51.1 Lymphs-39.5 Monos-4.8 Eos-3.5 Baso-1.1 [**2102-3-23**] 06:48AM BLOOD Neuts-61.1 Lymphs-31.9 Monos-4.5 Eos-1.8 Baso-0.8 [**2102-3-22**] 06:20AM BLOOD Neuts-77.5* Lymphs-18.2 Monos-2.6 Eos-0.8 Baso-0.9 [**2102-3-27**] 05:00AM BLOOD Plt Ct-356 [**2102-3-26**] 06:31AM BLOOD Plt Ct-351 [**2102-3-25**] 07:00AM BLOOD Plt Ct-332 [**2102-3-24**] 05:40AM BLOOD Plt Ct-352 [**2102-3-23**] 06:48AM BLOOD Plt Ct-327 [**2102-3-23**] 06:48AM BLOOD PT-12.0 PTT-30.5 INR(PT)-1.0 [**2102-3-22**] 06:20AM BLOOD Plt Ct-340 [**2102-3-27**] 05:00AM BLOOD Glucose-101 UreaN-18 Creat-0.5 Na-140 K-3.7 Cl-103 HCO3-26 AnGap-15 [**2102-3-26**] 06:31AM BLOOD Glucose-102 UreaN-13 Creat-0.5 Na-141 K-3.8 Cl-105 HCO3-28 AnGap-12 [**2102-3-25**] 07:00AM BLOOD Glucose-101 UreaN-12 Creat-0.4 Na-142 K-3.6 Cl-109* HCO3-27 AnGap-10 [**2102-3-24**] 05:40AM BLOOD Glucose-106* UreaN-13 Creat-0.5 Na-139 K-4.3 Cl-106 HCO3-24 AnGap-13 [**2102-3-23**] 06:48AM BLOOD Glucose-104 UreaN-10 Creat-0.4 Na-142 K-3.7 Cl-109* HCO3-27 AnGap-10 [**2102-3-22**] 08:50PM BLOOD Glucose-131* UreaN-8 Creat-0.6 Na-141 K-3.0* Cl-106 HCO3-25 AnGap-13 [**2102-3-22**] 06:20AM BLOOD Glucose-116* UreaN-9 Creat-0.4 Na-140 K-2.8* Cl-102 HCO3-26 AnGap-15 [**2102-3-27**] 05:00AM BLOOD CK(CPK)-31 [**2102-3-26**] 06:31AM BLOOD CK(CPK)-75 [**2102-3-25**] 02:30PM BLOOD CK(CPK)-167* [**2102-3-25**] 07:00AM BLOOD CK(CPK)-20* [**2102-3-23**] 06:48AM BLOOD CK(CPK)-56 [**2102-3-22**] 06:20AM BLOOD ALT-7 AST-24 LD(LDH)-129 AlkPhos-53 Amylase-57 TotBili-0.3 [**2102-3-22**] 06:20AM BLOOD CK(CPK)-153* [**2102-3-22**] 06:20AM BLOOD Lipase-20 [**2102-3-27**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.24* [**2102-3-26**] 06:31AM BLOOD CK-MB-NotDone cTropnT-0.35* [**2102-3-25**] 02:30PM BLOOD CK-MB-21* MB Indx-12.6* cTropnT-0.64* [**2102-3-25**] 07:00AM BLOOD CK-MB-2 cTropnT-0.21* [**2102-3-23**] 06:48AM BLOOD CK-MB-NotDone [**2102-3-22**] 06:20AM BLOOD cTropnT-0.51* [**2102-3-22**] 06:20AM BLOOD CK-MB-20* MB Indx-13.1* [**2102-3-27**] 05:00AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.6 [**2102-3-26**] 06:31AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.6 [**2102-3-25**] 07:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.4 [**2102-3-24**] 05:40AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 [**2102-3-23**] 06:48AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.5 [**2102-3-22**] 08:50PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.4 [**2102-3-22**] 06:20AM BLOOD Albumin-4.1 Iron-17* Cholest-136 [**2102-3-22**] 06:20AM BLOOD calTIBC-391 Ferritn-3.1* TRF-301 [**2102-3-22**] 06:20AM BLOOD Triglyc-44 HDL-38 CHOL/HD-3.6 LDLcalc-89 [**2102-3-22**] 06:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2102-3-22**] 01:04PM BLOOD Type-ART pO2-88 pCO2-43 pH-7.41 calTCO2-28 Base XS-1 Brief Hospital Course: 34 yo female who presented with chest pain, ruled in for NSTEMI, then s/p cath showing long LCx lesion (non-occlusive). Pt had recurrent chest pain in the setting of hypertensive episode, and was also found to have wall-motion abnormality on echo, thought secondary to coronary vasospasm. . 1. Chest pain/NSTEMI: Pt initally presented with NSTEMI; cath showed no occlusions with a long LCx lesion that was only 60-70% stenosed. She was chest pain free after admission, but then had recurrance of chest pain with EKG changes, severe hypertension, and WMA seen on echo. Episodes of chest pain may have represented coronary vasospasm in the setting of this LCx lesion. Chest pain resolved after starting a nitro drip, and pt was monitored in the CCU overnight. Pt had been started on amlodipine and imdur on admission, however she developed a severe heacache (? secondary to imdur). She was then switched back to long acting dilt (with increased dose of 240mg PO), and amlodipine 10mg qd was added for presumed vasospasm. Imdur was d/c'd. Pt was chest pain free while in the CCU, and had no arrhythmias on telemetry. She was transferred back to the cardiology floor, and remained free of chest pain. Pt was given aspirin 81mg qd, but this was uptitrated to 325mg qd on discharge. She had positive CK, MB, and troponins on admission, and cardiac enyzmes trended down. However, after recurrent episode of chest pain, cardiac enzymes again were elevated. Enzymes were trending down on discharge. She was not started on a statin during this admission, however this will be considered as an outpatient. . 2. Pump: TTE on admission showed only LVH, but normal wall motion. However, TTE several days later performed in the setting of chest pain showed focal severe hypokinesis of the mid/distal inferolateral wall. She is scheduled for a repeat echo in 1 month, prior to her follow-up appointment with Dr. [**Last Name (STitle) **]. . 3. Rhythm: Remained in NSR. . 4. Hypertension: Pt has long history of hypertension with a family history of early HTN. She underwent an abdominal MRI/MRA which did not show pheochromocytoma or renal artery stenosis. She had SBP's in 170's on admission, and had episode of chest pain in setting of SBP in 200's which required nitro drip. She was briefly on an ACEI during the admission, however pt was discharged on long acting diltiazem and amlodipine for presumed coronary vasospasm. She was normotensive on discharge. . 5. Anemia: Microcytic (unknown baseline). Iron studies c/w iron deficiency anemia (low iron and ferritin, although unclear why [**Name (NI) 59658**] not increased). Hct was stable during the admission. She had guaiac negative stools. She was discharged on iron therapy, and will follow-up with PCP regarding future hct monitoring. . 6. Hypokalemia: Pt was hypokalemic on admission, possibly secondary to HCTZ. HCTZ was d/c'd during this admission, and K normalized after IV and PO repletion. . 7. Headache: Pt had prolonged headache shortly after admission. This was thought to be a migraine or possibly secondary to nitrates. The headache improved with ibuprofen. Imdur was d/c'd. Head CT was negative for bleed. . 8. Incidental findings: Pt was found to have a small thyroid nodule seen on chest CT (may need outpatient f/u with ultrasound) and auditory canal thickening seen on head CT (may need outpatient f/u with MRI). These results were communicated to the pt's PCP prior to discharge. . 9. Code status: Full Code Medications on Admission: Cartia XT 180mg qd HCTZ 25mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: NSTEMI coronary vasospasm iron deficiency anemia hypokalemia Secondary diagnoses: HTN Discharge Condition: Stable. Ambulating. Chest pain free. Discharge Instructions: Seek medical attention immediately if you experience chest pain, shortness of breath, nausea, vomiting, dizziness, fevers, chills, bleeding from cath site, headache, hearing loss, ringing in ears, or any other concerning symptoms. Please attend all follow-up appointments. Please take all medications as prescribed. Followup Instructions: You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 71930**], within the next 7 days. You should have your blood pressure, hematocrit, and potassium checked at the next visit with him. You were found to have a 6-mm right sided thyroid nodule by chest CT, and it is recommended that your PCP evaluate this further with an ultrasound. You were also found on head CT to have a bulbous appearance of both internal auditory canals, which may represent a congenital variant, although masses could not be ruled out. You should speak to your PCP about possibly following up this finding with an MRI. Please call his office at [**Telephone/Fax (1) 71931**] to make an appointment. You have the following appointments scheduled: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2102-4-21**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2102-5-2**] 1:20 Completed by:[**2102-3-27**]

[ "427.89", "429.9", "410.71", "401.9", "280.9", "276.8", "784.0", "413.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13609, 13615

9302, 12779

325, 351

13765, 13804

2593, 3487

14170, 15214

1535, 1647

12862, 13586

13636, 13717

12805, 12839

3504, 9279

13828, 14147

1662, 2574

13738, 13744

275, 287

379, 1385

1407, 1412

1428, 1519

59,936

139,660

35656

Discharge summary

report

Admission Date: [**2153-1-4**] Discharge Date: [**2153-1-25**] Date of Birth: [**2080-3-15**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: Abnormal ETT, worsening shortness of breath Major Surgical or Invasive Procedure: Trach and Peg [**2153-1-24**] [**2153-1-6**] Urgent Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, vein grafts to obtuse marginal and PDA(on IABP) [**2153-1-4**] Cardiac Catheterization/Placement of IABP History of Present Illness: Pt is a 72F with a history of hypertension, hyperlipidemia and COPD. She was seen in cardiac consultation with Dr. [**Last Name (STitle) 8098**] on [**10-14**] for complaints of shortness of breath. She underwent an echocardiogram which revealed segmental wall abnormalities. She then underwent a nuclear stress test which was limited by functional capacity and shortness of breath. Nuclear images did reveal multiple perfusion defects involving the anterior wall, apex and part of the inferior wall. Pt reports developing increasing DOE over past year, reports she is able to walk one block and climb one flight of stairs "slowly" but without stopping. Can carry her groceries. Denies ever having experienced any chest discomfort. Otherwise on ROS: Denies orthopnea, LE edema. No HA, vision changes, dysphagia, palpitations, heart burn, abd pain, n/v/d/c, musculoskeletal pain. She has been worked up extensively by pulmonary and found to have COPD. Apparently she has never smoked but worked for thirty years in a factory with exposure to fiberglass on a daily basis. She was started on multiple inhalers and was doing well until this past fall when she developed a cold. She was given antibiotics and steroids which resolved her cold but she noticed that since that time she develops shortness of breath with exertion. She reports the episodes are inconsistent, some days she can walk the length of the grocery store without difficulty but other days she develops shortness of breath after one block. She denies chest discomfort, dizziness, lightheadedness, nausea, near syncope, or syncope. Past Medical History: Dyslipidemia Hypertension COPD, Fiberglass exposure Sciatica Tonsillectomy as a child Depression S/P lumpectomy of the left breast Iron deficient Anemia Monoclonal Gammopathy under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81136**] Arthritis Social History: She is a widow with one grown son. [**Name (NI) **] son and daughter-in-law will accompany her. Her son [**Name (NI) **]??????s cell phone # is [**Telephone/Fax (1) 81137**]. She has never smoked and drinks on very rare occasions. She worked in a curtain factory for 30 years and is currently retired. -Tobacco history: Never -ETOH: Rare -Illicit drugs: None Family History: Her sister died two years ago at age 72 of heart disease, she had multiple MI??????s and a CABG. Her brother died of a MI at age 59. Her father died a sudden cardiac death at age 60. Physical Exam: Admit PE VS: HR 67 158/60 PAP 75/29(48) 95% GENERAL: Elderly petite woman, NAD, laying flat comfortably. HEENT: NCAT. Alopecia. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP ~12cm. No carotid bruits CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR. IABP in place with loud systolic murmur and prominent S2, loudest in abdomen. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. Unable to ascultate abdominal bruits over IABP EXTREMITIES: No c/c/e. No femoral bruits. PA catheter in place in r groin, no ooze. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2153-1-4**] 12:21PM BLOOD WBC-9.1 RBC-4.17* Hgb-12.2 Hct-37.1 MCV-89 MCH-29.3 MCHC-33.0 RDW-14.5 Plt Ct-154 [**2153-1-4**] 12:21PM BLOOD PT-16.3* PTT-30.2 INR(PT)-1.5* [**2153-1-4**] 12:21PM BLOOD Glucose-132* UreaN-28* Creat-1.3* Na-139 K-3.6 Cl-99 HCO3-31 AnGap-13 [**2153-1-4**] 12:21PM BLOOD ALT-13 AST-34 CK(CPK)-26 AlkPhos-49 Amylase-18 TotBili-1.3 [**2153-1-4**] 12:21PM BLOOD Albumin-3.8 Calcium-8.9 [**2153-1-4**] 12:21PM BLOOD %HbA1c-5.3 [**2153-1-5**] 12:24AM BLOOD Triglyc-190* HDL-15 CHOL/HD-6.2 LDLcalc-40 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2153-1-25**] 03:37AM 16.0* 3.19* 10.0* 30.6* 96 31.5 32.7 19.1* 259 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2153-1-19**] 03:08AM 85.6* 0 6.3* 5.3 2.5 0.3 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2153-1-25**] 03:37AM 259 [**2153-1-25**] 03:37AM 17.3* 33.1 1.6* BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2153-1-25**] 03:37AM 401*# Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2153-1-25**] 03:37AM 105 25* 0.7 143 4.2 107 31 9 ESTIMATED GFR (MDRD CALCULATION) estGFR [**2153-1-19**] 03:08AM Using this ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2153-1-22**] 01:01AM 16 48* 82 76 1.8* OTHER ENZYMES & BILIRUBINS Lipase [**2153-1-15**] 03:06PM 165* [**2153-1-15**] 02:36AM 163* CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron Cholest [**2153-1-25**] 03:37AM 8.3* 2.5* [**2153-1-4**] Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed severe three vessel disease. There was a 70-80% stenosis of the distal LMCA. The LAD was totally occluded in the mid-vessel and filled distally via left-left and right-left collaterals. The LCx had a 40% proximal lesion. The RCA had a 80% proximal stenosis and a 70% ostial stenosis of the PDA branch. 2. Resting hemodynamics revealed severely elevated right and left heart filling pressures with a mean RA of 30mmHg and mean PCWP of 43mmHg. The PASP was markedly elevated at 90-100mmHg. The cardiac index was depressed at 1.9l/min/m2. 3. A 30cc IABP was successfully placed via the right femoral artery, with improvement of the cardiac index to 2.6l/min/m2. 4. Left ventriculography was deferred. [**2153-1-4**] Echocardiogram: There is mild to moderate regional left ventricular systolic dysfunction with anteroseptal and anterior hypokinesis (proximal LAD distribution). The remaining segments contract normally (LVEF = 40%). The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. [**2153-1-4**] Carotid Ultrasound: There is 60-69% stenosis in the left and right internal carotid arteries. [**2153-1-7**] Transesophogeal Echocardiogram: Small pericardial effusion without echocardiographic signs of tamponade physiology. Mild left ventricular systolic dysfunction. Mild mitral and aortic regurgitation. Patent foramen ovale with left-to-right shunting. [**2153-1-7**] Renal Ultrasound: 1. No hydronephrosis. Left renal cysts. 2. Both kidneys demonstrate blood flow though more precise evaluation of the arterial waveforms was limited. [**2153-1-10**] Transthoracic Echocardiogram: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened, but without discrete vegetation. Mild to moderate ([**12-8**]+) mitral regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2153-1-13**] Chest/Abdominal CT Scan: 1. Diffuse peribronchovascular ground-glass opacity in the lungs may represent infection or edema. Moderate left greater than right pleural effusions. 2. Small ascites and diffuse mesenteric edema. 3. Tiny gallstone. [**2153-1-15**] Head CT Scan: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is preserved. The ventricles are normal in size and symmetric. There is a moderate mucosal thickening within the sphenoid, ethmoid and partially visualized right maxillary sinus. Brief Hospital Course: Mrs. [**Known lastname **] was admitted and underwent cardiac catheterization which revealed severe severe three vessel coronary artery disease including a tight left main lesion. Catheterization was also notable for severely elevated right and left filling pressures as well as severe diastolic biventricular function. Given critical anatomy, Heparin was intiated and an IABP was placed without complication. Cardiac surgery was consulted and preoperative evaluation was performed. Please see result section for results of echocardiogram and carotid ultrasound. On [**2153-1-6**], Ms. [**Name13 (STitle) **] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one she was extubated however required reintubation due to acidosis and tachypnea. She was anuric with increased BUN/CREAT. A renal ultrasound obtained showed perfusion. Her Intra-aortic balloon pump was removed and pressors were started for hypotension. Gram positive rods were noted in her sputum and vancomycin and zosyn were started. A blood culture was positive for yeast and antifungal therapy was started. The infectious disease service was consulted for assistance with her care. She completed a 15 day course of antifungal therapy as of [**2153-1-25**]. She became hyponatremic and hypertonic sodium chloride was started intravenously. Her hyponatremia has corrected. She developed atrial fibrillation which was treated initially with amiodarone however this was later switched to digoxin and betablockade due to elevated liver enzymes. Her liver function tests improved and digoxin was d/c'd and amiodarone was restarted. Coumadin therapy was initiated. She was slow to wake and unable to wean from the vent therefore an MRI was obtained. MRI revealed no evidence of flow-limiting stenosis, occlusion, or aneurysm greater than 3 mm. Her mental status improved over time but remained unable to wean from the vent and required a trach and Peg. She continues to require vent support but is [**Last Name (un) 1815**] trach mask trials up to 4 hrs as of [**2153-1-24**]. Currently, she answers questions approp mouthing words and follows commands. A PICC line was placed [**2153-1-23**]. Medications on Admission: Albuterol 1-2 puffs PRN Q4 Alprazolam 0.5mg QHS Atenolol 100mg daily Fenofibrate 145mg daily Fluoxetine 20mg TID (dose confirmed with pt and pharmacy) Advair 500/50 Lisinopril 40mg daily Spiriva INH daily Torsemide 20mg [**Hospital1 **] Verapamil 200mg QHS Vitamin D ASA 81mg daily Ferrous sulfate Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Inhalation [**Hospital1 **] (2 times a day). 3. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily). 5. Fluoxetine 20 mg/5 mL Solution [**Hospital1 **]: One (1) PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 11. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2 times a day): was on torsemide 20 mg [**Hospital1 **] at home. transition when approp. 12. Potassium Chloride 20 mEq Packet [**Hospital1 **]: Twenty (20) meq PO as needed: prn to maintain K+>4-<4.5. 13. Warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day: AFIB INR goal 2-2.5. 14. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 15. Picc line care per protocol 16. sternal dressing care wet to dry dressing changes [**Hospital1 **] 17. Outpatient Lab Work INR, chemistries, CBC Discharge Disposition: Extended Care Facility: [**Hospital1 700**] Discharge Diagnosis: Coronary Artery Disease - s/p CABG Hypertension Dyslipidemia COPD Iron Deficiency Anemia Sepsis resp failure requiring tracheostomy and Peg [**2153-1-24**] Discharge Condition: deconditioned Discharge Instructions: 1)If you drive, No driving for at least one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery. 3)Do not apply creams, lotions or ointments to surgical incisions. 4)Shower daily and wash surgical incsions daily with soap and water only. Pat dry incisions, no rubbing. No baths or swimming. 5)Please call cardiac surgeon immediately if there is concern for wound infection. [**Telephone/Fax (1) 170**]. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks, call for appt Dr. [**Last Name (STitle) 8098**] in [**1-9**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**1-9**] weeks, call for appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2153-1-25**]

[ "401.9", "584.9", "570", "995.92", "518.81", "038.9", "496", "112.5", "414.01", "273.1", "416.8", "276.1", "E878.2", "276.2", "998.32", "272.4", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.55", "33.24", "37.61", "38.93", "36.15", "96.6", "96.04", "33.22", "88.52", "43.11", "39.61", "36.12", "31.1", "96.72", "37.22" ]

icd9pcs

[ [ [] ] ]

13314, 13360

8936, 11237

316, 592

13560, 13576

4021, 8913

14058, 14368

2913, 3098

11586, 13291

13381, 13539

11263, 11563

13600, 14035

3113, 4002

233, 278

620, 2218

2240, 2520

2536, 2897

62,004

123,404

42049

Discharge summary

report

Admission Date: [**2196-10-1**] Discharge Date: [**2196-10-15**] Date of Birth: [**2127-7-22**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [**2196-10-2**] 1. Open treatment, thoracic fracture-dislocation, T10-T11. 2. Open treatment thoracic fracture-dislocation, T11-T12-3. 3. Posterior fusion, T8-L1. 4. Posterior instrumentation, T8-L1. 5. Application of local autograft for fusion. 6. Allograft for fusion. [**2196-10-3**] 1. Open treatment, posterior wall acetabular fracture, with fragment excision. 2. Treatment of [**Doctor Last Name 24991**] femoral head fracture with total hip arthroplasty. History of Present Illness: Mr. [**Known lastname **] is a 69 year old male who was transferred to [**Hospital1 18**] from [**Hospital6 3105**] s/p MVA. Patient was a restrained driver who was T-boned at 40mph, prolonged 20 minute extrication. By outside hospital reads he was found to have T. and L-spine process fractures a left hip fracture with dislocation so he was transferred to [**Hospital1 18**] for further evaluation and management. Past Medical History: CKD [**1-20**] PSGN s/p AV fistula HTN Arthritis Gout Paroxysmal Afib BPH Social History: Prior tobacco quit 30 years ago, social ETOH, no illicit drug use Family History: noncontributory Physical Exam: On arrival to [**Hospital1 18**]: HR: 114 BP: 170 over palp Resp: 20 O(2)Sat: 96 Normal Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact C. collar placed hematoma left neck Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Extr/Back: Left lower extremity internally rotated and shortened +2 DP bilaterally no pain with range of motion right lower extremity or bilateral upper arms +2 radial pulse bilaterally Skin: Scattered abrasions on the left side contusion over the sternum with no crepitus Neuro: Speech fluent moving extremities Heme/[**Last Name (un) **]/[**Last Name (un) **]: Normal Pertinent Results: OSH Films: 1. Comminuted fracture-dislocation of the left hip. Posterior left acetabular fracture. 2. T10 and T11 vertebral fractures as above with fracture line appearing to cross the central canal at least at T11. MRI is recommended for further evaluation. Possible nondisplaced fracture of the posterior right T9 vertebral body. Fractures of the left L1 and L2 transverse processes. 3. Left first rib fracture. 4. Lingular and left lower lobe consolidations, may be due to contusions and/or aspiration. 5. Trace pericardial fluid. [**2196-10-1**] 07:00PM WBC-10.6 RBC-2.86* HGB-9.6* HCT-27.8* MCV-97 MCH-33.4* MCHC-34.5 RDW-14.4 [**2196-10-1**] 07:00PM NEUTS-92.7* LYMPHS-4.5* MONOS-2.3 EOS-0.4 BASOS-0.1 [**2196-10-1**] 07:00PM PLT COUNT-175 [**2196-10-1**] 07:00PM PT-12.5 PTT-26.4 INR(PT)-1.1 [**2196-10-1**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-8* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2196-10-1**] 07:00PM ALBUMIN-3.3* CALCIUM-9.3 PHOSPHATE-6.0* MAGNESIUM-2.1 [**2196-10-1**] 07:00PM LIPASE-33 [**2196-10-1**] 07:00PM ALT(SGPT)-28 AST(SGOT)-52* ALK PHOS-90 TOT BILI-0.5 [**2196-10-1**] 07:00PM estGFR-Using this [**2196-10-1**] 07:00PM GLUCOSE-115* UREA N-93* CREAT-6.2* SODIUM-136 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-23 ANION GAP-21* Brief Hospital Course: Mr [**Known lastname **] was admitted on [**2196-10-1**] after sustaining an MVC with loss of consciousness. His initial injuries were: left femoral neck fracture,left 1st rib fracture, T10,11 body fracture, left L1, L2 transverse process fracture. On HD2 he was taken to the operating room by orthopedic surgery for posterior fusion, T8-L1. The patient tolerated the procedure well and was transferred to the TSICU for further monitoring. Postoperatively he was mildly hypotensive on/off low-dose phenylephrine gtt which was weaned off shorlty after. His UOP decreased overnight,patient lasix-dependent at home, given lasix 20mg IV x1. He was kept intubated and the following day, HD3, underwent total hip arthroplasty. He was transfused 2u PRBCs while still in the ICU and 3u pRBCs intra-operatively for a HCt of 22.5. He required pressors postoperatively. His renal function deteriorated postoperatively with increasing Scr and decreasing UOP and a nephrology consult was obtained. It was determied that the patient has [**Last Name (un) **] superimposed on CKD possibly caused by hypovolemia from fluid loss or rhabdomyolysis from trauma. Currently fluid overloaded with increasing edema and pulmonary edema in the setting of ATN and oliguria after aggressive fluid resuscitation. Therefore, CVVH was started. This was transitioned to intermittent HD, which was performed on [**2196-10-5**] removing 4.5L of fluid. The patient was also in chronic afib while in the unit, which was temporarily managed with esmolol gtt, which was transitioned to lopressor and the patient was rate controlled on this regimen. Tube feeds were started for nutrition via a dobhoff tube. On [**2196-10-6**], the patient was transferred to the floor. At that time he was HDS, rate controlled on lopressor. He still had c-collar in place per ortho, and was receiving tube feeds via dobhoff. He was receiving humidified air via face tent. Neuro: The patient remained alert and oriented throughout the remainder of his hospitalization. His pain was well controlled with PO narcotics prn. Cardiac: On [**2196-10-7**] the patient was triggered for an a irregular rhythm that was conerning for afib on the monitor with a rate in the 140's. Throughout the episdoe the patient was asymptomatic and maintained a BP within normal limits. Cardiology was consulted, and upon further review of his ECG the rhythm was determined to be consistent with wondering atrial pacemaker (WAP) / multifocal atrial tachycardia (MAT). Cardiology recommended aspirin 325mg daily given history of pAF and metoprolol for rate control, which was ordered and administered. Pulm: He was weaned off humidified face tent was his oxygen saturation was within normal limits on room air at the time of discharge. He was without complaints of dyspnea. GI: On [**2196-10-7**], the patient self-d/c'd his dobhoff, but it was replaced. On [**10-10**] the dobhoff was removed and he was placed on a regular diet, which he tolerated without any difficulty swallowing. On [**10-13**] he began to have frequent loose stools. See heme/ID section for details. GU: The patient continued to tolerate HD for the remainder of his hospitalization. Given his ongoing leukocytosis (see Heme/ID), his HD catheter was removed and cultured on [**10-10**]. Dialysis was continued through his LUE AV fistula. His foley catheter was removed on [**10-10**]. Musk: Physical therapy was consulted given the patient's injuries who recommended continued therapy at an extended care facilityupon discharge. Heme/ID: His WBC began to increase after transfer to the floor. On [**10-10**] it reached 19.1. He was pancultured for this, including removal and culture of the tip of his HD catheter. On [**2196-10-12**] his leukocytosis was worsening, and he was started on IV vanco, cefepime and flagyl empirically. On [**10-13**], he began to have frequent loose BM's, and cultures were sent for c. diff. The vanco and cefepime were discontinued on [**10-14**], and he continued on IV flagyl for treatment of presumed c. diff. On the day of discharge on [**2196-10-15**] , his blood culture was pending but his stool culture grew out c. diff toxin. His electrolytes were continously monitored and repleted as needed. He developed a persistent hyopnatremia, as low as 127 on [**2196-10-14**], at which time he remained asymptomatic with no neurological changes. He was placed on a 1.5 L fluid restriction for this. Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for afib/tachycardia/HTN. 7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 13. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 17. epoetin alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 18. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous every eight (8) hours for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary: s/p MVC Injuries: 1. left femoral neck fracture 2. left 1st rib fracture 3. T10,11 body fracture 4. left L1, L2 transverse process fracture Secondary: acute kidney injury on CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, patient is allowed to weight bear on both legs. Discharge Instructions: You were admitted to the hospital after a motor vehicle accident. You sustained multiple injuries including a left hip fracture, left 1st rib fracture, and fractures to mutiple vertebrae in your spine. You had left hip arthroplasty on [**2196-10-3**] and T8-T11 fusion on [**2196-10-2**]. Your weight bearing status and follow-up appointments are listed below. Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in the orthopedic spine clinic in [**12-20**]. Call [**Telephone/Fax (1) 1228**] upon discharge to schedule an appointment. Please follow up with Dr. [**Last Name (STitle) 1005**] in the orthopedic clinic in [**12-20**]. Cal [**Telephone/Fax (1) 1228**] upon discharge to schedule an appointment. Completed by:[**2196-10-15**]

[ "805.2", "880.03", "861.21", "423.9", "808.0", "585.4", "272.4", "600.00", "599.0", "716.90", "922.2", "427.31", "008.45", "753.0", "285.9", "807.01", "584.5", "E812.0", "274.9", "403.90", "820.09", "913.0" ]

icd9cm

[ [ [] ] ]

[ "03.53", "77.70", "38.95", "81.05", "81.51", "97.88", "96.71", "81.63", "39.95", "79.29", "96.6" ]

icd9pcs

[ [ [] ] ]

9684, 9731

3555, 7989

312, 785

9964, 9964

2260, 3532

10574, 11000

1429, 1446

8012, 9661

9752, 9943

10188, 10551

1461, 2241

265, 274

813, 1231

9979, 10164

1253, 1329

1345, 1413

72,658

177,278

38643

Discharge summary

report

Admission Date: [**2145-1-14**] Discharge Date: [**2145-1-22**] Date of Birth: [**2061-9-27**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Vasotec / Pletal Attending:[**First Name3 (LF) 443**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with angioplasty and drug eluting stent to left main coronary artery and left anterior descending artery History of Present Illness: 83 yo with hx of AS s/p bioprosthetic AVR x 2, RIMA to RCA in [**7-/2130**] presented to [**Hospital3 17921**] Center on [**1-12**] with CP. She reported worsening of indeigestion with heartburn X 2 weeks with the episodes of [**2145-1-20**] dull chest discomfort becoming more constant. She was put on a PPI by her PCP without effect. Over several days her sxs have become worse with burning chest discomfort without associated SOB. She has 6 pillow orthopnea from 3 due to worse sxs at night. Her chest discomfort is worse with activity. Day prior ([**1-11**]) to admission she developed severe heartburn and CP which radiated to both arms with numbness and tingling of both arms as well. It was associated with SOB, diaphoresis, lightheadedness, and eventual vomiting. She has also had increasing fatigue and weakness. She called EMS at that point and was relieved with oxygen. . Initial OSH EKG showed: old RBBB with new TWI in V2-V3 and III and increased diffuse ST depressions. ST elevations in aVR. Initial troponin was 0.1 which increased to 1.85 on [**1-13**] at 720am. She was started on IV heparin on the am of [**1-12**]. . Patient had CP at 330 am on [**1-13**] relieved by increasing nitro gtt. Cardiac catheterization on [**1-13**] showed 98% discrete distal left main disease, 90% proximal/mid/distal RCA, patent RIMA-distal RCA, 85% mid right external iliac stenosis. LAD and circumflex were poorly visualized. She was started on a nitro gtt, high dose liptor, lopressor and norvasc. She was given Lasix IV for evidence of CHF on CXR and an elevated BNP to 2810. She is +1.2 L due to IVF for renal protection. . She had a Hct drop from 34 to 28 which was rechecked and 24 on day of transfer. Her creatinine was elevated at 1.8 (basline unknown). . On the floor, patient had developed [**9-26**] chest discomfort while on a heparin gtt and nitro gtt, which could not be put to max dose due to limitations to what can be administered on the general wards. The patient's chest discomfort relived on its own. . Additionally, patient was found to have BRBPR on rectal examination, although no bloody bowel movements. . On transfer, patient is CP free. Past Medical History: Cardiac Risk Factors: +Hypertension - Aortic Stenosis: unknown valve area: - AVR with periprostheic AR - RIMA to RCA [**2130-8-2**] - PVD with venous stripping RLE remote and intermittent claudication - basal cell carcinoma - renal insufficiency stage III-IV [**2144-10-9**]: 1.82 baseline; [**2142**]: 1.39, 1.48 - ACD - GERD - IBS - b/l cataracts [**8-/2134**] Colonscopy <5 years ago negative and told to return in 10 years; Colonscopies previously with polyps Social History: Widowed with currently 3 living children. She lives alone in an apartment and does own ADLs. Hx of tobacco use (25 pack-years, quit >10 years ago). No etoh. Uses a cane. Family History: Strong CAD with entire mother's side having heart problems. She is [**12-27**] children and 6 siblings have died of heart related problems. She also has a son who died of a sudden MI at age 52. Physical Exam: Gen: NAD. Oriented x3. Mood, affect appropriate. Speaking comfortably in full sentences. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. Neck: Supple with JVP of 8 cm. CV: Nondisplaced PMI. RR, normal S1, S2. 3/6 SEM radiating to carotids. Chest: Resp were unlabored, no accessory muscle use. Crackles at bases b/l L>R. Abd: Soft, NTND. No HSM or tenderness. Ext: Trace LE pitting edema. b/l femoral bruits. Warm and well perfused. 2+ DPs. Pertinent Results: [**2145-1-14**] 02:00PM WBC-8.5 RBC-2.73* HGB-8.5* HCT-25.1* MCV-92 MCH-31.2 MCHC-33.9 RDW-12.8 [**2145-1-14**] 02:00PM NEUTS-76.7* LYMPHS-17.0* MONOS-4.3 EOS-1.6 BASOS-0.4 [**2145-1-14**] 02:00PM CK(CPK)-26* [**2145-1-14**] 02:00PM CK-MB-NotDone cTropnT-0.26* [**2145-1-14**] 02:00PM PT-12.3 PTT-29.6 INR(PT)-1.0 [**2145-1-14**] 02:00PM GLUCOSE-101* UREA N-38* CREAT-1.7* SODIUM-139 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-34* ANION GAP-12 [**2145-1-14**] 09:54PM CALCIUM-8.4 PHOSPHATE-2.2* MAGNESIUM-2.5 [**2145-1-20**] 02:39PM DIPSTICK URINALYSIS: Blood Neg, Nitrite Neg, Protein Tr, Glucose Neg, Ketone Neg, Bilirub Neg, Urobiln Neg, pH 6.5, Leuks Lg MICROSCOPIC URINE EXAMINATION RBC 1, WBC 54, Bacteria Few, Yeast None, Epi 0 [**2145-1-20**] 2:39 pm URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML. . [**2145-1-14**] ECG: Normal sinus rhythm, rate 78. Right bundle branch block. Non-specific inferolateral repolarization changes. No previous tracing available for comparison. . [**2145-1-14**] Arterial duplex lower extremity u/s: There is significant calcified plaque bilaterally within the right and left common femoral and superficial femoral arterial distributions, now with elevated velocities within the superficial femoral arteries bilaterally. . [**2145-1-14**] CT abdomen pelvis: 1. No evidence of retroperitoneal hemorrhage. 2. Multiple well-circumscribed bilateral renal lesions, some of which may represent simple cysts, though with some incompletely characterized and correlation with prior imaging is recommended, and if no prior imaging is available, a renal ultrasound can be performed on a non-emergent basis for further evaluation. 3. Extensive atherosclerotic calcification and disease with associated luminal narrowing that is incompletely assessed on this non-contrast imaging study. . [**2145-1-15**] TTE: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Aortic valve bioprosthesis with thickened leaflets and abnormally-elevated gradients. Mild calcific mitral stenosis. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. . [**2145-1-18**] Cardiac catheterization: 1. Limited coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a distal 90% stenosis. The LAD had a 90% mid vessel stenosis. The RCA was not injected. 2. Abdominal aortography revealed mild bilateral renal artery stenosis. The iliac arteries were severely calcified and tortuous with a 70% right and 60% left common iliac stenosis. 3. Successful PTCA and stenting of the LMCA with a 4.5 x 13mm Ultra bare metal stent which was postdilated to 5.0mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. 4. Successful PTCA and stenting of the mid LAD with a 3.0 x 15mm Vision bare metal stent which was postdilated to 3.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. . Renal Ultrasound [**2145-1-22**] IMPRESSION: 1. Bilateral simple cysts measuring up to 1.7 cm. 2. Number of echogenic foci in the lower pole of the left kidney, the largest measuring 0.6 cm consistent with stone. 3. Bilateral small amount of pleural effusion. 4. Small amount of ascites. Brief Hospital Course: 83 year-old female with past medical history of AS, CAD s/p 1V [**Hospital **] transferred from OSH with 98% left main disease s/p BMS to LMCA and mid LAD. She was transferred back to [**Hospital **] hospital in [**Location (un) 3844**] on [**2145-1-22**] for further care because it is closer to home, so that her family can visit her more easily. #. CAD: The patient presented from an outside hospital with severe left main stenosis of 98%. The patient underwent a catheterization at the outside hospital. She was transfused 1u pRBC to a goal of 30. She was weaned off the nitroglycerin drip and her blood pressures were controlled with metoprolol tartrate and hydralazine. She was on high dose atorvastatin. She had back pain and had a CT abdomen and pelvis which was negative for RP bleed. Her EKG was stable from the OSH and she was monitored on telemetry. She underwent a high risk PCI with a bare metal stent placed in the LMCA and LAD. She was maintained on aspirin and plavix. Plavix should be continued for at least a month and should only be stopped by her cardiologist. Aspirin should be continued indefinitely and should only be stopped by her cardiologist. She was discharged on a beta blocker and hydralazine. When her kidney function returns she may warrant addition of an ACE inhibitor to regimen. She will need an appointment with her cardiologist in the near future that has been scheduled. #. Acute on chronic kidney disease: The patient has an unclear baseline creatinine, which may be around 1.4. The patient had a dye load from the OSH and a dye load during her catheterization procedure and developed an acute kidney injury about 48hours after the procedure, which appears to be Contrast-Induced Nephropathy. Her UA and microscopy show rare eosinophils, which is concerning for cholesterol emboli, however, no systemic signs of this. Her FENa was suggestive of a pre-renal picture. Her creatinine increased to 3.4 at the day of transfer. She was given 1.5L of IV fluid without response in creatinine. She may benefit from a nephrology consult on transfer. She should also follow up with her nephrologist as well in the near future. A renal ultrasound showed no hydronephrosis or obstruction but did show a number of echogenic foci in the lower pole of the left kidney, the largest measuring 0.6 cm consistent with stone. #. Hyponatremia: The patient developed hyponatremia when her creatinine began to worsen. Her low sodium was 121. She was given 1.5L NS with elevation of her sodium to 126. She was started on salt tablets briefly with elevation of her sodium to 127. This will need to be closely monitored. #. Guaiac positive stool: The patient presented with a history of dark stools. She also had a dark stool which was guaiac positive in house. She was transfused 1 u of pRBC the day of discharge for a hematocrit of 26. She remained hemodynamically stable. She should remain on aspirin and plavix due to recent stent placement but EGD may be indicated if hct cont to fall. #. Urinary Tract Infection: The patient had a positive UA and urine culture with gram negative rods, sensitivities pending. She has had a foley place intermittently and thus should continue with a 7 day course of antibiotics. She was transferred on ceftriaxone with day 1 being [**2145-1-22**]. She should see her primary care phsyician in the near future. #. Urinary retention: The patient had a post void bladder scan with 350cc of urine remaining in her bladder. A foley catheter was placed. The foley catheter had been removed and the patient was urinating without difficulty at discharge. #. Hypertension: She was well controlled on metoprolol tartrate and hydralazine. ACE inhibitor should be considered when her kidney function improves. #. Peripheral vascular disease: Stable. Held pentoxifylline. #. Code Status: Patient was Full Code during this hospitalization. #. Family contact: Daughter [**Name (NI) **] at [**0-0-**] cell Medications on Admission: at home: Pentoxifylline 400mg TID Toprol Xl 50mg daily Enalapril 5 mg daily Lasix 40mg daily ASA 81 mg daily Ferrous sulfate 325mg daily Tylenol #3 one daily on transfer: IV nitroglycerin at 180 mg/min (850) IV Heparin at 850 U/hr Norvasc 5mg daily Acetylcysteine 1200 mg Q12H Metoprolol 25mg Q6H Lipitor 80mg daily Plavix load [**1-13**] 300mg, now on 75mg daily Enalapril 5mg daily Ferrous sulfate 325mg daily Lasix 40mg daily (on hold) MVI daily protonix 40mg [**Hospital1 **] Pentoxifylline 400mg TID Tylenol #3, 1 tab daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for acid reflux. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Hold HR< 60. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Hold SBP < 100. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever: Max 3 grams per day. 11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn, dyspepsia. 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 15. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 16. Ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous once a day for 7 days: First day [**2145-1-22**], last day [**2145-1-28**]. 17. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 18. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Coronary Artery Disease Hypertention Acute on Chronic Kidney Disease Acute Blood Loss Anemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had a high risk cardiac catheterization and a bare metal stent was placed in your left main coronary artery. The procedure went well but you received a large amount of contrast that has caused your kidneys to stop working. We have given you fluid to support your kidneys and have been following your electrolytes closely. A kidney ultrasound was done and results are pending at this time. You also are losing some blood in your stool and have received 2 units of blood to treat your anemia. You will need to stay on aspirin and Plavix for at least one month and possibly longer. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s without speaking to Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] about this. You risk having another fatal heart attack if you stop taking aspirin and plavix. . Medication changes: 1. Start taking aspirin and Plavix every day to prevent the stent from clotting off 2. Stop taking Enalapril and lasix until kidney function improves. 3. Stop taking Pentoxifylline until your kidney function improves. 4. Metoprolol Succinate changed to Metoprolol tartrate while hospitalized 5. Start Hydralazine and Amlidipine to control your blood pressure. 6. Start Famotidine to prevent bleeding in your stomach 7. Start Ceftriaxone to treat your urinary tract infection 8. Start Heparin SC to prevent blood clots 9. Start Trazadone to help you sleep at night 10. Start Atorvastatin to control your cholesterol 11. You were started on colace, bisacodyl for your constipation Followup Instructions: Primary Care: [**Last Name (LF) 85865**],[**First Name3 (LF) 275**] N. Phone: [**Telephone/Fax (1) 85866**] Date/time: Please make an appt to see 1 week after discharge from Catholic [**Hospital1 107**] . Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 85867**] Date/time: Please keep your scheduled appt.

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Discharge summary

report

Admission Date: [**2132-10-8**] Discharge Date: [**2132-10-22**] Date of Birth: [**2072-1-15**] Sex: F Service: CARDIOTHORACIC Allergies: Crestor / lisinopril / Topamax / metformin / lovastatin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: -[**10-8**] Cardiac catheterization -[**10-13**] Coronary artery bypass grafting x3 (Left internal mammary to the Left anterior descending artery, Saphenous vein graft (SVG)->Obtuse marginal artery, SVG->Posterior desceding artery.) History of Present Illness: Ms. [**Known lastname **] is a 60yo woman with h/o hypertension, hyperlipidemia, type 2 diabetes, fibromyalgia and CAD s/p BMS to the left Cx in [**2130-7-22**]. In [**2132-5-21**], she got repeat catheterization after c/o daily episodes of chest discomfort; angiography revealed a 30% proximal RCA, 40% proximal LAD, 90% mid LAD, 60% D2 and an 80% proximal Cx. The LAD and Cx were treated with bare metal stents. . She has felt well for several months following her procedure in [**5-31**] but then developed a recurrence of chest discomfort. The discomfort is a dull substernal pain, She describes having from one to three episodes per day, occurring both at rest and with exertion. SL nitroglycerin is effective in treating her discomfort. She has not had stress testing since her last PCI and is now referred for relook catheterization with possible surgical revascularization. Denies LE edema, orthopnea, PND, lightheadedness, dizziness, claudication. + Increase in dyspnea with exertion or when bending over. Slight improvement in SOB after being prescribed lasix 20mg qd about 3months ago. Denies BRBPR, hematuria. Past Medical History: Coronary artery disease s/p coronary artery bypass garfts noninsulin dependent Diabetes mellitus Dyslipidemia Hypertension obstructive Sleep Apnea fibromyalgia Social History: Patient is married without children. Tobacco: Patient has smoked 1ppd up to 20+ year. She is currently smoking 6 cigarettes a day. ETOH: Denies Family History: FH: Father with CAD/MI's, dying in his 60's. Brother died from an MI in his 50's. Mother died at age 45 from "a heart issue". Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.2...BP=126/53...HR=46...RR=16...O2 sat=94%RA GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP not elevated above clavicle. CARDIAC: RR but brady HR in 40s, normal S1, S2. Occasional pauses. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. SKIN: Bruising from recent cupping on back. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2132-10-8**] 10:40AM BLOOD WBC-6.0 RBC-3.51* Hgb-10.9* Hct-31.9* MCV-91 MCH-31.1 MCHC-34.3 RDW-13.7 Plt Ct-255 [**2132-10-8**] 10:40AM BLOOD PT-12.3 INR(PT)-1.0 [**2132-10-8**] 10:40AM BLOOD Neuts-62.7 Lymphs-31.3 Monos-4.0 Eos-1.6 Baso-0.5 [**2132-10-8**] 10:40AM BLOOD Glucose-215* UreaN-11 Creat-0.7 Na-138 K-4.1 Cl-104 HCO3-25 AnGap-13 [**2132-10-8**] 10:40AM BLOOD ALT-26 AST-31 AlkPhos-57 TotBili-0.4 [**2132-10-9**] 06:50AM BLOOD CK(CPK)-114 [**2132-10-8**] 10:40AM BLOOD CK-MB-5 cTropnT-<0.01 [**2132-10-9**] 06:50AM BLOOD CK-MB-5 [**2132-10-9**] 06:50AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0 [**2132-10-8**] 10:40AM BLOOD %HbA1c-9.2* eAG-217* . DISCHARGE LABS: [**2132-10-22**] 06:20AM BLOOD WBC-8.2# RBC-3.39* Hgb-10.1* Hct-31.6* MCV-93 MCH-29.9 MCHC-32.1 RDW-14.1 Plt Ct-523* [**2132-10-20**] 05:35AM BLOOD WBC-4.6 RBC-3.38* Hgb-10.1* Hct-31.2* MCV-92 MCH-29.9 MCHC-32.4 RDW-13.9 Plt Ct-387 [**2132-10-19**] 06:01AM BLOOD WBC-5.4 RBC-3.03* Hgb-9.2* Hct-27.7* MCV-91 MCH-30.3 MCHC-33.2 RDW-13.9 Plt Ct-306# [**2132-10-22**] 06:20AM BLOOD PT-13.3 INR(PT)-1.1 [**2132-10-22**] 06:20AM BLOOD Glucose-77 UreaN-7 Creat-0.9 Na-140 K-5.1 Cl-101 HCO3-30 AnGap-14 [**2132-10-21**] 05:50AM BLOOD UreaN-8 Creat-0.8 Na-136 K-4.6 Cl-100 [**2132-10-20**] 05:35AM BLOOD Glucose-90 UreaN-7 Creat-0.8 Na-139 K-4.3 Cl-101 HCO3-29 AnGap-13 . MICROBIOLOGY: -[**2132-10-8**] 12:29 pm URINE Site: CLEAN CATCH CATH LAB. **FINAL REPORT [**2132-10-9**]** URINE CULTURE (Final [**2132-10-9**]): <10,000 organisms/ml. . IMAGING: -[**10-8**] Cardiac cath: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. CT surgical evaluation for possible CABG. 3. Admit patient for revascularization during this admission given the rest anginal symptoms. . -[**10-9**] Echo: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. . -[**10-9**] CXR: IMPRESSION: 1. Focal opacity overlying thoracic vertebra on lateral view likely represents degenerative changes. However, recommend left and right lateral oblique views to rule out lung nodule. 2. Small left mid lung linear atelectasis. Otherwise, no acute cardiopulmonary process. . -[**10-9**] CAROTID SERIES COMPLETE: IMPRESSION: No evidence of carotid artery stenosis bilaterally. . -[**10-11**] CXR obliques: IMPRESSION: Routine frontal and a shallow lateral oblique were performed to evaluate questionable lung nodule projecting over the lower thoracic spine on conventional radiographs taken [**2132-10-9**]. The opacity is due to degenerative spinal osteophyte not lung nodule. . [**2132-10-13**] ECHO PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical incision POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. No new valvular lesions. Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2132-10-8**] where she underwent a cardiac catheterization. This revealed severe three vessel disease and the cardiac surgical service was consulted. She was worked-up in the usual preoperative manner. A carotid ultrasound showed no evidence of carotid artery stenosis bilaterally. Spirometry testing was performed which was normal. The neurology service was consulted given her history of stroke and cerebral bleed. She was cleared from a neuological perspective. Plavix was allowed to washout over a few days. On [**2132-10-13**], Mrs. [**Known lastname **] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Please see operative note for details. postoperatively she was trnasferred to the intensive care unit for monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She was transferred to the floor on POD #2 to begin increasing her activity level. She was gently diuresed toward her pre-op weight. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She was followed by [**Hospital **] Clinic for elvated blood sugars in the 200's, Lantus with insulin sliding scale was started with better control. Insulin teaching was initiated. The patient experienced difficulty with self administration due to her baseline cognitive deficits. Occupational Therapy was consulted for assistance. Additionally, the sternal incision developed erythema at the inferior pole and the patient was started on IV Ancef. Erythema resolved and the patient will bedischarged on PO Keflex. By the time of discharge on POD 9 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] HealthCare Center in good condition with appropriate follow up instructions. Medications on Admission: as of [**2132-10-7**]: ACARBOSE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth at lunch and dinner ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once daily ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth alternating with half a tablet daily (PM) BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once a day CYCLOBENZAPRINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth three times a day FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth every morning GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule - 6 Capsule(s) by mouth 2 in the morning and 2 at midday and 2 at dinner time GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - 1 Tablet(s) by mouth at bedtime HYDROXYZINE HCL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth three times a day as needed NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually as needed for chest discomfort PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth every 6 hours as needed [**Last Name (un) **] SINUS SPRAY - (Prescribed by Other Provider) - Dosage uncertain ZOLPIDEM - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN - (OTC) - 325 mg Tablet - 1 Tablet(s) by mouth once a day (PM) MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth qam OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day): Take 2 in the morning, 2 at midday, and 2 at dinner time. 6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID PRN () as needed for itching. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 15. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for bronchospasm. 18. insulin glargine 100 unit/mL Solution Sig: Twenty (20) Subcutaneous once a day: 20 Units daily with breakfast. 19. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 1 weeks. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Continuing Care Center - [**Hospital1 392**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass garfts noninsulin dependent Diabetes mellitus Dyslipidemia Hypertension obstructive Sleep Apnea fibromyalgia Discharge Condition: Alert and oriented, short-term memory loss Deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - c/d/i without erythema or drainage (will be d/c'd on Keflex for previous erythema at inferior pole) Leg -Left - healing well, no erythema or drainage. Edema -trace Discharge Instructions: 1) 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. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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: [**Doctor Last Name **] on Wed, [**2132-11-19**] 1:15 Cardiologist: Dr.[**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2258**]) on [**2132-11-10**] at 1:30pm at [**Hospital1 392**] office Please call to schedule appointments with: Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**] ([**Telephone/Fax (1) 68410**]in [**3-25**] weeks Call for a follow-up appointment with Dr. [**Last Name (STitle) **] at [**Hospital **] Clinic [**Telephone/Fax (1) 2378**] **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:[**2132-10-22**]

[ "272.4", "428.0", "996.72", "311", "V12.54", "493.90", "327.23", "250.00", "331.83", "414.01", "729.1", "411.1", "305.1", "V49.86", "287.5", "401.9", "E878.1", "427.89" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13187, 13328

7209, 9278

334, 570

13532, 13821

2964, 2964

14795, 15563

2086, 2213

11348, 13164

13349, 13511

9304, 11325

4581, 7186

13845, 14772

3649, 4564

2228, 2238

2260, 2945

284, 296

598, 1723

2980, 3633

1745, 1907

1923, 2070

26,013

155,657

46946

Discharge summary

report

Admission Date: [**2108-5-25**] Discharge Date: [**2108-6-11**] Date of Birth: [**2038-1-21**] Sex: F Service: Date of surgery: [**2108-6-1**] CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 99571**] is a 70-year-old woman with a history of coronary artery disease, status post stenting to LAD and RCA in [**6-4**] with two subsequent cardiac catheterizations, diabetes mellitus and status post liver transplant who presents with chest pain. Chest pain is similar to previous episodes occurring intermittently with rest and exertion. These episodes have been increasing in frequency recently. She has had no syncope, orthopnea, paroxysmal nocturnal dyspnea or lower extremity edema. She was admitted to the medical service at [**Hospital1 **] Hospital for further evaluation. Electrocardiogram examination upon admission revealed no changes from previous reads. Mrs. [**Known lastname 99571**] was then taken for cardiac catheterization on [**2108-5-28**]. This test revealed a left ventricular ejection fraction of 60%. Left main coronary artery was without significant obstructive disease. LAD was 90% ostial before stent with aggressive re-stenosis. Left circumflex was 40% ostial. RCA 70%, mid RCA 80% PDA. Given these results, Mrs. [**Known lastname 99571**] was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Diabetes mellitus 3. Status post liver transplant SOCIAL HISTORY: Prior tobacco use, quit two years ago. She is retired and lives with husband. MEDICATIONS: 1. Zestril 20 2. Prograf 2 [**Hospital1 **] 3. Lopressor 15 [**Hospital1 **] 4. Glyburide 15 [**Hospital1 **] 5. Paxil 20 qd 6. Lipitor 10 qd 7. Aspirin 8. Plavix 75 qd ALLERGIES: PENICILLIN REVIEW OF SYSTEMS: Negative unless otherwise stated above. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 48, blood pressure 113/50, respirations 20, O2 saturation 98% on 2 liters, afebrile. GENERAL: Mrs. [**Known lastname 99571**] is a pleasant woman in no apparent distress. HEAD, EARS, EYES, NOSE AND THROAT: Extraocular muscles are intact, anicteric sclerae. NECK: Supple. CARDIOVASCULAR: Bradycardia without murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Without cyanosis, clubbing or edema. SKIN: No rashes. NEUROLOGIC: Alert and oriented. Cranial nerves were grossly intact. HOSPITAL COURSE: Mrs. [**Known lastname 99571**] was taken to the Operating Room on [**2108-6-1**] for coronary artery bypass graft x4. Grafts included left internal mammary artery to LAD, saphenous vein graft to diagonal 2 OM, saphenous vein graft to PDA. The operation was performed without complication and Mrs. [**Known lastname 99571**] was subsequently transferred to the Surgical Intensive Care Unit. Initially, Mrs. [**Known lastname 99571**] did have some low urine output which was treated with aggressive fluid resuscitation. She responded to this well. She was extubated on postoperative day #2 and her chest tube was discontinued on postoperative day #3. Foley catheter was discontinued on postoperative day #4. On postoperative day #5, Mrs. [**Known lastname 99571**] required captopril to control her blood pressures. By postoperative day #6, Mrs.[**Known lastname 99572**] blood pressure was under good control. Her urine output was satisfactory and she was felt to be stable to be transferred to the floor. While on the floor, her blood pressure was controlled with metoprolol 50 mg [**Hospital1 **], captopril 50 mg po bid and amlodipine 15 mg qd. She continued to improve and was able to ambulate with assistance. She also tolerated po diet. Because Mrs. [**Known lastname 99571**] is status post liver transplant, she was followed by hepatology during this hospital stay. Her Prograf was restarted shortly after her operation and measured blood levels of her Prograf revealed them to be within the normal range. By postoperative day #10, Mrs. [**Known lastname 99571**] was felt stable to be transferred to a rehabilitation facility. PHYSICAL EXAMINATION AT DISCHARGE: VITAL SIGNS: Temperature 98.2??????, pulse 70, blood pressure 124/51, respirations 18, O2 saturation 92% on 2 liters. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. EXTREMITIES: Without cyanosis, clubbing or edema. Incision was clean, dry and intact. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 milliequivalents qd x7 days 2. Lasix 20 mg qd x7 days 3. Metoprolol 50 mg po bid 4. Docusate 100 mg [**Hospital1 **] while taking Percocet 5. Amlodipine 10 mg qd 6. Captopril 50 mg po bid 7. Calcium carbonate 1000 mg po bid for four days 8. Tacrolimus 2 mg q a.m., 1 mg q p.m. 9. Heparin 5000 units subcutaneous q 12 hours until ambulating consistently 10. Atorvastatin 10 mg po qd 11. Paroxetine 20 mg po qd 12. Pantoprazole 40 mg po qd 13. Enteric coated aspirin 14. Percocet 1 to 2 tablets po q 4 to 6 hours prn for pain 15. Insulin sliding scale regimen, regular insulin for glucose 0 to 150 measured q6h, glucose 1 to 150 0 units,151 to 200 3 units, 201 to 250 6 units, 251 to 300 9 units, 301 to 350 12 units, 351 to 400 15 units, greater than 400 units 18 greater. If glucose is less than 55, please give juice. FOLLOW UP: Mrs. [**Known lastname 99571**] is to follow up with Dr. [**Last Name (STitle) 70**] in six weeks. She should also follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 99573**], in three to four weeks. DISCHARGE CONDITION: Stable DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft x4 [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Doctor First Name 24423**] MEDQUIST36 D: [**2108-6-11**] 10:47 T: [**2108-6-11**] 10:57 JOB#: [**Job Number 99574**]

[ "578.1", "V45.82", "280.9", "414.01", "250.00", "411.1", "V42.7" ]

icd9cm

[ [ [] ] ]

[ "88.72", "88.56", "37.22", "39.61", "36.13", "99.20", "36.15" ]

icd9pcs

[ [ [] ] ]

5693, 5783

4555, 5410

5805, 6148

2493, 4167

5422, 5671

1882, 2475

4181, 4532

1819, 1860

183, 195

224, 1381

1403, 1487

1504, 1799

26,804

141,199

53173

Discharge summary

report

Admission Date: [**2129-9-15**] Discharge Date: [**2129-9-26**] Date of Birth: [**2051-8-14**] Sex: F Service: MEDICINE Allergies: Oxycodone / Morphine Attending:[**First Name3 (LF) 898**] Chief Complaint: Change in mental status, shortness of breath Major Surgical or Invasive Procedure: Bronchoalveolar lavage Intubation History of Present Illness: 78 F recent hospitalization for cellulitis, was at [**Hospital 7137**] and doing well with the exception of a mild cough this past week. This morning, she was noted to be more somnolent and with a cough productive of green sputum. . She was transferred to the ED where she was noted to be febrile to 102 and tachycardic to 105. She initially received 2 mg narcan with minimal effect. CXR showed multifocal lower lobe patchy opacities. She received ceftaz & vancomycin. She was intubated for respiratory distress. She briefly became hypotensive while on propofol, but responded to 3L NS. . On arrival to ICU, again noted to be hypotensive to SBP 70s. Propofol stopped, and started on Levophed but was quickly weaned off. Past Medical History: 1. Spinal stenosis 2. Depression 3. Hypothyroidism 4. Status post bilateral adrenalectomy secondary to b/l pheos 5. History of tuberculosis at age 16 6. Chronic headaches 7. Melanoma 8. Recurrent urinary tract infection 9. B/L knee replacement first in [**2129-4-29**], second in [**Month (only) 216**] [**2128**]. 10. GERD Social History: Currently living at [**Hospital3 2558**]. Married for 55 years to [**Last Name (un) 109474**]. Daughter [**Name (NI) 6480**] [**Name (NI) **] (HCP) Family History: NC Physical Exam: Physical Examination on arrival VS - T 96.8, BP 112/55, HR 80 100% on AC 500x14, FiO2 1.0, PEEP 5 general - intubated & sedated, but opens eyes to voice, nods to yes/no questions HEENT - ET tube and RIJ in place, PERRL CV - RRR, no m/r/g chest - coarse ventilated breath sounds abd - obest, soft, nt/nd ext - bilat chronic venous stasis On discharge, the patient was awake, alert and oriented. Her vital signs were stable. She was afebrile. Breathing was unlabored. Her bilateral lower extremities had skin changes consistent with chronic venous stasis. Pertinent Results: ECHO ([**2129-9-19**]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 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 no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CT Head ([**2129-9-15**]): No evidence of intracranial hemorrhage, mass effect, shift of midline structures, hydrocephalus, or acute major vascular territorial infarcts. [**Doctor Last Name **]-white matter differentiation is well preserved. Small calcific density within the posterior left parietal lobe may represent old sequelae of infection, trauma, or thrombosed vascular anomaly. Soft tissues and osseous structures appear unremarkable. There is pooling of secretions within the oropharynx consistent with patient's intubated status. MRI/MRA ([**2129-9-20**]): No evidence for acute ischemia. CT Abdomen/Pelvis/Chest: 1. No evidence of abdominal or pelvic abscess. 2. The endotracheal tube is located 1 cm above the carina. 3. Bilateral pleural effusions are noted. 4. There is a marked amount of stool noted within the rectum and sigmoid colon. 5. There is extensive degenerative change noted in the humeral head bilaterally. 6. There is bronchomalacia of the carina as well as the right and left bronchus. 7. Hyperdensities in the lower posterior lung fields may represent barium aspiration or sequelae of prior granulomatous disease. 8. Pulmonary artery enlargement. . [**2129-9-26**] 06:28AM BLOOD WBC-9.4 RBC-3.88* Hgb-9.7* Hct-30.1* MCV-78* MCH-24.9* MCHC-32.1 RDW-15.8* Plt Ct-504* [**2129-9-26**] 06:28AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-142 K-3.3 Cl-103 HCO3-32 AnGap-10 [**2129-9-22**] 01:55AM BLOOD ALT-9 AST-12 AlkPhos-62 TotBili-0.4 [**2129-9-26**] 06:28AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.5 Brief Hospital Course: 78 year old female who was originally admitted with fever, respiratory distress and acute change in mental status. She was found somnolent at her rehabilitation center, where she has been living since her knee replacement over the summer. She was initially admitted to the intensive care unit where she was intubated for airway protection. She was treated for a presumed multi-focal pneumonia with vancomycin, Zosyn and azithromycin given her elevated white blood cell count and fever. While in the ICU she had a BAL which did not show any evidence of gram negative rods, which had been noted on a previous sputum. Cultures from her sputum were negative for legionella, acid fast bacilli and PCP. [**Name10 (NameIs) **] addition on presentation, the patient was hypotensive, which resolved with fluids, antibiotics and stress dose steriods. She then developed episodes of hypertension during sedative weaning. The patient was started on beta blocker to help with hypertension. Chest x-ray after extubation demonstrated evidence of mild pulmonary edema. She was diuresed with a slightly higher dose of Lasix (compared to her home dose). The patient also had a cardiac work-up to exclude acute coronary disease as well as an ECHO, which did not show any evidence of an acute process. After extubation, her altered mental status persisted, prompting an evaluation by the Neurologists. She had a negative head CT as well as an MRI which was also negative for any acute process. As the infection cleared as well as sedating medication, her mental status cleared to her baseline. The patient has baseline anemia which has been stable over the course of this admission. The patient was admitted on coumadin which was started by her orthopedic doctors after a recent total knee replacement in [**Month (only) 216**]. The coumadin was held during this admission until the records were obtained. Once records were obtained verifying the reason for anti-coagulation, the patient was restarted on her home dose of coumadin. Goal INR per ortho is between 2 and 3 and should be maintained for six months. The patient also experienced renal insufficiency which resolved with intravenous fluids to normal. The patient has baseline adrenal insufficiency; secondary to bilateral adrenalectomy. She was initially started on higher doses of her home medications to treat with stress dose steriods. She has been transitioned to her home doses of corticosteroids, fludrocortisone, and levothyroxine. Given her long standing history of constipation, the patient was maintained on an aggressive bowel regimen. She has been moving her bowels daily. Daughter, [**First Name4 (NamePattern1) 6480**] [**Known lastname **] [**Telephone/Fax (1) 109475**] (cell) or [**Telephone/Fax (1) 109476**] (home) Medications on Admission: Hydrocort 20 qam, 10 qpm Zyprexa 1.25 qam Synthroid 175 qam Iron 325 qam fludrocort 0.1 qam Discharge Medications: 1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrocortisone 5 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Potassium Please take 20 mg by mouth daily 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once Daily at 16). 18. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 19. Methadone The patient has not been taking methadone as an inpatient, however she has used it in the past for pain control. The patient may take Methadone 20 mg PO TID as needed for pain. 20. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 21. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 23. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed. 24. Miralax 17 gram PO daily PRN constipation Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: Pneumonia with respiratory failure Secondary diagnosis: 1. Spinal stenosis 2. Depression 3. Hypothyroidism 4. Status post bilateral adrenalectomy secondary to b/l pheos 5. B/L knee replacement first in [**2129-4-29**], second in [**Month (only) 216**] [**2128**]. 6. GERD Discharge Condition: Stable, saturating well on room air Discharge Instructions: You were admitted to the hospital for change in mental status. When you arrived to the hospital you were found to have a fever and a fast heart rate. Because of your difficulty breathing, you were intubated to help you breathe. While you were in the hospital you were maintained on most of your outpatient medications. We held your methadone because your mental status was altered. We also started a medication named metoprolol because your blood pressure was slightly high. Please continue your outpatient medications as prescribed by your doctors. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 4127**] on [**2129-10-5**] at 2:30 pm. . Please follow up with your orthopedic doctors as needed.

[ "785.0", "790.92", "459.81", "285.9", "584.9", "518.81", "E944.4", "255.5", "E849.7", "486", "348.31", "428.31", "458.9", "V43.65", "276.8", "428.0", "311", "530.81", "564.00", "244.9", "172.7" ]

icd9cm

[ [ [] ] ]

[ "96.08", "33.24", "96.04", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

9541, 9611

4551, 7350

325, 361

9947, 9985

2240, 4528

10587, 10736

1642, 1646

7493, 9518

9632, 9632

7376, 7470

10009, 10564

1661, 2221

241, 287

389, 1111

9708, 9926

9651, 9687

1133, 1458

1474, 1626

3,601

194,430

12156

Discharge summary

report

Admission Date: [**2125-3-14**] Discharge Date: [**2125-3-22**] Date of Birth: [**2045-2-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Aspirin / Macrodantin / Zestril / Shellfish Attending:[**First Name3 (LF) 2078**] Chief Complaint: symptomatic aortic stenosis Major Surgical or Invasive Procedure: Sternotomy Valvuloplasty History of Present Illness: Pt is a 80 yo female with known aortic stenosis ([**Location (un) 109**] 0.5 cm2, gradient 61 mm Hg, EF 65%), HTN, Hyperchol, who experienced a syncopal episode [**2125-2-25**]. On admission pt denied chest pain/ chest pressure/ palpitations/ nausea/ vomiting, neck pain, and arm pain. No DOE, though pt has significantly decreased exercise tolerance in recent months (cannot walk up flight of stairs [**2-28**] dyspnea whereas before she could). On [**2125-3-14**] pt went to the OR for a planned Aortic Valve Replacement. After the sternotomy, the procedure was abandoned after heavily calcified valve found. Post op pt had intermitent atrial fibrillation. She was given lopressor and loaded on amiodarone and went back in to normal sinus rhythm and then reverted to atrial fibrillation again. On [**2124-3-19**] pt underwent a balloon valvuloplasty with valve area .49 cm2 pre-op. She was then transferred to [**Hospital Unit Name 196**] team for further medical management and was in sinus rhythm upon arrival. Past Medical History: 1. AS- [**Location (un) 109**] .5 cm2. Gradient 61 mmHg. EF 65%. 2. HTN 3. Hypercholesterolemia 4. Osteoporosis 5. Barretts 6. TAH 7. S/p appy Social History: Married with children. No history of tobacco or alcohol. Family History: Non-contributory Physical Exam: Upon admission to Cardiology Medicine from Surgery: T: 97.5; BP: 154/71; HR: 86; RR: 18; O2: 97% on RA Gen: Laying in bed, speaking in full sentences in NAD HEENT: NCAT, PERRL, EOMI Neck: Supple, JVP flat CV: RRR IV/VI harsh systolic murmur radiating to carotids Chest: CTA b/l though limited by patient effort. Median sternotomy scar well healed. No purulence Abd: NABS, soft, nd, nt Ext: 1+ edema b/l. 2+ DP/1+ PT b/l. Right groin without hematoma or bruit. Soft. Pertinent Results: Labs on admission: [**2125-3-14**] 11:51AM BLOOD Hct-28.0* Plt Ct-176 [**2125-3-14**] 11:51AM BLOOD PT-13.9* PTT-32.1 INR(PT)-1.2 [**2125-3-14**] 11:51AM BLOOD UreaN-8 Creat-0.5 Na-133 Cl-103 HCO3-26 [**2125-3-14**] 11:51AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.4* ______________________ Labs on discharge: [**2125-3-22**] 01:05PM BLOOD WBC-10.4 RBC-3.39* Hgb-10.3* Hct-29.4* MCV-87 MCH-30.5 MCHC-35.1* RDW-14.4 Plt Ct-402 [**2125-3-22**] 06:00AM BLOOD WBC-10.1 RBC-3.56* Hgb-10.7* Hct-30.8* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.8 Plt Ct-381 [**2125-3-22**] 01:05PM BLOOD PT-13.0 PTT-22.2 INR(PT)-1.1 [**2125-3-22**] 01:05PM BLOOD Glucose-113* UreaN-16 Creat-0.7 Na-127* K-4.3 Cl-93* HCO3-24 AnGap-14 [**2125-3-22**] 06:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 [**2125-3-21**] 06:10AM BLOOD TSH-0.57 _______________________ Radiology: [**2125-3-15**] CT chest- IMPRESSION: 1) Densely calcified ascending aorta, descending aorta, and aortic arch. Multiplanar reformatted images will be available for review. 2) Coronary artery calcifications. 3) Cardiomegaly, bilateral pleural effusions, and interlobular septal thickening, all consistent with volume overload. 4) Post-surgical gas within the soft tissues, pericardium, and mediastinum, as well as a small high-density pericardial effusion consistent with small amount of postoperative hemorrhage. ADDENDUM: Multiplanar reformation images confirm the presence of diffuse aortic calcifications. These images are available for review on PACS to assist preoperative planning. [**2125-3-20**] Echo pre-valvuloplasty- The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are several thickened/ deformed. There is severe calcific aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. IMPRESSION: Severe calcific aortic stenosis .6 cm2 with mild aortic regurgitation. [**2125-3-20**]- Cardiac catheterization/ balloon valvuloplasty - 1. Resting hemodynamic were performed before valvuloplasty. Right sided filling pressures were normal (mean RA pressure was 6 mm Hg and RVEDP was 10 mm Hg). Pulmonary arterial pressures were moderately elevated (PA pressure was 42/14 mm Hg). Left sided filling pressures were mildly elevated (mean PCW pressure was 12 mm Hg and LVEDP was 15 mm Hg). Central arterial pressure was moderately elevated (aortic pressure was 184/80 mm Hg). Cardiac index was normal (at 2.7 L/min/m2). 2. The aortic valve was evaluated. The mean aortic valve gradient was 38 mm Hg and the calculated aortic valve area was 0.49 cm2. An additional 30 mm Hg gradient was noted in the outflow tract consistent with dynamic outflow tract obstruction. 3. Double balloon valvuloplasty (10 x 60 x 2) was performed with successful inflation and dilatation of the aortic valve. 4. Resting hemodynamics after balloon valvuloplasty were not performed. 5. Peripheral angiography at the close of the case revealed small thrombus distal to the sheath insertion site at the location of a previous AngioSeal at the right femoral arterial access site. The left femoral arterial access site had trivial extravasation of contrast with note of a trivial AV fistula. [**2125-3-21**] Echo post valvuloplasty-Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2125-3-20**], aortic valve gradient today is slightly lower and the aortic stenosis is probably slightly less severe. Brief Hospital Course: 80 yo female, HTN, hypercholesterolemia, known Aortic stenosis, presents for aortic valve replacement. AVR abandoned secondary to heavily calcified valve, and is now status post valvuloplasty. 1. Aortic stenosis Aortic valve area was .6 cm 2 with aortic gradient of 121 pre-valvuloplasty. Pt had valvuloplasty without complication on [**2125-3-20**]. Echo post procedure, shows a valve area of 0.8 cm 2 with a gradient of 76 mm Hg. We increased pt's beta blocker, metoprolol, to 100 [**Hospital1 **] qday, as we slowly titrated it up. We discontinued pt's calcium channel blocker (verapamil) as we did not want pt to have two nodal agents as the calcific aortic valve liking abutting the AV Node and increased chance of AV block or arrythmia from that. Additionally, pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was continued. 2. [**Name (NI) 4964**] Pt with normal EF but was fluid overloaded s/p operation. She was given Lasix for diuresis and on transfer to cardiology was euvolemic, remained so, and did not require further diuresis. 3. A fib Pt was in atrial fibrillation post-operatively and converted with beta blocker and was also amiodarone loaded. She was initially put on a heparin gtt but this was discontinued as it was decided not to anticoagulate this pt who has no history of atrial fibrillation and only had it transiently post op for a few days. She was monitored on telemetry and was in sinus. Amiodarone was d/cd upon discharge as atrial fibrillation likely only post-op and risk of fall outweighs possibility of recurrence. If atrial fibrillation recurs, will need to evaluate situation further. 4. Hypertension- D/cd calcium channel blocker as above. We titrated up beta blocker and kept pt on [**Last Name (un) **] 5. Hypercholesterolemia- Continued Lipitor. 6. Barrets- continued Zantac. 7. CAD- No known coronary disease. Pt not on aspirin. On beta blocker, Statin. 8. Anemia- Baseline appears to be in the lowering 30s. She got transfused post-op and Hct stable on cardiology floor in low 30s. This will need to be watched as outpt. 9. Barrets- Continued H2 blocker. 10. PPx: H2 blocker, d/cd heparin gtt. 11. F/E/N- Cardiac heart healthy diet. 12. Code Status- Was full code Medications on Admission: Verapamil 240 mg qday Diovan 160 mg qday Atenolol 12.5 mg qday Terazosin 4 mg qday Lipitor 10 mg qday Actonel 35 mg qweek Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipa. 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for SBP <100, HR <55. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP <100. 9. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. Capsule(s) 10. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Primary diagnosis: Aortic stenosis s/p sternotomy s/p valvuloplasty Anemia Secondary diagnosis: Hypertension Hypercholesterolemia GERD Discharge Condition: Good. Pt is s/p aortic valvuloplasty and sternotomy. She is doing well. Discharge Instructions: Call your doctor and go to the emergency room immediately if you have chest pain, problems breathing, faint, shortness of breath, dizziness, fever, redness at the insertion site or any other health concern. Make your appointments below. Take your medications as prescribed. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Follow-up appointment should be in 1 week Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month

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icd9cm

[ [ [] ] ]

[ "37.12", "35.96", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

10127, 10194

6766, 9003

354, 381

10374, 10447

2206, 2211

10771, 11075

1683, 1701

9177, 10104

10215, 10215

9029, 9153

10471, 10748

1716, 2187

287, 316

2509, 6743

409, 1426

10312, 10353

10234, 10291

2225, 2489

1448, 1593

1609, 1667

8,850

170,576

45411

Discharge summary

report

Admission Date: [**2185-9-7**] Discharge Date: [**2185-9-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10842**] Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: Upper Endoscopy x2 with clipping and epinephrine injections IR-guided vessel embolization History of Present Illness: 84 yo female with PMH significant for severe AS, diastolic CHF with preserved EF(EF 45-50%), recent admission ([**Date range (1) 25773**]) for ARF and transaminitis (unclear etiology, ?autoimmune), presents with 2-3 days of malaise and decreased appetite. She reports that for about a week after being discharged she was feeling well with good appetite. Then over the past few days she has had increasing general weakness, malaise, and decreased appetite. She has been drinking some fluids but has not taken any food PO over the past few days. Family members tried to encourage PO intake, supplemental shakes, etc with little success. She reports some associated nausea but no vomiting, only dry heaves. Earlier today she was described as lethargic and confused and so was brought to the ED. In the ED, T 96.3 BP 133/50 HR 60 RR 17 SpO2 99% on RA. EKG and CXR were normal. Stool was heme positive but pt is taking iron. Received IVF. On arrival to the floor, pt reports that she feels better than when she initially presented to the ED though still feels weak. Past Medical History: -Severe Aortic stenosis [Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR] -Moderate to severe MR [**Name13 (STitle) **] to severe TR -H/O small bowel obstruction s/p resection [**2185-5-11**] -dCHF and mild sCHF with EF 45-50% [Mild global RV free wall hypokinesis. Mild global LV hypokinesis]. -? Hepatic congestion from R sided heart failure -Anemia of chronic disease baseline HCT 28-30 -coagulopathy on chronic Vit K -hyponatremia PSH: - 2 distant c-sections - SB volvulus s/p bowel resection 3 months ago [**2185-5-11**] featuring: 1. Exploratory laparotomy. 2. Lysis of adhesions. 3. Reduction of small bowel volvulus. 4. Small bowel resection, primary anastomosis. Social History: Widowed and has been living with one of her daughters since her recent surgery in [**5-16**]. She has 6 daughters and 2 sons. Denies EtOH, smoking, illicit drugs. Prior to recent admission was fairly active, would walk to the store, help with grocery shopping. Family History: n/c Physical Exam: VITALS: T 96.0 BP 118/84 SpO2 98% on RA GENERAL: pleasant, thin elderly female lying in bed with multiple family members at the bedside, in no acute distress HEENT: NCAT, dry MM, OP clear without erythema or exudate NECK: supple HEART: RRR, [**3-15**] harsh systolic murmur throughout precordium but loudest at LUSB with radiation to the axilla LUNGS: bibasilar rales, no wheeze or rhonchi ABDOMEN: +BS, soft, nontender, nondistended, no organomegaly EXTREMITIES: 1+ LE edema bilaterally to below the knees, 2+ radial pulses b/l Pertinent Results: [**2185-9-7**] 12:45PM PT-20.7* PTT-33.7 INR(PT)-2.0* [**2185-9-7**] 12:45PM PLT SMR-NORMAL PLT COUNT-299# [**2185-9-7**] 12:45PM HYPOCHROM-3+ ANISOCYT-NORMAL POIKILOCY-3+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-2+ OVALOCYT-3+ SCHISTOCY-2+ ACANTHOCY-2+ [**2185-9-7**] 12:45PM NEUTS-94.4* BANDS-0 LYMPHS-3.4* MONOS-1.7* EOS-0.2 BASOS-0.2 [**2185-9-7**] 12:45PM WBC-15.8*# RBC-2.69* HGB-8.7* HCT-27.5* MCV-103* MCH-32.5* MCHC-31.7 RDW-20.3* [**2185-9-7**] 12:45PM CK-MB-9 cTropnT-0.09* [**2185-9-7**] 12:45PM LIPASE-67* [**2185-9-7**] 12:45PM ALT(SGPT)-335* AST(SGOT)-382* CK(CPK)-126 ALK PHOS-86 AMYLASE-50 TOT BILI-1.4 DIR BILI-0.7* INDIR BIL-0.7 [**2185-9-7**] 12:45PM GLUCOSE-121* UREA N-86* CREAT-2.4*# SODIUM-123* POTASSIUM-6.6* CHLORIDE-90* TOTAL CO2-17* ANION GAP-23* [**2185-9-7**] 02:06PM K+-5.1 [**2185-9-7**] 03:00PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2185-9-7**] 03:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2185-9-7**] 09:27PM URINE OSMOLAL-403 [**2185-9-7**] 09:27PM URINE HOURS-RANDOM UREA N-701 CREAT-46 SODIUM-24 Studies: [**9-11**] Abd CT: IMPRESSION: 1. No evidence of any retroperitoneal bleed. 2. Markedly distended stomach, both small and large bowel are decompressed. 3. Mild bilateral pleural effusions and associated atelectasis. 4. Ascites. 5. Unchanged duplication cyst in right lower quadrant. 6. Free fluid in the pelvis. 7. Fluid containing right inguinal hernia. [**9-15**] LENIs: IMPRESSION: Limited evaluation of the superficial femoral veins bilaterally due to leg edema. Otherwise, no evidence of deep venous thrombosis in either extremity. [**9-16**] CXR: The ET tube has been slightly repositioned with its tip now 11 mm above the carina, still low. Mild overinflation of the ET tube cuff is seen. There is no significant change in the cardiac silhouette. Severe calcifications of the mitral valve are again noted. New since [**9-13**], rounded opacity projecting over the right mid and lower lung are demonstrated and given the fast development, infectious in origin. Bilateral pleural effusions are again noted, small-to-moderate and may partially loculated on the right. Brief Hospital Course: Ms. [**Known lastname 10446**] is an 84yo female with a history of aortic stenosis and CHF who presented on [**2185-9-7**] failure to thrive, nausea, and vomiting. Her brief hospital course by problem is as follows: #)GI Bleed: Pt was found to have melanotic stools on the floor and her Hct dropped from 33 to 22, so she was transfered to the MICU where she received 7u PRBCs. Upper endoscopy on [**9-12**] revealed multiple non-bleeding ulcers in the whole stomach and a bleeding Dieualfoy lesion in the duodenum which was clipped and injected with epinephrine. Due to concern for continued bleeding, she then underwent repeat endoscopy on [**9-13**] which showed persistent bleeding of one of her ulcers; successful hemostasis was acheived with clipping. AFter 2 days of observation and stable hematocrits, she was transferred to the floor. On the night of transfer, she developed large BRBPR admixed with clots, but remained hemodynamically stable. Her BPs remained >100 systolic. She was tachycardiac to the 100s-110s and her Hct dropped from 29.0 to 20.2. She was transfered back to the MICU, transfused and underwent IR guided embolization. In total, she received 20u PRBC, 13u FFP, and 4u platelets. Since coming to the floor on [**9-20**], her Hct has been stable and her pressures have been adequate. She has had several small melanotic stools (which is expected as per GI) and has remained hemodynamically stable. Pt was sent home on a PPI [**Hospital1 **]. ** Pt was not sent home on aspirin given her recent massive bleed; this can be restarted as an outpatient as appropriate. #) Pneumonia: During her first MICU stay, the pt was intubated and subsequently developed respiratory symptoms consistent w/ hospital-acquired pneumonia. She was started on Vanc/Cefepime for an 8-day course, and when sputum cultures revealed MSSA and 1+ budding yeast, she was transitioned to nafcillin and completed the course in-house. At discharge, she was without respiratory symptoms and had adequate O2 sats on RA. #) Volume overload: Pt developed volume overload evidenced by [**3-13**]+ pitting edema in both lower extremities up to her thighs and in both upper extremities. This was in the setting of her mild CHF (EF 45-50%) and numerous transfusions. When she came to the floor, pt was started on Lasix 20mg IV BID and was nearly 2L negative for 2 days. She began to improve clinically and was transitioned back to her home regimen of Lasix PO 40mg daily. At discharge, her edema had improved and will likely continue to improve on her home regimen. **Pt was not restarted on her home spironolactone as she was diuresing well on lasix; spironolactone can be restarted as an outpatient as appropriate. **Pt was also not sent home on her usual metoprolol regimen, as her pressures were low-normal during the diuresis and we did not want to tip her into hypotension (which had apparently been a problem in the MICU). This can be restarted as an outpatient as appropriate. #)Acute renal failure: Pt was found to have elevated Cr for the first several days of admission, likely secondary to prerenal etiology given poor PO intake, diuretic use at home, and severe bleeding. Cr resolved to near baseline on HD4 and remained stable afterwards. Pt had good urine output on discharge. #)Aortic stenosis: Pt was evaluated by cardiothoracic surgery during one of her recent admissions and was found not to be a surgical candidate due to her comorbidities, so no further steps were taken on this admission and her fluid status was monitored closely. #) LE edema: Pt was found to have L lower extremity edema greater than R for several days. In the setting of tachycardia, hospitalization, and reversal of coagulopathy for GI bleed, there was a moderate suspicion for DVT/PE, however LENIs were negative for DVT (though of poor quality). This was thought to be due to her volume overload, and the patient was diuresed as above. #)Chronic low back pain: Pt was started on a lidocaine patch which provided some relief of this chronic problem. However, anesthesia recommended that she be started on 12mcg fentanyl patch, which provided added relief. Pt was sent home on the fentanyl patch. #)Coagulopathy: Patient presented with INR of 2.0 on admission, which lowered to 1.4 on discharge. This is possibly secondary to her underlying liver disease. Pt was continued on her home vitamin K regimen. #) Health maintenance: Pt was sent home on calcium supplements and vitamin D, which were not previously part of her regimen. Medications on Admission: Metoprolol 25mg [**Hospital1 **] Iron 325mg daily Hexavitamin 1 capsule daily Lasix 40mg daily (recently increased from 20mg by Dr. [**Last Name (STitle) **] on [**9-5**]) Vitamin K 10mg daily Spironolactone 25mg daily Aspirin 325mg daily Tramadol 50mg q6-8 prn Discharge Medications: 1. Vitamin D-3 400 unit Capsule Sig: Two (2) Capsule PO once a day. 2. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. 5. 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* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): Please place on lower back. Disp:*10 Patch 72 hr(s)* Refills:*2* 9. Calcium 600 600 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Blood loss anemia Hospital-acquired pneumonia Volume overload Secondary: Aortic stenosis Chronic low back pain History of transaminitis Coagulopathy - on chronic vit. K Discharge Condition: Good. Discharge Instructions: You were admitted with nausea and vomiting on [**2185-9-7**]. You were found to have multiple ulcers in your GI tract for which you were transfered to the intensive care unit, transfused with several units of blood, and for which you required two endoscopies. You were then transfered back to the floor, but when your blood counts continued to drop, you were transfered back to the intensive care unit, transfused with more blood, and underwent vessel embolization (clotting) with interventional radiology. During this time, you were also noted to have developed a pneumonia, so you were started on antibiotics. When your blood counts and blood pressure was stable, you were transfered back to the floor. There, you were found to have a lot of extra fluid in your body, likely from all of the transfusions you received, so you were started on intravenous lasix to take some of the fluid off. At time of discharge, you had lost a lot of the extra fluid, and it will continue to come off at home with oral lasix. Your pressures were stable, your blood pressures were stable, your back pain was under better control with a fentanyl patch, and you were eating and drinking better. You were sent home in good condition. Your home medications have been changed to the following: - Please do NOT take the following medications anymore: metoprolol, spironolactone, aspirin. These can be restarted by Dr. [**Last Name (STitle) 1147**] as an outpatient if he feels it is appropriate. - Please start the following medications: lasix 40mg daily, vitamin D 800mg daily (over the counter), calcium tablets 600mg twice a day (over the counter), fentanyl patch 12mcg to be changed every 72 hrs. - You can continue to take your home iron tablet 325mg daily, multivitamin daily, and tramadol as needed for pain (though if this can be minimized, that would be good given that you will also be taking a fentanyl patch). Please see your PCP or return to the emergency department if you have any concerning symptoms such as: fever>101.5, chills, night sweats, bleeding per rectum or from anywhere, dark tarry stools, extreme fatigue, sever lightheadedness/dizziness, abdominal pain, difficulty breathing, chest pain, palpitations, blood in your urine, worsening extremity swelling, or any other worrisome symptoms. Followup Instructions: Please call Dr. [**Last Name (STitle) 1147**] ([**0-0-**]) on Monday [**2185-9-26**] to set up a follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "44.43", "99.05", "99.07", "44.44", "99.04" ]

icd9pcs

[ [ [] ] ]

11152, 11201

5343, 9860

280, 372

11424, 11432

3078, 5320

13776, 13899

2506, 2511

10172, 11129

11222, 11403

9886, 10149

11456, 13753

2526, 3059

223, 242

400, 1468

1490, 2211

2227, 2490

7,685

187,618

44615

Discharge summary

report

Admission Date: [**2140-5-31**] Discharge Date: [**2140-6-3**] Date of Birth: [**2079-5-19**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: Aorto-bifemoral bypass with PTFE [**2140-6-2**] History of Present Illness: 61 M w/ h/o aortobifem in [**2132**], presents to the ED w/ new chest and LLE pain. The patient states that he has had ~12 hrs of chest pain w/ no radiation as well as worsening LLE pain. He has noticed that his left foot is cooler than his right, although is unsure how for how long this has been present. He states that he has not had previous difficulty with his LLE. He has been seen in the ED previously with similar chest pain, and report of LLE pain at that time. The patient states he can only walk [**8-12**] steps before he has to stop because of pain. He has had one episode of emesis, no fevers or chills. He was taking plavix and aspirin for a drug eluding stent, but stopped because of difficulty obtaining the medication. Past Medical History: VASCULAR HISTORY: Lower Extremity Bypass Graft: Aortobifem. Hypertension, dyslipidemia, coronary artery disease, s/p MI, h/o SBO s/p LOA PAST SURGICAL HISTORY: PSH: Aortobifemoral bypass [**2132**], exlap, LOA [**2132**], ORIF/internal fixation of L wrist fx, s/p PCA to RCA in [**2123**] and LCx in [**2128**], LAD stent (DES) [**2132**] Social History: 30 pack/yr tobacco history, currently smokes 2 packs a day. Denies ETOH and illicits. Family History: Mother - Pancreatic Ca. Father - DM2, CAD, MI in his 80s, died from cardiac arrest. Physical Exam: Admission Exam Temp: 98.0 RR: 16 Pulse: 90 BP: 135/80 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline. Nodes: No clavicular/cervical adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear. Gastrointestinal: Non distended, No masses, Guarding or rebound. Rectal: Not Examined. Extremities: No RLE edema, No LLE Edema. Left leg slightly cooler than right leg, no lesions or ulcerations Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. Popiteal: D. DP: D. PT: D. LLE Femoral: P. Popiteal: N. DP: N. PT: N. On discharge still no dopplerable signals on left lower extremity, ax-bifem graft faintly palpable pulse. Pertinent Results: [**2140-6-3**] 05:50AM BLOOD WBC-8.9 RBC-3.95* Hgb-11.7* Hct-35.6* MCV-90 MCH-29.6 MCHC-32.9 RDW-13.8 Plt Ct-192 [**2140-6-3**] 03:01AM BLOOD PTT-31.6 (at Hep gtt of 500units/hr -> heparin increased to 700units/hr. PTT to be drawn) [**2140-6-3**] 05:50AM BLOOD Glucose-130* UreaN-11 Creat-1.2 Na-136 K-4.1 Cl-102 HCO3-26 AnGap-12 [**2140-6-3**] 05:50AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9 [**2140-6-1**] 07:30AM BLOOD Triglyc-161* HDL-42 CHOL/HD-5.1 LDLcalc-139* [**2140-6-2**] 07:25PM BLOOD CK-MB-2 cTropnT-<0.01 (all troponin levels drawn this admission <.01) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CTA chest/abdomen/pelvis with b/l LE runoff [**2140-5-31**] 1. Severe atherosclerotic disease of the distal aorta and iliac system, with complete occlusion of the left limb of an aortobifem graft. The left superficial and deep femoral arteries are reconstituted by collateral flow near the level of the distal graft touchdown. There is a three-vessel runoff in the left calf, however, the anterior tibial and peroneal branches become attenuated at the mid calf due to delayed bolus arrival. 2. Patent right aortofemoral graft, which is moderately narrowed. There is two-vessel runoff in the right calf, noting the anterior tibial artery becomes occluded just dital to its origin. 3. Thyroid isthmus nodule; recommend correlation with prior thyroid imaging, and if indicated further evaluation with thyroid ultrasound if not done elsewhere. 4. Moderate pulmonary emphysema. Brief Hospital Course: The patient was admitted to the vascular surgical service after undergoing a CTA of his torso with run off that showed an occlusion of his prior aorto-bifemoral bypass graft. His original complaint of chest pain resolved prior to his admision and his cardiac enzymes remained within normal limits without EKG changes. A heparin drip was initiated and PTT optimized at a goal of 60-80. A cardiology consult was obtained (see inclosed) for his history of chest pain and to evaluate for preoperative cardiac clearance. Medical opitimization was recommended without further cardiac studies. An axillo-bifemoral graft (a repeat aorto-bifem was deferred in favor of the axillobifem due to his cardiac disease) was undertaken [**2140-6-2**]. The operative note can be requested if needed but is currently in dictation. He tolerated the procedure well. The origin of the graft was the right proximal axillary artery and propaten graft was used. The distal limbs were anastamosed to the right SFA and the left profunda arteries. The flow intraoperatively was excellent. Postoperatively he was resumed on a heparin gtt but initially started at 500units/hr then increased to 700units the following morning. A graft pulse was palpable however it was noted to be weaker on POD1 and an ultrasound was planned which the patient refused. A venous signal only was dopplerable in the patient's left foot postoperatively as he had preop. He continued to have pain in his left lower extremity and a consideration of a future left femoral to above knee popliteal graft will need to be made. He was monitored overnight on POD 1 with an arterial line without issue and removed on POD1. A central line that was placed [**2140-6-2**] in the operating room was left in place for access. His foley catheter was placed [**2140-6-2**] and was removed POD1 due to patient request. Medications on Admission: None Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H pain 7. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 700units/hr Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital 1263**] Hospital Inpt Discharge Diagnosis: Left lower extremity ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Transfer to acute care facility, [**Hospital 1263**] Hospital Followup Instructions: Dr. [**Last Name (STitle) 1391**] ([**Telephone/Fax (1) 4852**]

[ "413.9", "440.0", "996.74", "E878.2", "272.4", "401.9", "305.1", "412", "414.01", "492.8", "440.8", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.29" ]

icd9pcs

[ [ [] ] ]

6444, 6504

3922, 5790

284, 334

6578, 6578

2391, 3899

6815, 6882

1584, 1669

5845, 6421

6525, 6557

5816, 5822

6729, 6792

1284, 1465

1684, 2372

231, 246

362, 1101

6593, 6705

1123, 1261

1481, 1568

4,656

149,339

22319+22320

Discharge summary

report+report

Admission Date: [**2164-7-28**] Discharge Date: Date of Birth: [**2113-3-18**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with a history of hypertension, insulin-dependent diabetes mellitus, asthma and question of valvulopathy, transferred from an outside hospital. He awoke this morning with sudden onset of right frontal/orbital headache which descended down to the neck. No nausea or vomiting. No visual changes. No extremity deficits. He was brought to [**Hospital3 **]. CT of the head showed subarachnoid hemorrhage. GCS was equal to 15. He was brought to [**Hospital6 256**] for further evaluation. CT at [**Hospital6 2018**] showed a subarachnoid hemorrhage and there were two aneurysms associated with this supraclinoid carotid on the right, the larger being at the internal carotid artery bifurcation measuring 7 x 5 mm in size with a neck width 0.3 mm. A second carotid aneurysm measuring 4 x 2 mm with a neck width of 2 is located proximal to this larger aneurysm and directed more posteriorly. There is no evidence of vasospasm. Angiography showed right posterior communicating aneurysm and right anterior choroidal aneurysm, which were both coiled and EVD placed in the right lateral ventricle frontal [**Doctor Last Name 534**]. The patient was intubated and brought to the Intensive Care Unit intubated. PAST MEDICAL HISTORY: Hypertension, asthma, seizures two weeks ago, insulin-dependent diabetes mellitus, unknown cardiac history. CONDITION: Valvulopathy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Toprol-XL 100, Combivent, insulin 40/40, penicillin, Motrin and Prinivil. SOCIAL HISTORY: Positive smoking one and a half pack per day, no ETOH. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Examination upon arrival to Surgical Intensive Care Unit postoperatively: Temperature 96.1, blood pressure 148/93, heart rate 53, respiratory rate 12. In general, he was intubated and sedated. He is a Spanish speaking individual. HEENT: Pupils equal, round and reactive two to one bilaterally. Chest was clear to auscultation without rubs. Cardiac was regular rate and rhythm. Abdomen is soft, nontender, nondistended. Extremities: No cyanosis, clubbing or edema. LABORATORY DATA: His potassium is 4.5, creatinine 1.1, hematocrit 43. His coagulations were good. Electrocardiogram showed sinus rhythm, no ST changes. Chest x-ray showed no pneumothorax, nasogastric tube was in place. HISTORY OF PRESENT ILLNESS: The patient went into congestive heart failure on [**2164-8-8**]. His bronchi were mucous plugged. He was intubated. A Swan was placed. The patient had angiography on [**2164-8-8**] which showed no vasospasm, congestive heart failure and pulmonary edema and mucous plug. He was reintubated on [**2164-8-8**] plus bronchoscoped. Echocardiogram on [**2164-8-9**] was within normal limits. T-tube for acalculous cholecystitis which then showed blood cultures on [**2164-8-10**] with coagulase negative Staphylococcus. Repeat blood culture was negative, but his sputum showed pseudomonas and Serratia. Culture on [**2164-8-10**] which was pansensitive. Angiography on [**2164-8-16**] was negative for vasospasm. CT of the head and neck on [**2164-8-17**] showed no changes. It was repeated on [**2164-8-22**] and was negative. Lower extremity Doppler on [**2164-8-23**]. CT status post drain out was unchanged. CT on [**2164-8-26**] was unchanged. The patient was screened for rehabilitation and sent to a rehabilitation facility. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 15649**] MEDQUIST36 D: [**2164-8-29**] 10:04:19 T: [**2164-8-29**] 11:07:16 Job#: [**Job Number **] Admission Date: [**2164-7-28**] Discharge Date: [**2164-9-1**] Service: NSURG ADDENDUM: The patient's discharge was delayed due to lack of appropriate rehabilitation facility being available. He was eventually discharged on [**2164-9-1**], without any changes to his plan of care. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern4) 26792**] MEDQUIST36 D: [**2164-12-7**] 17:24:29 T: [**2164-12-9**] 08:03:24 Job#: [**Job Number 58134**]

[ "038.19", "933.1", "995.91", "996.62", "576.8", "428.0", "401.9", "430", "250.00" ]

icd9cm

[ [ [] ] ]

[ "33.23", "96.72", "03.31", "38.7", "39.72", "39.99", "88.41", "96.04", "02.39", "96.6", "51.10", "99.04", "51.01" ]

icd9pcs

[ [ [] ] ]

1768, 1786

1603, 1678

1809, 2498

2527, 4354

1402, 1576

1695, 1751

77,718

181,464

14228

Discharge summary

report

Admission Date: [**2126-5-21**] Discharge Date: [**2126-5-24**] Date of Birth: [**2081-7-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: enteroscopy colonoscopy capsule endoscopy History of Present Illness: 44 yo M with PMH CAD s/p DES to LAD x 2 in [**2124**], recent GIB who presents with BRBPR. . At 3pm on [**5-21**] patient reports development of acute onset BRBPR X 1 episodes with one minute of dizziness, lightheaded, diaphoresis. Stool was loose without any brown, only red blood. He had a prodrome of epigastric pain which resolved after about an hour. Due to recent bleed patient presented immediately to the ED. Initial vital signs were: 98.2 103 93/44 16 100% RA. Hct 32. In the ED he had another 2 BMs with BRBPR in smaller volume than first episode. CTA was done which did not show any active extravasation. Repeat Hct dropped to 28. He was started on transfusion of 2 units pRBCs (just started 1st on transfer). Vital signs on tranfer were: 98.0 112/54 98 20 100%ra. . Of note patient had recent admission in early [**Month (only) 547**] for melena and epigastric pain. During that hospitalization he was transfused 2 units pRBCs for Hct 25 (down from baseline 42). Ensocopy showed antral erosions seen but no ulcerations, clots, or active bleeding, biopsies were taken of stomach and duodenum. Colonoscopy showed a polyp, which was resected and sent for pathology. He underwent capsule ensocopy on [**2126-5-17**] which showed capsule with a signle angioectasia int he third part of the duodenum. He underwent single baloon enterosocopy with argon cautery to one in the distal duodenum. . On arrival to the MICU, patient denies any recent bleeding, denies any complaint. . 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 vomiting, diarrhea. dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. CAD: DES to mid LAD, POBA to jailed diagonal, restent of LAD [**4-/2124**] 2. Hypertension 3. Hyperlipidemia 4. GIB in [**5-/2125**] secondary to angioectasia in 3rd part of duodenum Social History: Patient works in a bank doing financial work. Lives with his wife and 3 young children (ages 13, 10, and 7). Has a 10 PYH but quit 6 years ago. Tries to walk for exercise, but often doesn't get the time. Drinks about 7-9 beers on Friday and Saturday nights. Denies any other drug use. Family History: Grandfather died of MI at age 57. Mother and uncles with multiple cardiac stents. Physical Exam: Admission Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, 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 Pertinent Results: Admission labs: [**2126-5-21**] 06:30PM BLOOD WBC-12.6* RBC-3.65* Hgb-10.5* Hct-32.7* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.8 Plt Ct-336 [**2126-5-21**] 06:30PM BLOOD Neuts-77.8* Lymphs-16.3* Monos-4.4 Eos-1.0 Baso-0.4 [**2126-5-21**] 06:30PM BLOOD PT-11.9 PTT-26.3 INR(PT)-1.1 [**2126-5-21**] 06:30PM BLOOD Glucose-124* UreaN-23* Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-23 AnGap-15 . Discharge labs: [**2126-5-24**] 06:55AM BLOOD WBC-7.1 RBC-3.14* Hgb-8.9* Hct-27.5* MCV-87 MCH-28.3 MCHC-32.4 RDW-14.4 Plt Ct-244 [**2126-5-24**] 06:55AM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-142 K-3.4 Cl-107 HCO3-24 AnGap-14 . Micro: MRSA screen [**2126-5-22**]: negative . CTA abdomen/pelvis [**2126-5-21**]: No acute abdominal or pelvic process identified. There is no evidence of active arterial extravasation to suggest arterial bleeding within the bowel. . GI biopsy [**2126-5-23**]: pending . Small bowel enteroscopy [**2126-5-23**]: Normal Small Bowel Enteroscopy to mid jejunum. . Colonoscopy [**2126-5-23**]: In the terminal ileum there were lymphoid follicles with some overlying petechiae. Biopsies of this area was obtained. The remainnder of the distal ileum appeared normal. 30cm into the ileum was investigated. [**Country 11150**] ink was used to [**Country **] the most proximal area evaluated. (biopsy, injection) Internal hemorrhoids Normal colonoscopy to cecum and 30cm into the ileum Brief Hospital Course: 44yo man with CAD s/p DES in [**2124**] and history of in-stent rethrombosis, recent GIB from angioectasia of the duodenum who presented with new BRBPR. # BRBPR: The patient received 1 unit of PRBC in the ER and remained hemodynamically stable throughout his hospital course. The patient was seen by GI in consultation, who performed small bowel enteroscopy and colonoscopy without identifying a source of bleeding. He was discharged with a capsule endoscopy with plans to follow-up in [**Hospital **] clinic. At the time of discharge, the patient had a stable hematocrit and no evidence of further bleeding. In fact, he had no episodes of BRBPR during his brief admission. He was prescribed omeprazole to take twice daily. . # CAD: Continued aspirin 81 mg daily. The patient's outpatient cardiologist was contact[**Name (NI) **] and agreed with aspirin 81 mg daily. Metoprolol was initially held and then restarted. Lisinopril was stopped due to low blood pressure. The patient will follow up with his primary care doctor and cardiologist to consider restarting Lisinopril if BP becomes uncontrolled. . # ETOH use: Patient reports binge drinking behavior. This medical effects of this were discussed and binge drinking was discouraged. SW was not consulted. Medications on Admission: 1. [**Name (NI) 42297**] 40 mg daily 2. ezetimibe 10 mg daily 3. lisinopril 10 mg daily 4. [**Name (NI) 42298**]-3 fatty acids daily 5. aspirin 81mg daily 6. [**Name (NI) 42296**] 40 mg [**Hospital1 **] 7. Metoprolol Succinate 25mg daily Discharge Medications: 1. [**Hospital1 42297**] 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. [**Hospital1 **] 3 350-400 mg Capsule Sig: One (1) Capsule PO twice a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. GI bleeding . Secondary: 1. Coronary artery disease 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 bleeding from you GI track. You had an enteroscopy and upper endoscopy, which did not identify the cause of the bleeding. You were set up with a capsule endoscopy and will follow up in the gastroenterology clinic. . Please continue to take omeprazole (Prilosec) 20 mg twice daily. . There is one change to your medications: STOP lisinopril for now. Your primary care doctor and cardiology can add this back in the future as tolerated by your blood pressure. Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/CARDIOLOGY Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 5768**] When: [**Last Name (LF) 766**], [**2124-6-2**]:15 AM . Name: [**Last Name (LF) 903**],[**First Name3 (LF) 251**] J. Location: [**Hospital6 9657**] MEDICAL GROUP Address: [**Location (un) **], [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 24396**] Appt: [**5-30**] at 11am . You will be contact[**Name (NI) **] by the gastroenterology clinic with a follow-up appointment. Please call the gastroenterology clinic at ([**Telephone/Fax (1) 2233**] if you do not hear about an appointment by [**Telephone/Fax (1) 766**] [**5-27**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

[ "272.4", "414.01", "285.1", "V45.82", "401.9", "V15.82", "280.0", "578.1" ]

icd9cm

[ [ [] ] ]

[ "45.25", "45.13" ]

icd9pcs

[ [ [] ] ]

7069, 7075

4911, 6172

310, 354

7183, 7183

3507, 3507

7846, 8804

2797, 2882

6461, 7046

7096, 7162

6198, 6438

7334, 7823

3898, 4888

2897, 3488

1890, 2265

265, 272

382, 1871

3523, 3882

7198, 7310

2287, 2478

2494, 2781

82,713

191,545

53557

Discharge summary

report

Admission Date: [**2200-3-27**] Discharge Date: [**2200-4-3**] Date of Birth: [**2179-6-26**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: motorcycle crash Major Surgical or Invasive Procedure: [**2200-3-28**]: Intramedullary nailing reconstruction nail of right femoral shaft fracture, and irrigation debridement down to and inclusive of bone of an 8-cm tibial laceration. [**2200-3-28**]: 1. Closed reduction and percutaneous pinning of right 2nd, 3rd, 5th carpometacarpal fracture-dislocations. 2. Closed reduction and percutaneous pinning of right metacarpal shaft fracture. 3. Application of uniplanar external spanning fixator. 4. Irrigation and debridement of dorsal hand wound. History of Present Illness: 20yo M with no pertinent PMHx presenting from OSH with concern for R femur fx with possible vascular injury, multiple R metacarpal fx, R PNX post pigtail, grade 1 liver lac. Onset: immed prior to presenting to OSH. Precede: practicing riding on motorcycle hills, struck pole head on. Charac: Helmeted, no LOC, no amnesia, no seizure activity, unknown speed (approx 30-40mph). Known injuries per below. Denies f/c, n/v/d, HA/change in vision/neck pain, CP/SOB/cough, abd pain, lower back pain, GI incont/GU retention, focal n/t/w of R hand distal to injuries and distal to R femur fx. Pt arrived to ED with exam notable for a R femoral artery thrill and no palpable distal pulses whilst in traction. 15 minutes post removal of Buck's Traction, pulses returned. ABI of 0.4 was concerning for aterial injury. CTA demonstrated R CFA dissection. Past Medical History: PMH: Denies PSH: Appendectomy Social History: Not currently working. Occasional alcohol use. Denies smoking or illicit drugs Family History: non-contributory Physical Exam: Admission Exam - Vitals: BP 104/50 HR 88 GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses. Large abrasion on the RLQ Ext: Large right thigh hematoma with deformity consistent with right femur fracture. Large deep laceration anterior to the tibia. Pulses: Initially Fem [**Doctor Last Name **] DP PT [**Name (NI) 2325**] 2+ 1+ 1+ 1+ Right 2+ - - - On traction of RLE Fem [**Doctor Last Name **] DP PT [**Name (NI) 2325**] 2+ 1+ 1+ 1+ Right 2+ 1+ 1+ 1+ On discharge: VS: 98.3 76 129/69 16 !00% RA GEN: A&O, NAD PULM: CTAB ABD: Soft, nontender, nondistended. No palpable masses. Large abrasion on the RLQ healing well. EXTR: RUE with orthoplast spint and external fixator. Pin sites with minimal errythema and no drainage. Minimal swelling with good distal pulses. RLE with moderate edema, soft compartments, strong DP and TP pulses. RLE warm and pink. Pertinent Results: Labs on admission: Lactate:2.2 140 105 16 -------------< 135 3.8 23 0.9 24.3 > 45.8 < 294 N:90 Band:0 L:6 M:3 E:0 Bas:0 Metas: 1 PT: 11.9 PTT: 25.0 INR: 1.1 ABIs (off traction): 0.49 (right) - 0.9 (left) [**2200-3-27**] 03:50PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2200-3-27**] 03:50PM URINE RBC->182* WBC-25* BACTERIA-NONE YEAST-OCC EPI-0 [**2200-3-27**] 03:50PM URINE RBC->182* WBC-25* BACTERIA-NONE YEAST-OCC EPI-0 [**2200-3-27**] 03:50PM URINE MUCOUS-RARE [**2200-3-27**] CT RUE: 1. Minimally displaced ulnar styloid fracture. 2. Fracture of the proximal pole of the pisiform bone. 3. Comminuted fracture of the trapezoid bone. 4. Fracture of the base of the hook of hamate. 5. Fracture of the base of the index finger metacarpal. 6. Comminuted fracture of the proximal shaft of the middle finger metacarpal. 7. Comminuted fracture of the mid shaft of the ring finger metacarpal. 8. Intra-articular comminuted fracture at the base of the small finger metacarpal. 9. Intra-articular fracture of the base of the middle phalanx, ring finger. 10. Subcutaneous edema and soft tissue swelling consistent with recent trauma. [**2200-3-27**]: CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS 1. Stable appearance of segment VI liver laceration and liver contusion. 2. Hemorrhagic fluid within the right paracolic gutter. 3. Stable enlargement of the right psoas muscle with multiple foci of air suspicious for right psoas hematoma. 4. Completely displaced fracture of the right mid femur. 5. Thrombus and small dissection within the right common femoral artery. The remainder of the visualized vessels are patent. 6. Hematoma surrounding the right common femoral artery, right SFA and right and left popliteal arteries. [**2200-3-27**] CT RLE: Right Mid Shaft Femur Fracture [**2200-3-30**] Chest x-ray: No evidence of chest tube or pneumothorax. Opacification at the right base medially persists. Remainder of the lungs is essentially clear. Labs at discharge: [**2200-4-3**] 04:46AM BLOOD WBC-9.9 RBC-3.51*# Hgb-10.6*# Hct-32.1*# MCV-92 MCH-30.1 MCHC-32.9 RDW-17.2* Plt Ct-301 [**2200-4-1**] 04:54AM BLOOD Glucose-100 UreaN-13 Creat-0.6 Na-140 K-3.5 Cl-102 HCO3-29 AnGap-13 [**2200-4-1**] 04:54AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 Brief Hospital Course: Mr [**Known lastname 185**] was admitted to the trauma ICU given the complexity of his injuries and need for frequent vascular checks of his right lower extremity. In brief during his ICU stay, he went to the OR HD 2 for fixation of his right hand and thigh, then was transferred to the floor HD 3. His hospital course is summarized below by system. Neurologic: He remained alert and oriented. Pain control was achieved with a dilaudid PCA initially, and he was transitioned to an oral regimen with adequate pain control by discharge. Cardiovascular: Imaging at presentation was consistent with a right CFA filling defect, most consistent with an intimal flap. A vascular surgery consult was obtained. Pulse checks were done Q1 hour which consistently showed a bounding DP/PT pulse (pulse had returned after reducing fracture). An ABI done intra-op [**3-28**] was 0.68, improved from 0.45 the day prior. He was started on a heparin drip (goal PTT 50-70) following fixation of his fractures on [**2200-3-28**]. On [**3-31**] he was transitioned to a lovenox bridge to coumadin. By [**4-2**] his INR was therapeutic and lovenox was discontinued. At discharge his INR is 2.8. Plan is for VNA to draw PT/INR on [**4-4**] and anticoagulation to be monitored by pt's PCP who has been notified. His vital signs were routinely monitored throughout his hospitalization and he remained hemodynamically stable. His hematocrit was checked serially initially given his liver laceration for the first 48 hours, and remained stable. However, he continued to be orthostatic and dizzy when getting out of bed and ambulating with physical therapy. On [**4-2**] he was transfused 2 units of pRBC's and his hematocrit went from 24.6 to 32.1. He was no longer orthostatic or dizzy when ambulating after the transfusion. Pulmonary: On presentation he had a small right pneumothorax with no evidence of rib fracture or pulmonary contusion/hematoma. A small 14Fr pigtail catheter was placed in the ED with good evacuation of the pleural air. The catheter was kept on -20cm H20 suction for 48 hours then removed. His OSH CT scan showed bilateral pulmonary lesions, initally read as contusions, but did not appear consistent with this diagnosis, instead seeming more likely to be infectious in nature. His supplemental oxygen was weaned and his oxygenation remained excellent on room air. Pulmonary toileting was encouraged. He remained without cough, shortness of breath or any further evidence of pneumothorax or an infectious process. Gastrointestinal / Abdomen: He presented with a Grade 1 liver laceration for which no intervention was indicated. Hematocrits were stable further reassuring that his liver had no clinically significant bleed. His diet was advanced to regular on POD#1 which he tolerated without abdominal pain. He was also started on a bowel regimen given the administration of narcotics. He was passing flatus and having bowel movements at discharge. Renal: He presented with hematuria, presumed to be from a blunt renal injury not visually apparent on CT scan. His urine continued to clear and his foley was removed once the hematuria resolved. At discharge he had no further evidence of hematuria and was voiding without difficulty. Musculoskeletal: His right metacarpal fractures were placed in an external fixator. Follow up was scheduled with hand surgery prior to discharge. His right femur fracture was fixed with an intramedullary nail. He remained weightbearing as tolerated on his RLE and weightbearing through a platform crutch on his RUE. Physical therapy and occupational therapy were consulted and work with the patient to progress his mobility status. On [**4-3**] he was cleared for discharge home with home PT and OT at home. ID: His WBC count normalized within 24 hours from 24.3 on admission to 9.7. At discharge he is afebrile without any signs of infection. He was placed perioperatively on prophylactic IV cefazolin, which was discontinued on POD#4. He had recently started on a course of doxycycline as an outpatient per pt history for treatment of chlamydia. The course was continued when tolerating PO's and he was discharged with a prescription for 2 more days to complete a 7 day course. On [**4-3**] he remains afebrile without any evidence of infection and stable vital signs. He is ambulatory with assistance and his pain is well controlled on an oral regimen. He is tolerating a regular diet and voiding without difficulty. His INR is therapeutic on coumadin and he continues to have good peripheral pulses, sensation and color in his RLE. He is being discharged home with scheduled follow up with his PCP, [**Name10 (NameIs) 2536**], ortho, and vascular. Medications on Admission: none Discharge Medications: 1. Outpatient Lab Work Please draw PT/INR on [**4-4**] and as needed per patient's PCP [**Name Initial (PRE) 19009**]. Fax results to: [**Name Initial (PRE) **],GOSLYN R, Location: [**Location (un) **] MEDICAL Address: [**Street Address(2) **]., NO. [**Location (un) **],[**Numeric Identifier 21771**] Phone: [**Telephone/Fax (1) 82227**] Fax: [**Telephone/Fax (1) 110076**] 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. warfarin 5 mg Tablet Sig: 0.5 Tablet PO once a day: Take 2.5 mg on [**4-3**]. Dose to be adjusted for goal INR [**1-17**]. Dr.[**Name (NI) 110077**] office to adjust dosing as needed. Disp:*30 Tablet(s)* Refills:*1* 5. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Dosing to be adjusted by Dr. [**Last Name (STitle) **] for goal INR [**1-17**]. Disp:*30 Tablet(s)* Refills:*1* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 days. Disp:*4 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: s/p motorcycle crash Inujuries: 1. Right midshaft femur fracture, closed 2. Right common femoral artery dissection 3. Right pneumothorax 4. Grade I liver laceration 5. Minimally displaced ulnar styloid fracture 6. Right 2nd, 3rd, 5th carpometacarpal fracture- dislocations. 7. Right 4th metacarpal shaft fracture. 8. Trapezoid fracture. 9. Hook of hamate fracture. 10. Fracture of the proximal pole of the pisiform bone 11. Acute Blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after motorcycle accident. You sustained multiple injuries including multiple broken bones in your right hand and wrist, right femur fracture, dissection of your right femoral artery, a collapse in your right lung and a small laceration to your liver. You were taken to the operating room with the hand surgeons and orthopedic surgeons to fix your fractures. You had a chest tube placed to pull your lung back up and you have no evidence on x-ray of remaining collapse. You also have no evidence of bleeding from your liver injury. Because of the dissection in your artery, the vascular surgeons recommend that you be on a blood thinning medication called coumadin (warfarin) for 3 months. You will need to have your blood work checked frequently in the first couple of weeks while taking coumadin. You should take this medication at the same time every day. Your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] has been notified of this. The VNA will draw you lab work tomorrow and send the results to Dr.[**Name (NI) 110077**] office, who will contact you and adjust the dosing of the coumadin as needed. It is important that you keep your follow up appointments as scheduled below and that you see your PCP next week. You are being discharged on narcotic pain medication. Narcotic medications can cause constipation. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. Narcotic medications also cause sedation so you should not drink alcohol or drive while taking narcotics. Followup Instructions: PCP [**Name Initial (PRE) **]: Tuesday, [**4-8**] at 1:30pm With:GOSLYN [**Name Initial (MD) **] [**Name Initial (MD) **],MD Location: [**Location (un) **] MEDICAL Address: [**Street Address(2) **]., NO. [**Location (un) **],[**Numeric Identifier 21771**] Phone: [**Telephone/Fax (1) 82227**] Department: ORTHOPEDICS When: TUESDAY [**2200-4-15**] at 12:20 PM 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 [**2200-4-15**] at 12:40 PM 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: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2200-4-22**] at 2:15 PM With: ACUTE CARE CLINIC/DR.[**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: Vascular Surgery When:PENDING With:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] Phone: [**Telephone/Fax (1) 1393**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage ***We are working on a follow up appt in the Vascular department with Dr. [**Last Name (STitle) 1391**]. You will be called at home with the appointment. If you have not heard with in 2 business days from your discharge or have questions, please call the above number. Completed by:[**2200-4-3**]

[ "867.0", "815.03", "814.06", "079.98", "814.04", "813.43", "814.08", "891.1", "959.4", "904.0", "860.0", "864.12", "E823.2", "821.01", "285.1", "599.71" ]

icd9cm

[ [ [] ] ]

[ "79.15", "79.03", "78.14", "79.13", "77.67", "34.04", "84.71", "93.44" ]

icd9pcs

[ [ [] ] ]

11385, 11468

5319, 10014

319, 822

11965, 11965

2995, 3000

13867, 15697

1860, 1878

10069, 11362

11489, 11944

10040, 10046

12148, 13844

1893, 2575

2589, 2976

263, 281

5024, 5296

850, 1693

3014, 5004

11980, 12124

1715, 1747

1763, 1844

16,637

133,896

52708

Discharge summary

report

Admission Date: [**2122-7-14**] Discharge Date: [**2122-7-20**] Date of Birth: [**2081-11-7**] Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: This is a 40-year-old male found down [**Location (un) 108737**]with apparent facial trauma. The patient was unresponsive at the scene and intubated by EMS secondary to a GCS of less than 8. The patient did have spontaneous respirations and lower extremity movements noted. The patient was transported, boarded and collared in the Emergency Room. The patient was noted to be moving his left upper extremity and right foot spontaneously with a GCS for reevaluation at 7+. While in the Emergency Room, the patient received a CT of the head, neck, abdomen and pelvis and a chest x-ray. A chest x-ray revealed no pneumothorax. CT of the neck showed no fracture, dislocation. CT of the abdomen and pelvis showed no intra-abdominal pathology. Most notable was a CT of the head which showed extensive facial bone injuries, including displaced fractures of the anterior and posterior left maxillary walls, lateral orbital wall, orbital floor, possibly the medial orbital wall. There is extensive hemorrhage inferiorly within the left orbit causing superior displacement of the inferior rectus muscle and exophthalmos with an intact globe. There was, however, no evidence of intracranial hemorrhage or mass effect. At this point, the patient was admitted to the SICU under the trauma service for continued care with consultation of the ophthalmology service and plastic surgery. The patient's initial past medical history and past surgical history was unknown. On extubation, past medical history of severe hypertension noted. The patient is a homeless gentleman with severe alcoholism and history of DTs and polysubstance abuse. MEDICATION: 1. Atenolol, unknown dose ALLERGIES: LATER NOTED TO BE PENICILLIN, FOR WHICH THE PATIENT DEVELOPS HIVES. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Temperature 98.8??????, pulse of 120, blood pressure 170/palpation, 20 and 98% on vent of 600 x 12. GENERAL: The patient was intubated. Patient with extensive facial trauma, left facial ecchymosis, edentulous. HEAD, EARS, EYES, NOSE AND THROAT: Tympanic membranes were clear bilaterally. Right pupil was minimally reactive and sluggish. Left pupil 6 mm and reactive. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, pelvis stable. EXTREMITIES: Without palpable deformities, pulses distally 2+ bilaterally, warm. RECTAL: Tone was normal. BACK: No apparent stepoff. NEUROLOGIC: Patient with spontaneous left hand movements. ADMISSION LABS: The patient had a white count of 8, hematocrit of 44, platelets of 161. Sodium of 142, potassium of 4.1, chloride of 102, bicarbonate of 20, BUN of 7, creatinine of 0.6, sugar of 166. Fibrinogen was 348. Amylase was 176. Arterial blood gases was 7.57, 24, 544, 23 and +2. Urine toxicology had an alcohol level of 361. HOSPITAL COURSE: The patient was admitted to the SICU intubated for further evaluation. The patient's main issues were his multiple left facial fractures. On hospital day #2 the patient was extubated. The patient received an urgent ophthalmology evaluation, at which point a lateral canthotomy was performed due to increased intraocular pressure and orbital pressure and the concern of entrapment. On hospital day #2, the patient continued with pain and pressure of the eye and complaints of withdrawal. The patient was placed on the CIWA scale with Ativan to prevent DTs. After the lateral canthotomy was performed, the patient was placed on timolol and Diamox to decrease intraocular pressure. The patient was followed by plastics for the extensive orbital fractures, but ultimately felt that outpatient management of these fractures could be performed. On hospital day #3, the spine service was consulted for spinal clearance and an MRI of the neck was performed. The MR of the cervical spine showed suspicion for intraligamentous injury of the interspinous ligaments of T2 to T3. In addition, a superficial paraspinal muscular injury extending to the subcutaneous space at the T2-T3 level, however no cord compression was seen. An MR of the head was also performed at this time which showed no evidence of subarachnoid hemorrhage. The area of trauma showed extensive soft tissue and bony facial injuries with displaced fractures of anterior and lateral maxillary sinuses. Left sided exophthalmos again noted. Ophthalmology continued to follow the patient. The patient was continued on Xalatan to left eye q hs, Alphagan to left eye b.i.d. and Timoptic to both eyes b.i.d. On hospital day #4, there is still no evidence of entrapment, although the patient continued with limited extraocular movements due to swelling. His vision remained intact. He did, however, have left sided nose numbness. At this point, the patient was seen by the orthopedic service and recommended [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**] brace for ligamentous injury at T2 to T3. The patient will then follow up with the orthopedic service in two to three weeks. He is to call ([**Telephone/Fax (1) 108738**] for an appointment. As for the facial fractures, the patient will follow up at the Plastic Surgery service at [**Telephone/Fax (1) **]. The patient did remain on clindamycin for a facial fracture and this will continue for a total of a 10 day course. At the time of discharge, the patient is planning on going to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. Follow up will be as above. The patient will also follow up with the trauma surgery service on Thursday. Call [**Telephone/Fax (1) **] for appointment. Final ophthalmology recommendations are pending at this time. DISCHARGE MEDICATIONS: 1. OxyContin 20 mg po q 12 hours 2. Colace 100 mg po bid 3. Lopressor 25 mg po bid 4. Clindamycin 400 mg po qid x3 more days 5. Percocet 5/325 1 to 2 tablets po q4h prn Ophthalmologic medications pending at this time and will be on page 1. FOLLOW UP: As above. The patient will be discharged to the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 34926**] MEDQUIST36 D: [**2122-7-20**] 08:24 T: [**2122-7-20**] 10:12 JOB#: [**Job Number 108739**]

[ "802.0", "847.1", "E960.0", "801.06", "305.00", "958.8", "401.9", "291.81", "802.6" ]

icd9cm

[ [ [] ] ]

[ "08.51" ]

icd9pcs

[ [ [] ] ]

5853, 6100

3000, 5830

6112, 6514

168, 1939

2659, 2982

1953, 2642

30,547

134,271

50135

Discharge summary

report

Admission Date: [**2164-6-27**] Discharge Date: [**2164-6-30**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: 85 year old male with myelodysplastic syndrome, HTN, started on hydroxyurea yesterday based on evidence for worsending MDS versus conversion presents with slurred speech and headache. He was at dinner last night and liquids were draining out of the left side of his mouth. He spoke to his son on the telephone and his speech sounded slurred. He went to bed and was up coughing all night and noted a frontal headache. Awoke this morning with continued slurred speech. Called his PCP with these symptoms who suggested taking three aspirin. Head CT in the ED reveals right frontal epidural vs. subdural hemorrhage with subdural spread over the right posterior tentorium. He was taken off aspirin within the last few weeks by his PCP for easy bruising. Past Medical History: Gout Pacemaker ([**2157-12-27**]) with LBBB after ?silent MI [**75**] yrs ago MOHS procedure right eyebrow on [**2160-6-26**] for squamous cell cancer. Dermatologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] at [**Hospital3 5097**] monitors his skin every 6 months, using cyrotherapy for actinic keratoses. T1b prostate cancer detected incidentally on prostatectomy for BPH in [**2156-1-20**], followed by Dr. [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] Pneumonia in [**2156-10-14**]. Cystitis in [**2141**] Mild hydronephrosis with chronic renal insufficiency and creatinines in the 1.5 to 1.7 mg/dL range Right hernia repair in [**2143**] History of adenomatous and Hyperplastic polyps in [**2156**] (last colonoscopy in [**2160**]) HTN Social History: EtOH (2 glasses of wine per day), remote cigarette use many years ago. Family History: Father, "liver cancer," age 79. Mother, "leaky heart valve," age 89. Sister, "pancreatic cancer," 50. No known history of hematologic dyscrasias. Physical Exam: T 99.2, HR 72, BP 156/60, R 18, Sat 96% RA Gen- well appearing, NAD HEENT: NCAT, anicteric, OP clear, MMM Neck- no carotid bruits CV- RRR, no MRG Pulm- expiratory wheezes on left chest. ABd- soft, nt, nd, BS+ Extrem- SC ecchymosis, chronic venous changes in bilat LE. warm, well-perfused. MS- alert, oriented to person, place, date, speech is notable for labial dysarthria, naming, repitition intact. interprets cookie theft picture without neglect. He is attentive. CN- PERRL 4--2mm, EOMI, fundi flat wihtout hemorrhages, VFF to confrontation, left NL effacement, facial sensation symm, palate eleavtes symm, hearing intact bilat, SCM trap [**4-16**] bilat. Motor- no pronator drift, no adventitious movements. He has giveaway weakness at his IP's bilaterally, but is otherwise full strength at delt, [**Hospital1 **], tri, WE, FE, IP, Q, H, TA, PF, [**Last Name (un) 938**]. Sensory- intact to LT, PP, vibration, proprioception. Reflexes- 2+ symmetric [**Hospital1 **], tri, brachiorad, patellar, absent ankle jerk. Left toe is upgoing. Right toe down. Gait- not tested given intracranial hemorrhage. Pertinent Results: [**2164-6-29**] 06:18AM BLOOD WBC-132.1* RBC-2.72* Hgb-9.4* Hct-29.6* MCV-109* MCH-34.6* MCHC-31.8 RDW-17.9* Plt Ct-125* [**2164-6-29**] 06:18AM BLOOD Plt Ct-125* [**2164-6-28**] 04:02AM BLOOD Fibrino-579* [**2164-6-29**] 06:18AM BLOOD Glucose-82 UreaN-23* Creat-1.9* Na-142 K-3.5 Cl-104 HCO3-25 AnGap-17 [**2164-6-27**] 08:00AM BLOOD cTropnT-0.01 [**2164-6-29**] 06:18AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2 [**2164-6-29**] 06:18AM BLOOD Phenyto-3.5* Brief Hospital Course: Mr [**Known lastname 31102**] was admitted to the ICU for close neurological checks his speech worsened on admission to the ICU but otherwise he remained stable. His coumadin was reversed with FFP, vit K, and plts. His blood pressure was kept below 140. On hospital day number 1 he had a repeat head CT stable, less mass effect and a CTA which showed no dural AV fistula. On hospital day three his speech was much improved he was transferred to the neurosurgery floor. Hematology recommended Vitamin K PO to reverse his INR. He had no motor deficits and he passed a speech and swallow eval. On [**6-29**] he was seen by PT who felt he would be safe to go home on [**6-30**]. Medications on Admission: Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety, insomnia. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily Discharge Medications: keppra 500 mg po bid x 7 days Discharge Disposition: Home Discharge Diagnosis: Myelodsyplastic Syndrome Right Subdural Hematoma Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 4 weeks with head CT, call [**Telephone/Fax (1) 1669**] Completed by:[**2164-6-30**]

[ "585.9", "432.1", "403.90", "426.3", "V10.46", "414.01", "238.79", "238.75", "274.9", "V45.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5048, 5054

3766, 4443

282, 289

5147, 5171

3293, 3743

6206, 6340

1995, 2144

4994, 5025

5075, 5126

4469, 4971

5195, 6183

2159, 3274

227, 244

317, 1071

1093, 1890

1906, 1979

25,406

143,444

44049

Discharge summary

report

Admission Date: [**2181-2-10**] Discharge Date: [**2181-2-15**] Date of Birth: [**2119-2-19**] Sex: M Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 5368**] Chief Complaint: Severe left flank pain, LLL PNA Major Surgical or Invasive Procedure: None History of Present Illness: HPI:: 61 YO man with h/o COPD, hepatitis, IVDU (distant) whoe presented to [**Hospital1 18**] after experiencing shortness of breath and severe rib/flank pain. the pain came on suddenly at midnight while sleeping. He was seen by his pulmnologist Dr. [**Last Name (STitle) **] approximately 4 days ago who prescribed telithromycin (ketec) for presumed pneumonia given increaed sections. The secretion have since resolved. Yeterday he did very heavy exercising including upside down push ups, chin upts. He felt to be in his usual state of health and went to sleep without symptoms. He woke up at midnight with sharp, aching pain on his left side. He could not take deep breaths and had difficulty moving around. This morning he had chills which were relieved by motrin and a sweat shirt. He denies any headaches, diarrhea, nausea, vomitting or abdominal pain. Past Medical History: Hypertension, IVDU, COPD Social History: Lives at home, history of Etoh, 30yrs tobacco quit [**2172**] Family History: NC Physical Exam: VS 99.8 84 98/60 20 96%RA Gen: Pleasant elderly male in NAD HEENT: PERRL, MMM, scleara anicteric Neck: No lymphadenopathy CV: nl s1s2 rrr no mrg Chest [**Month (only) **]. BS at L base Pertinent Results: CT CHEST W/O CONTRAST [**2181-2-11**] 4:54 PM CT CHEST W/O CONTRAST Reason: pt with left hilar mass on CXR; please evaluate for pericard Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 61 year old man with hx of COPD, tobacco abuse who presents with left chest pain, shortness of breath, hypotension REASON FOR THIS EXAMINATION: pt with left hilar mass on CXR; please evaluate for pericardial involement as etiology of hypotension CONTRAINDICATIONS for IV CONTRAST: ARF PROCEDURE: Chest CT without contrast. HISTORY: 61-year-old man with history of COPD, tobacco abuse who presents with left chest pain, shortness of breath and hypertension, please evaluate for pericardial involvement as etiology of hypertension. There are no prior cross-sectional studies available for comparison. TECHNIQUE: Multidetector CT images throughout the chest without contrast. CT OF THE CHEST WITHOUT IV CONTRAST: Important emphysematous changes are seen throughout both lungs with some small areas of scarring in both upper lungs. There is diffuse consolidation opacity throughout the medial and posterior basal segments of the left lower lobe associated with small left pleural effusion consistent with diffuse pneumonia. There is no evidence to suggest focal mass. The heart, pericardium and great vessels are unremarkable. There are no pathologically enlarged axillary or mediastinal lymph nodes. The airways are patent. Very limited axial imaging throughout the upper abdomen demonstrates no abnormalities. BONE WINDOWS: There are no concerning bone lesions. Mild degenerative changes are seen throughout the spine. IMPRESSION: 1. Left basal pneumonia with small quantity of left pleural effusion. 2. Important emphysematous changes throughout the rest of the pulmonary parenchyma [**2181-2-10**] Echocardiagram Findings: LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting tachycardia (HR>100bpm). Emergency study performed by the cardiology fellow on call. Conclusions: The left atrium is normal in size. The left ventricular cavity size is normal. Views are technically suboptimal for assessment of systolic function (grossly preserved). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricle may be dilated. There is no pericardial effusion. [**2181-2-10**] 09:27AM URINE HOURS-RANDOM CREAT-81 SODIUM-67 [**2181-2-10**] 09:27AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2181-2-10**] 09:27AM URINE RBC-0-2 WBC-[**12-17**]* BACTERIA-FEW YEAST-MOD EPI-[**7-7**] TRANS EPI-[**12-17**] RENAL EPI-[**4-1**] [**2181-2-10**] 07:30AM GLUCOSE-95 UREA N-32* CREAT-2.1*# SODIUM-138 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-19* ANION GAP-17 [**2181-2-10**] 07:30AM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.4* [**2181-2-10**] 07:30AM WBC-12.2* RBC-4.30* HGB-13.8* HCT-37.7* MCV-88 MCH-32.1* MCHC-36.6* RDW-13.7 [**2181-2-9**] 10:21PM LACTATE-1.5 [**2181-2-9**] 10:19PM NEUTS-87.8* BANDS-0 LYMPHS-7.8* MONOS-3.6 EOS-0.3 BASOS-0.6 [**2181-2-9**] 10:19PM PLT COUNT-181 Brief Hospital Course: 61 YO with history of COPD, HTN, p/w LLL PNA and left sided pain LLL PNA- He was admitted with shortness of breath and productive cough. He initially was being treated with telithromycin but noted no improvement. The patient on admission showed progression of pneumonia on his admission xray. He was started on ceftriaxone and azithromycin. Ultimately his sputum culture grew out MRSA and he was started on vancomycin. Blood cultures were taken and were all negative at time of discharge. The following day after admission, he developed hypotension and associated shortness of breath. He had increasing oxygen requirements and was transferred to the unit. There was no indications of pericardial tamponade or pulmonary embolism noted on his ABG or ekg. He blood pressure was stabilized in the unit, and he was transferred back to the floor where, he treated solely with vancomycin and nebulizers with good improvement in his respiratory status with decreasing oxygen requirements and he was weaned to room air. He was discharged with a total 14 day course of antibiotics, he was discharged with linezolid. Leukocytosis- This was likely associated with his pneumonia and returned to baseline limits at time of discharge. ARF: This was likely prerenal as with hydration it returned to a baseline 0.9. Although his FeNA was 1.26 not suggestive of a prerenal acute renal failure. Hypotension: On the floor, pt's initial BP was 100/70 with a HR of 116. Over the next few hours, his BP dropped to 80s/40s with an increase in his heart rate to the 130s. An EKG showed sinus tach with low voltage. He was given 2.5L of NS and BP response was poor. It remained in the 70s-80s for the next several hours and pt was transferred to the ICU for further care. In CCU, SBP 110, given 3L IVF (total 4-5 L during MICU stay.) There was no demonstration of pericardial tamponade on echocardiagram and after his blood pressure was stabilized he was returned to the floor with no more episodes of hypotension. COPD- He was continued on his outpatient regiemtn of flovent, albuterol and spiriva. Medications on Admission: Telithromycin (ketec), zestril 10mg, flovent, albuterol, spiriva Discharge Medications: 1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO qd () for 1 days. Disp:*3 Tablet(s)* Refills:*0* 2. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO qd () for 3 days: Start on [**2181-2-17**]. Disp:*9 Tablet(s)* Refills:*0* 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 3 days: [**2181-2-20**]. Disp:*3 Tablet(s)* Refills:*0* 4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:*22 Tablet(s)* Refills:*0* 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 unit* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia MRSA Discharge Condition: Stable Discharge Instructions: If you experience increased shortness of breath, fevers, chills or other concerning symptoms please call your PCP Please take your medications as instructed Please follow up with the doctors listed below Followup Instructions: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] at [**2181-2-22**] 1:40pm Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**] Date/Time:[**2181-3-13**] 3:00 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2181-5-7**] 9:15 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2181-5-7**] 9:35

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icd9cm

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35355

Discharge summary

report

Admission Date: [**2135-3-22**] Discharge Date: [**2135-4-4**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Headaches Major Surgical or Invasive Procedure: [**3-25**] lumbar drain placment [**3-28**] posterior neck csf collection fine needle aspiration [**3-28**] picc line placment History of Present Illness: 84yo RH M who was admitted to neurosurgical service in [**2-6**] after posterior fossa subdural hematoma, evacuated by suboccipital crani, course complicated by PNA, CSF leak (no intervention) and dysphagia/aspiration requiring PEG, who has been in rehab since. On [**3-21**], he was febrile to 100.4 and started on vanco/levaquin for UTI (pseudomonas). His son reports that he has been unable to walk since [**Month (only) 956**] and sundowns nightly. He has noted no new deficits. Two days ago, however, in the absence of trauma or HTN, the patient reported new onset headache that was bifrontal and throbbing. It has not woken him from sleep. He denies diplopia or new deficits. He does not recall how quickly it came on. Today, he was noted in rehab to be more "confused" and had copious amount of clear drainage on his pillow. He was sent here for ? CSF leak. Head CT showed "Acute parenchymal hemorrhage right frontal cortex, measuring 18x13mm, with mass effect on anterior [**Doctor Last Name 534**] of right lateral ventricle and overlying sulci. No fracture. No midline shift." Past Medical History: Mitral valve regurgitation with prosthetic heart valve ([**Hospital 10014**]) Pacemaker Gastric ulcer CHF HTN Aortic valve insufficiency Hyperlipidemia Social History: Widowed Power of attorney Nephew Family History: Noncontributory Physical Exam: PE VS 98.2 125/75 84 18 97% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity. I do not appreciate any drainage at the incision site Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Oriented only to self. Months of the year backwards were impaired. Speech fluent, with normal naming, [**Location (un) 1131**], comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Interprets cookie theft picture appropriately. No dysarthria. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-3**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. No pronator drift D B T WE FE FF IP Q H DF PF TE L 4+ 5 4+ 5 5 5 5 5 5 5 5 5 Sensory intact to light touch, pinprick throughout. No extinction to double simultaneous stimulation. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2 2 2 2 1 down R 2 2 2 2 1 down Coordination Fine finger movements, rapid alternating movements, finger-to-nose, and heel-to-shin were all normal Gait deferred Pertinent Results: Admition: IMPRESSION: 1. New right inferior frontal intraparenchymal hemorrhage measuring up to 18 mm, with surrounding edema and mild mass effect. 2. Interval increase in fluid collection adjacent to the sub-occipital craniotomy site, likely tracking to the skin surface, although incompletely imaged. Fluid collection has the same attenuation as the posterior fossa CSF and is suspicious for a CSF leak. Alternatively, this could represent a postoperative seroma. 3. No change in size of ventricles. [**2135-4-4**] 05:51AM BLOOD WBC-6.6 RBC-2.73* Hgb-8.8* Hct-25.5* MCV-93 MCH-32.3* MCHC-34.6 RDW-14.6 Plt Ct-257 [**2135-4-4**] 05:51AM BLOOD Neuts-65.9 Lymphs-19.2 Monos-9.9 Eos-4.4* Baso-0.6 [**2135-4-4**] 05:51AM BLOOD Plt Ct-257 [**2135-4-4**] 05:51AM BLOOD Glucose-118* UreaN-16 Creat-0.7 Na-138 K-4.5 Cl-102 HCO3-28 AnGap-13 [**2135-3-27**] 04:20AM BLOOD CK(CPK)-18* [**2135-3-27**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2135-4-4**] 05:51AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.3 [**2135-3-30**] 08:42AM BLOOD Vanco-20.6* Brief Hospital Course: Two days prior to admition, in the absence of trauma or HTN, the patient reported new onset headache that was bifrontal and throbbing. It has not woken him from sleep. He denies diplopia or new deficits. He does not recall how quickly it came on. He was noted in rehab to be more "confused" and had copious amount of clear drainage on his pillow. He was brought to [**Hospital1 18**] for evaluation. On primary eval it was discovered that he also had a He was sent here head CT showed "Acute parenchymal hemorrhage right frontal cortex, measuring 18x13mm, with mass effect on anterior [**Doctor Last Name 534**] of right lateral ventricle and overlying sulci. No fracture. No midline shift." Also noted was clear drainage from his previous posterior fossa craniotomy drainage, presumably CSF. An LP was performed to evaluate whether the patient had any signs of meningitis prior to placing a VP shunt for hydrocephalus. The cell count of the tap was questionable for meningitis with no growth on gram stain. Infectious disease was consulted and the patient was placed on broad spectrum coverage to treat meningitis which completed on [**4-2**]. With continued leaking from the posterior fossa, Dr. [**First Name (STitle) **] aspirated fluid from the area of the CSF leak, which was sent for cultures as well, and a lumbar drain was placed for a period of five days to divert CSF flow and allow for wound closure. CSF leak from the posterior incision stopped. Patients mental status declined over the course of his ICU stay to the point where he no longer opened his eyes to voice and was not following commands. A CT of the head did not reveal any new area of hemorrhage or stroke. Pt. was started on a heparin drip for anticoagulation for his mechanical heart valve during his ICU stay. On [**3-30**] lumbar drain was discontinued. Geriatrics was consulted to review causes for the altered mental status. In depth conversation with the patient's power of attorney, [**First Name8 (NamePattern2) **] [**Known lastname **], led us to make change the patient's code status to DNR/DNI. Antibiotics continued through [**4-2**] for full coverage of meningitis. He was transitioned to coumadin. Plan is to continue with anticoagulation and home meds and observe the patient's mental status off antibiotics to see if there is an improvement in mentation. Palliative medicine is involved at this time with the care of this patient Mr [**Known lastname **] began to slowly wake up over 4-5 days prior to discharge, we are unsure if this is related to stopping medications. Prior to discharge he was orientated to name, year, antigravity in all extremities and followed commands and answered questions. Medications on Admission: MEDS: ASA 81 Coumadin Bisacodyl prn Catapres 0.2mg PG TID Colace 50mg PG [**Hospital1 **] Enoxaparin 80mg [**Hospital1 **] Feosol 300mg PG daily Lasix 60mg [**Hospital1 **] Hydral 20mg q6 Levaquin 500mg IV daily ([**3-20**]- Vancomycin 1g IV daily ([**3-20**]- Reglan 10mg q6 Metoprolol 50mg TID Omeprazole 20 Prazosin 1mg [**Hospital1 **] Senna Zocor 20 Discharge Medications: . 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal HS (at bedtime) as needed. 3. Prazosin 1 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Hydralazine 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection ASDIR (AS DIRECTED). 9. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 10. Warfarin 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TODAY AT 1700 (): Daily dosing. Tablet(s) 11. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [**Last Name (STitle) **]: One (1) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Right frontal intracranial hemorrhage ? CSF leakage Discharge Condition: Neurologically stable Discharge Instructions: . General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: . Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr [**First Name (STitle) **] in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2135-4-4**]

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2181-6-7**] Discharge Date: [**2181-6-19**] Date of Birth: [**2102-11-4**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 689**] Chief Complaint: weakness, fever . Major Surgical or Invasive Procedure: Central line s/p fiberoptic intubation History of Present Illness: This is a 78 year old man with a history of multiple CVAs with right side weakness who presented to the ED on [**2181-6-8**] complaining of weakness x 3 days. He also complained of abdominal pain which he has had in the past with a negative workup. He denied N/V/D. . In the ED, abdominal CT scan revealed some diverticulosis but otherwise no explanation for his abdominal pain. He had a fever to 101.1 in the ED and was admitted to Medicine for workup of his weakness/fever/abdominal pain. In the ED, he was started on empirical levo and flagyl and blood cultures were drawn. a U/A, and CT abdomen/pelvis were negative. CXR showed mild fluid overload and enlarged heart, and CT of his head was neg for new pathology. He had a neuro consult that demonstrated no neurological changes from baseline. The patient had a ground level fall in the ED, and a repeat CT scan of the head showed no bleeding. Past Medical History: hypertension s/p CVA (mulitple, large R ischemic CVA, multiple small CVAs in white matter) h/o HOCM by last echo seizures hyperlipidemia s/p hip fracture anemia ? hx of hyperglycemia Chronic low back pain s/p laminectomy migraines depression Social History: -lives with wife -smokes one cigar per day -no alcohol use -worked in sales Family History: -both parents with CAD Physical Exam: VS:T:99.0 BP:130/82 HR:80 RR:16 O2sat:95%RA gen: mildly confused elderly man in NAD. difficulty sitteing up on own HEENT: EOMI, PERRLA, some L facial droop. Oropharynx: mild erythema Ears: TMs clear bilaterally. Some erythema in canal in R ear. Neck: no JVD Chest: Lungs CTA Heart: distant heart sounds, RRR, no murmur Abd: soft, non-distended, +BS, mildly tender to palpation periumbilical. No rebound, no guarding, no hepatosplenomegaly. Ext: [**4-13**] motor strength in all extremities. Decreased DTRs L side. Mild facial drop L side. Pertinent Results: CT head:No evidence of intracranial hemorrhage or mass effect. Chronic changes. Stable appearance compared to [**2181-5-14**]. CT A/P:Diverticulosis without evidence of diverticulitis. No explanation seen for the patient's acute abdominal pain KUB: Normal bowel gas pattern without evidence of obstruction. CXR:Mild CHF/volume overload. No evidence of pneumonia CT chest: 1. No evidence of pulmonary embolism or aortic dissection. 2. Small bilateral pleural effusions and associated bibasilar atelectasis. The effusions are new since the prior chest CT in [**2179**]. 3. Coronary arterial calcification. The study was not performed using gated technique. ECHO: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic systolic function (EF>75%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). There is systolic anterior motion of the mitral valve leaflets with a moderate resting left ventricular outflow tract obstruction (peak 54mmhg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Severe aortic stenosis is not suggested, but mild aortic stenosis cannot be excluded/possible. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a a very small anterior pericardial effusion with a prominent epicardial fat pad. No hemodynamic compromise is suggested. CT neck: Suboptimal study due to the artifacts from the teeth. No evidence of parotid abscess/stones. Evidence of inflammation in the soft tissues of the neck. . [**2181-6-6**] 03:35PM PT-11.3 PTT-23.3 INR(PT)-1.0 [**2181-6-6**] 03:35PM PLT COUNT-131* [**2181-6-6**] 03:35PM WBC-6.7 RBC-4.10* HGB-13.9* HCT-40.3 MCV-98 MCH-33.9* MCHC-34.5 RDW-13.1 [**2181-6-6**] 03:35PM cTropnT-<0.01 [**2181-6-6**] 03:35PM ALT(SGPT)-20 AST(SGOT)-33 ALK PHOS-85 AMYLASE-41 [**2181-6-6**] 03:35PM GLUCOSE-103 UREA N-18 CREAT-1.0 SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15 [**2181-6-6**] 09:40PM cTropnT-<0.01 [**2181-6-7**] 05:00PM CK(CPK)-74 Brief Hospital Course: # Angioedema/ airway compromise: While on the floor, the pt's throat and cheeks and neck began to swell. Two days later, on [**2181-6-10**], his blood pressure dropped to 50/palp. He was given 3L NS and his BP rebounded to the 80's. However, his O2 sats dropped to 90% on 4L and he was transferred to the ICU for further management of his hypotension/ hypoxia/ angioedema. A CT of the neck was negative for abscess, however soft tissue inflammation was seen. Pt's O2 requirement was felt to likely related to airway compromise from severe facial/neck swelling. He underwent fiber optic intubation for airway protection. He was initially on AC which was weaned to PSV 5/5 and he was successfully extubated on [**2181-6-14**] and comfortable on room air prior to discharge to floor. In terms of his fever/facial swelling, the differential included mumps, adeno, paraflu, parotid duct obstruction, bacterial parotitis, or facial cellulitis. Angioedema also possible given hx of lisinopril (most likely cause), aspirin, and ibuprofen use, combined with eosinophilia. His neck CT findings were not consistent with enlarged parotid glands or severe facial cellulits; hence angioedema seemed most likely. His lisinopril and ASA were stopped because of their penchant (especially lisinopril) for causing angioedema. ENT was also consulted and did not find any obvious sources for his neck swelling. Steroids were held because of concern for infectious etiology (though 1 dose was given; ENT had felt that holding the steroids for use until prior to extubation would be a better strategy). Viral throat cx negative, strep throat cx negative. After his initial neck CT, he had a repeat neck CT on [**6-12**] which showed new stranding in the subcutaneous soft tissues of the posterior neck and occiput consistent with edema. THere was also stranding of soft tissues of the chest, slight stranding near the parotid glands is stable, irregularity of opacification of the left internal jugular vein (probably due to filling artefact as this appears to occur near the entry point of an anterior venous structure), and iterval opacification of the paranasal sinuses with increasing mucosal thickening. Unclear [**Name2 (NI) 100410**] of these findings, as diagnosis still remained uncertain. The filling defect was not a thrombus as confirmed by US. He was initially on steroids, but stopped per ENT as it was felt that the effects of the steroids would be most useful to decrease airway edema prior to extubation. Allergy was consulted who felt that patient should not be continued on lisinopril, but K to restart ASA and dipyridamole. Per dental consult, tooth pathology likely not cause of pt's neck swelling. With Diphenhydramine alone, the patient's edema had started to resolve and his oxygenation and ventilation were appropriate four days after intubate; hence he was extubated without difficulty. On discharge C1 esterase inhibitor, Mumps antibody and C2 was still pending. . # Hypotension: no clear etiology of the pt's hypotension during the initial episode of neck swelling was found. The pt was thought to be hypovolemic and he was thought to have increased intrathoracic pressures due to airway obstruction from the swelling. These two factors were thought to decrease the pt's diastolic filling on which he was largly dependent given his outflow obstruction in the context of HCOM. The pt was treated with Nafcillin, Levo and Flagyl for five days, but antibtiotics were subsequently discontinued as the pt was afebrile and all cultures were negative and no clear source of infection was found. THe pt remained afebrile for four days after discontinuation of the antibiotics. . # Hypoxia: Pt's O2 requirement was felt to likely related to airway compromise from severe facial/neck swelling. He underwent fiber optic intubation for airway protection. He was initially on AC which was weaned to PSV 5/5 and he was successfully extubated on [**2181-6-14**] and comfortable on room air prior to discharge to floor. On CXR, he was found to have a slightly widened mediastinum; a chest CT ruled out dissection. Of note, his CXR was also consistent with pulm edema, likely secondary to aggressive IVF, but did not impair his oxygenation. . # Abdominal pain: no evidence of intrabdominal pathology on CT. POssible in the context of angioedema. Resolved. . # Anemia: Pt hematocrit was trending down in the setting of acute disease. Guaiac negative. No other source of bleeding. Folate and Vit B12 normal. Iron studies consistent with anemia of chronic disease. The pt's hct stabilized with improvement of clinical status, although his reticulocyte count was not adequate. The pt was not on any medications other then Depakote that could explain his anemia, especially no marrow suppressive medications. Further work up should be performed as an outpatient if the pt persists to be anemic. F/u hct recommended within one week. . # Seizures: Continued depakote. THe pt missed a few doses while he was intubated which explains his transiently low valproic acid level. Levels were rising as Depakote was restarted at home dose. F/u level in one week is recommended to ensure adequate levels. . # Rash: The pt developed a mild diffuse rash thought to be secondary to antibiotics which was given when he was hypotensive to treat for sepsis emperically. His rash improved after withdrawing the antibiotics. . # Low back pain-chronic s/p laminectomy. Pt on oxycontin at home, held in the context of hypotension. Not restarted upon discharge as the pt was pain free. . # Code: full Medications on Admission: Ativan 1mg daily depacote 500mg [**Hospital1 **] gemfibrozil 600mg [**Hospital1 **] atorvastatin 40mg daily lisinopril 2.5mg daily neurontin 300mg TID oxycontin 10mg [**Hospital1 **] zoloft 50mg daily aggrenox 1 cap daily Discharge Medications: 1. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. Aggrenox 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap, Multiphasic Release 12 HR PO twice a day. Disp:*60 Cap, Multiphasic Release 12 HR(s)* Refills:*2* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: PRIMARY DX: Angioedema of the throat, tongue and lip Abdominal pain secondary to ?angioedema Hypotension Respiratory failure due to airway obstruction from angioedema Anemia of chronic disease . SECONDARY DX: Chronic low back pain HCOM Discharge Condition: Hemodynamically stable, afebrile, out of bed with assistance. Discharge Instructions: Please take all medication as prescribe. Follow up with all appointments. If you experience any more swelling or difficulty breathing, please call your doctor. Also call your doctor if you have chest pain or shortness of breath. Please make sure you remove all Lisinopril from you medication boxes. You should never again in your live take Lisinopril or any medication from the same class. Followup Instructions: Follow up with your doctor in the week after discharge from rehab: [**Last Name (LF) 10531**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 9347**]. . Other appointments: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2181-8-20**] 12:30 Name: [**Known lastname 16132**],[**Known firstname 133**] Unit No: [**Numeric Identifier 16133**] Admission Date: [**2181-6-7**] Discharge Date: [**2181-6-19**] Date of Birth: [**2102-11-4**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 161**] Addendum: 78 year old man with h/o stroke admitted for weakness, course complicated by angioedema s/p intubation. . # Fever + Leukocytosis: Patient devoloped low grade fever (100.4) the day before discharge. He has no localizing symptoms. UA and CXR is negative. Blood cultures are pending. However he has been having diarrhea during this time. Stool cultures and Cdiff panel were sent. He has been afebrile overnight and this morning and afternoon. Please follow up on stool and cdiff cultures. Cdiff has only been sent once so it will have to be sent twice more to rule out infection. . # Anemia: Normocytic anemia. B12 and Folate normal. Haptoglobin Likely anemia of chronic disease: Iron: 49, calTIBC: 211, Ferritn: 1169, TRF: 162 . # Insulin resistance: His blood sugars has been elevated: fingersticks 115-170. He should follow up as an outpatient. He may benefit from Metformin. . # Aspiration: Per speech and swallow eval by video: he continues to aspirate thin liquids which may be his baseline from his history of strokes. He is currently on a pureed, nectar prethickened liquids diet. He may resume a thin liquid diet on discharge if he chooses to knowning that he will aspirate small amounts. Of note, speech and swallow recommends that all his meds be crushed and given in apple sauce. However, Mr. [**Known lastname **] does not like to have his medications crushed. He understands that he has risks of aspiration that might result in pneumonia and other complications. He should have another swallow video done in two weeks. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 321**] Nursing & Rehabilitation Center - [**Location (un) 322**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**] Completed by:[**2181-6-19**]

[ "285.29", "250.00", "789.04", "780.39", "E942.9", "458.9", "995.1", "783.7", "786.50", "729.89", "438.89", "562.10", "428.0", "425.1", "518.81", "780.6" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14774, 15040

4664, 10237

292, 333

11998, 12061

2256, 2256

12502, 14751

1643, 1667

10510, 11591

11740, 11977

10263, 10487

12085, 12479

1682, 2237

234, 254

361, 1268

2264, 4641

1290, 1533

1549, 1627

2,321

171,365

26085

Discharge summary

report

Admission Date: [**2159-2-2**] Discharge Date: [**2159-2-8**] Date of Birth: [**2095-11-23**] Sex: F Service: HEPATOBILIARY SURGERY SERVICE ADMITTING DIAGNOSIS: Colorectal metastases to the liver. HISTORY OF PRESENT ILLNESS: The patient is a 63-year old female with a history of colon cancer. Underwent a right hemicolectomy on [**2158-7-5**] for an ulcerated poorly differentiated adenocarcinoma. The tumor stage was T3, N2, M1. A liver biopsy at the time of that exploration confirmed metastatic adenocarcinoma consistent with a colonic primary. From a CT scan that was from [**2158-6-26**]; it documented metastatic disease, and she was subsequently treated with 5- FU, leucovorin - and she believes irinotecan and Avastin. On [**2158-6-29**] she underwent a CT of her chest that demonstrated a 3- to 4-mm tiny pulmonary nodule peripherally and posteriorly at the right lung base. A follow-up CT of the abdomen was performed demonstrating that the liver had multiple lesions that were present on a prior examination from [**2158-6-26**] and that all the lesions had increased in size; with the largest located posteriorly in the right lobe and measuring 7 cm. There was 1 new lesion that developed peripherally in the right lobe since her prior study. Dr. [**Last Name (STitle) **] had reviewed the CT scans of her abdomen from [**2158-11-29**] which demonstrated 5 lesions in the right lobe of the liver; with the largest lesion posteriorly abutting the inferior vena cava and splitting the right middle hepatic veins. There appeared to be no extrahepatic disease, and no disease in the left lobe of the liver. She is presently asymptomatic. She denies any fevers, chills, nausea, vomiting, diarrhea or constipation. Her last dose of Avastin was 3 weeks ago. PAST MEDICAL HISTORY: Significant for colon cancer diagnosed in [**2158-6-9**], status post chemotherapy; history of prolapsed mitral valve diagnosed in the [**2142**]; history of osteoporosis diagnosed in [**2157**]. PAST SURGICAL HISTORY: Significant for a right hemicolectomy and liver biopsy on [**2158-7-5**]; status post hysterectomy in [**2152**]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Estradiol 0.5 mg daily. SOCIAL HISTORY: She is married. No children. Works as a full- time librarian. Tobacco: No history of tobacco. No history of IV drug use. No history of tattoos, hepatitis. Alcohol: She has an occasional glass of wine every other day. She has had multiple blood transfusions in the past. PHYSICAL EXAMINATION: Temperature 96.8, blood pressure 120/68, heart rate 84, respirations 16, height 5 feet, weight 101 pounds. The patient is a thin, well-developed, well- nourished female in no acute distress. SKIN: Unremarkable. HEENT: There is scleral icterus. Pupils equal, round and reactive to light. MOUTH: Tongue midline. No exudates. NECK: No lymphadenopathy. No thyromegaly. Carotids 2+/4 without bruits. LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm, normal S1/S2, without murmurs or rubs. ABDOMEN: Positive bowel sounds. No tenderness. No ascites. No hepatosplenomegaly. She has a well-healed lower midline scar, and also a well-healed port site from her laparoscopic colectomy. EXTREMITIES: No peripheral edema, 2+/4 bilaterally. NEUROLOGIC: Exam is unremarkable. LABORATORY DATA: WBC of 5.9, hematocrit of 37.9, platelets of 262. Sodium 139, potassium 4.6, chloride 101, bicarbonate 29, BUN 15, creatinine 0.9. Albumin 4.7, AST 26, ALT 20, alkaline phosphatase 98, total bilirubin 0.4, and a CEA of 140. HOSPITAL COURSE: So, the patient was admitted on [**2159-2-2**]. Preop diagnosis of metastatic colon cancer to the liver. The patient had a right hepatic trisegmentectomy, portal lymph node dissection, cholecystectomy, intraoperative ultrasound performed by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. The patient tolerated the procedure well. Please see operative note for more details. Postoperatively, the patient went to the ICU. The patient was on Unasyn postoperatively, afebrile, vital signs stable. Good I's and O's. The patient had a JP drain in place. On postop day #1, continued to do well, afebrile, vital signs stable, awake, alert. Abdomen soft, mild tenderness. Lungs were clear. Labs with white count of 13.3, hematocrit of 38.9, platelets of 230. Sodium 139, potassium 5.0, chloride 109, bicarbonate 22, BUN 6, creatinine 0.5, with a glucose of 245. INR was 1.3. ALT 596, AST 633, alkaline phosphatase 61, total bilirubin 1.3, albumin 2.0. On postop day #2, the patient was on [**Hospital Ward Name 121**] Ten. JP drain output was 185. Unasyn was discontinued. The patient was started on clears, out of bed, IV fluids were decreased. On [**2159-2-5**] the patient had an ultrasound of her liver demonstrating unremarkable appearance of the remaining liver and intrahepatic vessels, status post trisegmentectomy. Her diet was advanced, out of bed, urinating without difficulty. The patient was transitioned from IV pain medications to p.o. pain medications and doing well. Physical therapy was consulted and felt that the patient was doing well and that she could be discharged home or to the hotel that she was staying for a few days after being discharged. Pain was well controlled. The patient was given intermittent boluses for a low urine output. On postop day #6, the patient continued to be afebrile, vital signs stable. Her JP drain output for 24 hours was [**2177**] since midnight 220. Her labs on [**2159-2-8**] were the following: WBC of 10.3, hematocrit of 42, platelets of 289. Sodium 134, potassium 4.2, chloride 101, bicarbonate 26, BUN 4, creatinine 0.6, with a glucose of 116. AST was 27, ALT was 62, alkaline phosphatase was 74, total bilirubin was 0.7, and albumin was 2.8. Her pathology results are still pending. So, she was doing well overnight. She could potentially be discharged tomorrow. Depending on how her JP drain output is overnight, there may be a possibility of the drain being removed tomorrow and she would be able to go home or to the hotel where she is going to be staying at for a few days. The patient will be going on home on the following medications. DISCHARGE MEDICATIONS: Colace 100 mg twice a day and Vicodin 1 to 2 tablets q.4-6h. p.r.n.. DISCHARGE INSTRUCTIONS: 1. The patient should call ([**Telephone/Fax (1) 3618**] (which is the Transplant Surgery Department) if there is any fevers, chills, nausea, vomiting, inability to take medications; any abdominal pain, jaundice, incision that appears red/bleeding or any purulent drainage. 2. The patient may shower. 3. The patient will have a follow-up appointment with Dr. [**Last Name (STitle) **]. FINAL DISCHARGE DIAGNOSES: Metastatic colon cancer to the liver with a history of metastatic colorectal adenocarcinoma; pathology is still pending. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2159-2-8**] 19:36:06 T: [**2159-2-8**] 20:35:47 Job#: [**Job Number 64734**]

[ "V10.05", "196.2", "197.7" ]

icd9cm

[ [ [] ] ]

[ "40.3", "50.22", "51.22" ]

icd9pcs

[ [ [] ] ]

6253, 6324

2230, 2255

3609, 6229

6348, 6754

2034, 2203

2566, 3591

6782, 7177

249, 1790

183, 220

1813, 2010

2272, 2543

3,510

189,607

5574

Discharge summary

report

Admission Date: [**2198-8-1**] Discharge Date: [**2198-8-7**] Service: HISTORY OF PRESENT ILLNESS: Patient is a [**Age over 90 **]-year-old male who presented to [**Hospital 22428**] Clinic for Mohs revision surgery. Mohs defect was created in the anterior face involving the nasolabial fold on the right cheek. Serial excisions penetrated the SMAS and continued to track along the facial nerve, and Plastic Surgery was called to evaluate the patient for closure. After evaluation of closure, it was deemed the patient would be admitted overnight and brought into the hospital for closure with a cervicofacial flap. DIAGNOSIS: Open wound left cheek and right ear. PAST SURGICAL HISTORY: 1. Basal cell carcinoma. 2. Squamous cell carcinoma. 3. Skin grafts of the legs. 4. Fracture of the femur status post motorcycle accident with a perforated viscus. 5. Left heel surgery, multiple. 6. Status post coronary artery bypass graft in [**2192**]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. Patient does not have diabetes mellitus. MEDICATIONS ON DAILY BASIS: 1. Lipitor. 2. Atenolol. 3. Aspirin. 4. Vitamin E. 5. Lasix. SOCIAL HISTORY: 100-pack years smoking history. He recently quit five years ago. One glass of vodka per day. Three beers per day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: His vital signs are stable. No acute distress. Open wound left cheek and right ear defect. Lungs: Clear to auscultation, however coarse breath sounds at the bases, the right greater than the left. Cardiac: S1, S2, no murmurs, rubs, or gallops were apparent. Abdomen was soft, nontender, nondistended, positive bowel sounds noted. Extremity: Multiple healing scabs in areas of skin breakdown status post multiple skin grafts to arms. Multiple surgeries to left heel with skin graft. IMPRESSION: [**Age over 90 **]-year-old male, history of squamous cell, basal cell carcinoma who needed closure of primary Mohs defect. HOSPITAL COURSE: Patient was admitted on [**2198-8-1**]. Cardiac clearance was needed prior to surgery. Therefore, surgery was delayed after evaluation of chest x-ray, EKG, and preoperative lab. Cardiology clearance was obtained, and patient was operated on [**2198-8-3**]. A cervicofacial flap was performed for closure. Patient received [**2194**] crystalloid and had an estimated blood loss of greater than 250 cc. Please see operative note dictation. Patient continued to improve; however, there was a tenuous area of the cervicofacial flap which was showing rather brisk capillary refill, less than one second at times, and was slightly dusky. This was a small preauricular area which did eventually demonstrate some epidermolysis. However, the remainder of the flap remained viable, warm, with good capillary refill and was doing nicely. It was decided on [**2198-8-6**], that the patientwould meet criteria for discharge from the hospital. However being the patient was rather frail, he would be better served in an acute rehab setting. Physical Therapy was consulted for home safety evaluation and for rehab evaluation. The flap continued to look well, and the patient was without complaint. His [**Location (un) 1661**]-[**Last Name (un) 12828**] continue to function and put out a serosanguineous discharge. No hematomas were noted. The only area of question was the preauricular area in which some epidermolysis was noted. Patient was given some instructions as to follow up with Dr. [**First Name (STitle) **]. An appointment was made for Friday at 9 a.m. in the office, Seventh Floor, [**Hospital Ward Name 23**]. DISCHARGE MEDICATIONS: 1. Furosemide 20 mg tablet q.d. 2. Lipitor 10 mg tablet q.d. 3. Acetaminophen p.r.n. 4. Milk of magnesia p.r.n. 5. Oxycodone. 6. Percocet one to two tablets q. four to six hours p.r.n. 7. Atenolol 25 mg q.d. 8. Colace 100 mg b.i.d. 9. Lorazepam p.r.n. 10. Bacitracin ointment t.i.d. to suture lines. 11. Keflex one tablet p.o. four times a day for five days. DISCHARGE INSTRUCTIONS: 1. Apply Bacitracin to facial suture lines. 2. Sutures to be removed in the office Friday with Dr. [**First Name (STitle) **] at appointment, which has already been arranged. 3. J-P drains are to be stripped t.i.d. and outputs recorded q.d. 4. Patient was given regular diet. DISCHARGE CONDITION: Stable. MAJOR DIAGNOSIS: Squamous cell carcinoma of face status post cervicofacial advancement flap. COMORBIDITIES: 1. Hypertension. 2. Hypercholesterolemia. 3. Coronary artery disease. [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], M.D. [**MD Number(1) 22429**] Dictated By:[**Last Name (NamePattern1) 740**] MEDQUIST36 D: [**2198-8-6**] 11:16 T: [**2198-8-7**] 15:32 JOB#: [**Job Number 22430**]

[ "V45.81", "V10.83", "401.9", "V58.41" ]

icd9cm

[ [ [] ] ]

[ "18.79", "86.74" ]

icd9pcs

[ [ [] ] ]

4360, 4858

3664, 4033

2015, 3641

4057, 4338

703, 965

1368, 1997

109, 680

987, 1172

1189, 1345

32,407

145,951

34934

Discharge summary

report

Admission Date: [**2142-10-12**] Discharge Date: [**2142-10-15**] Date of Birth: [**2117-6-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Mental status change Major Surgical or Invasive Procedure: None History of Present Illness: This is a 25 year-old male with history of IVDU(cocaine/heroine) who presents from detox with mental status change. Patient was admitted to detox at [**Hospital **] Rehab two days ([**2142-10-9**]) prior to presentation from treatment for his heroine and cocaine use directly from [**Hospital1 2025**]. He presented to [**Hospital1 2025**] on [**2142-10-8**] with suicidal ideations and was treated for heroine/cocaine withdrawal and admitted to a dual diagnosis bed at [**Hospital1 **]. At [**Hospital1 **] he was being treated with methadone, vistaril, benadryl, and ativan. One day prior to presentation, patient was noted to be more agitated and combative and on the morning of presentation to the ED was combative and felt to have altered mental status. . In the ED, VS T 98.3 BP 152/71 HR 115 RR 20 POx 99% on RA. Head CT was negative for acute process. Tox screen positive for benzos which the patient had received in the ED and opiates. Patient required 4 point restraints and received 60mg Valium for concern of ETOH/Benzo withdrawal and 25mg IV benadryl for concern of neuroleptic malignant syndrome and dystonia with jaw stiffness. He also received MVI, thiamine, folate in IVF. Toxacology was consulted. . On presentation to the [**Hospital Unit Name 153**], patient was sedated from valium and entire history was taken from the medical record available. Past Medical History: IVDU Heroine and Cocaine Abuse Asthma Depression Social History: Originally from [**Male First Name (un) 1056**] moved to US at age 3. History of incarceration, last released 6/[**2142**]. Current IVDU, heroine and cocaine. Has 2.5 year old son, had lived with sister until 5 days prior to admission and is now homeless. Unknown alcohol history. Family History: Denies FH of substance abuse or psychiatric illness. One cousin committed suicide by hanging. Physical Exam: Vitals: T:97.5 BP: 134/83 HR: 67 RR: 18 O2Sat:100% on RA GEN: pleasant, interactive on exam. Able to ambulate without difficulty. HEENT: eomi, MMM. RESP: CTA B Abd: benign Ext: no cee. Neuro: CN 2-12 grossly intact. No focal defecits. No tremor or asterixis. Pertinent Results: On Admission: [**2142-10-12**] 12:01PM LACTATE-2.1* [**2142-10-12**] 11:51AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2142-10-12**] 11:36AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2142-10-12**] 11:36AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-10-12**] 08:48AM GLUCOSE-87 LACTATE-2.8* NA+-143 K+-3.8 CL--100 TCO2-29 [**2142-10-12**] 08:35AM UREA N-9 CREAT-1.1 [**2142-10-12**] 08:35AM estGFR-Using this [**2142-10-12**] 08:35AM ALT(SGPT)-25 AST(SGOT)-48* CK(CPK)-1564* ALK PHOS-83 AMYLASE-49 TOT BILI-0.2 [**2142-10-12**] 08:35AM LIPASE-23 [**2142-10-12**] 08:35AM IRON-66 [**2142-10-12**] 08:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-10-12**] 08:35AM WBC-7.3 RBC-4.39* HGB-13.0* HCT-37.8* MCV-86 MCH-29.6 MCHC-34.3 RDW-12.8 [**2142-10-12**] 08:35AM PLT COUNT-161 [**2142-10-12**] 08:35AM PT-15.4* PTT-29.1 INR(PT)-1.4* [**2142-10-12**] 08:35AM FIBRINOGE-223 Imaging Head CT w/o contrast ([**2142-10-12**]): No acute intracranial process. . . Discharge [**2142-10-15**] 06:30AM BLOOD WBC-7.4 RBC-4.83 Hgb-14.1 Hct-41.7 MCV-86 MCH-29.3 MCHC-33.9 RDW-12.5 Plt Ct-162 [**2142-10-15**] 06:30AM BLOOD Glucose-87 UreaN-8 Creat-1.0 Na-141 K-4.2 Cl-104 HCO3-28 AnGap-13 [**2142-10-15**] 06:30AM BLOOD CK(CPK)-512* [**2142-10-14**] 05:10AM BLOOD ALT-33 AST-51* CK(CPK)-1138* AlkPhos-89 TotBili-0.3 [**2142-10-13**] 02:51AM BLOOD ALT-33 AST-76* LD(LDH)-287* CK(CPK)-2783* AlkPhos-89 TotBili-0.5 [**2142-10-12**] 08:35AM BLOOD ALT-25 AST-48* CK(CPK)-1564* AlkPhos-83 Amylase-49 TotBili-0.2 Brief Hospital Course: # Mental Status Change: Differential includes ETOH or benzo withdrawal, toxidrome, or NMS. Head CT negative on admission supporting toxic/metabolic process. No evidence of infection on admission labs. Patient presenting outside the 72 hour window for ETOH withdrawal if he truly has been in a monitored setting since [**2142-10-8**] and ETOH level 0 at [**Hospital1 2025**]. No evidence of cholinergic toxidrome on presentation. Slight increase in CK, but patient has been significantly agitated and requiring restraints making NMS less likely. Benzo withdrawal most likely as serum tox can be negative and the withdrawal syndrome prolonged. Pt returned to baseline mental status prior to discharge. . # Polysubstance Abuse - Patient at [**Hospital1 **] detox for Heroine/cocaine detox. . # H/O SI - Per report, patient placed at [**Hospital1 **] in dual diagnosis unit. . Pt stated was going to live with relative after discharge. Pt was recommended to return to seek [**Hospital 4820**] rehab program. Medications on Admission: Methadone 15mg ([**10-10**]), 10mg ([**10-11**])then 5mg QD Trazadone 50mg QHs Clonidine 0.1mg po Q6H prn anxiety Dicyclomine 20mg PO Q6H prn GI cramping Quinine sulfate 324mg po q6H muscle cramping Thorazine 100mg po Q4H prn agitation/psychosis Ativan 1mg po Q4 H prn agitation/psychosis Benadryl 50mg po Q4H prn agitation/psychosis Haldol 5mg po prn agitation Pt received haldol 5mg, ativan 4mg, benadryl 75mg, thorazine 100mg, clonidine, diclclomine, quinine on the am of transfer to [**Hospital1 18**] ED. Discharge Medications: Methadone 15mg ([**10-10**]), 10mg ([**10-11**])then 5mg QD Trazadone 50mg QHs Clonidine 0.1mg po Q6H prn anxiety Dicyclomine 20mg PO Q6H prn GI cramping Quinine sulfate 324mg po q6H muscle cramping Thorazine 100mg po Q4H prn agitation/psychosis Ativan 1mg po Q4 H prn agitation/psychosis Benadryl 50mg po Q4H prn agitation/psychosis Haldol 5mg po prn agitation Pt received haldol 5mg, ativan 4mg, benadryl 75mg, thorazine 100mg, clonidine, diclclomine, quinine on the am of transfer to [**Hospital1 18**] ED. Discharge Disposition: Home Discharge Diagnosis: # drug/benzodiazepine withdrawl # altered mental status # rhabdomyolysis Discharge Condition: stable Discharge Instructions: Avoid all drugs and alcohol. If you have any increase in confusion, muscle aches, tremors, or any other concern, please visit your local emergency department. Followup Instructions: Please follow up with your primary care provider within the next week, and with your rehab facility as needed.

[ "728.88", "304.20", "304.10", "292.0", "493.90", "304.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6341, 6347

4242, 5247

339, 345

6464, 6473

2521, 2521

6680, 6794

2131, 2226

5807, 6318

6368, 6443

5273, 5784

6497, 6657

2241, 2502

278, 301

373, 1743

2535, 4219

1765, 1816

1832, 2115

57,818

118,018

24021

Discharge summary

report

Admission Date: [**2165-7-1**] Discharge Date: [**2165-7-5**] Date of Birth: [**2094-12-16**] Sex: M Service: MEDICINE Allergies: Sulfate Salt Attending:[**First Name3 (LF) 1253**] Chief Complaint: upper GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: 70 yo M with unresectable hepatocellular carcinoma and Child Class A Hep B cirrhosis s/p chemo-embolization early [**6-/2165**] admitted [**2165-7-1**] with an upper GI bleed to the [**Hospital Unit Name 153**]. . Of note, he was recently admitted to [**Hospital1 18**] [**Date range (1) 61140**] with acute renal failure. After discharge from the hospital he developed melena at home. On arrival to the [**Hospital1 18**] ED on [**2165-7-1**] his his vital signs were as follows: T 98.5, P 75, BP 138/68, 99% on RA. His initial labs were notable as above for a Hct of 26.2 down from 31.0 the day prior. . In the [**Hospital Unit Name 153**], he received IV pantoprazole and received 1 unit of pRBCs. His repeat HCT was 27.2. An upper endoscopy revealed a single non-bleeding 15 mm ulcer on the anterior wall of the first part of the duodenum and esophagitis. Past Medical History: 1. Hepatocellular carcinoma: diagnosed with HBV prior to immigrating to US from [**Country 651**]. He reportedly eventually had a splenectomy for cytopenias whil in [**Country 651**]. Recently, he was noted to have liver masses on ultrasound and an AFP of 100. A CT performed on [**2165-5-14**] demonstrated a large lesion in the caudate lobe measuring 9.6 cm and a second lesion in segment VI of the right lobe measuring 6.3 cm. There were also multiple lymph nodes in the porta hepatis and with the common hepatic artery concerning for local disease spread. There was also a 1.1 cm left adrenal nodule identified. The patient's AFP on [**2165-4-15**] was [**2167**], on [**2165-5-21**] it was 9229 and most recently on [**2165-5-27**] it was 12,189. 2. Hypertension 3. Chronic venous insufficiency resulting in chronic lower extremity edema and chronic venous stasis changes associated with the skin. The patient apparently had radiofrequency ablation of the left greater saphenous vein on [**2165-4-17**] with clinical improvement in LE edema 4. Type 2 diabetes controlled with diet and medication. 5. Cirrhosis. 6. History of splenectomy, status post thrombocytopenia approximately 15 years ago in [**Country 651**], it is unclear whether he received vaccinations for this. Social History: The patient is an immigrant from [**Country 651**] as described above. He came to America approximately nine years ago with his family. Denies drinking alcohol or smoking cigarettes. He is a retired engineer. He currently lives with his son's family in [**Location (un) **], [**State 350**]. He is Mandarin speaking. Denies any illicit IV drug abuse history or tattoos and no history of blood transfusions. Family History: Notable for grandparents with hepatitis B, though no confirmed diagnoses of hepatocellular carcinoma. His wife and two children who also been tested for hepatitis B and they are all negative and received HPV vaccine. There is no other pertinent family history. Physical Exam: Vital Signs: T 97.2, P 82, BP 158/60, 96% on RA. . Physical examination: - Gen: Thin, elderly male in NAD. - HEENT: Sclera anicteric - Neck: JVP <5cm - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: Regular rhythm. Normal S1, S2. IV/VI HSM at LSB with some radiation to carotids. - Abdomen: Normal bowel sounds. Has tenderness and mass in RUQ. No peritoneal signs or rebounding. - Extremities: 3+ edema to upper thigh, [**Male First Name (un) **] hose in place - Skin: Diffuse erythematous, maculopapular rash on trunk predominantly Pertinent Results: [**2165-6-30**] 07:05AM BLOOD WBC-3.6* RBC-3.11* Hgb-9.8* Hct-31.0* MCV-100* MCH-31.7 MCHC-31.7 RDW-18.8* Plt Ct-167 [**2165-7-5**] 07:42AM BLOOD WBC-4.2 RBC-2.95* Hgb-9.6* Hct-30.2* MCV-102* MCH-32.4* MCHC-31.8 RDW-21.6* Plt Ct-188 [**2165-7-2**] 04:25AM BLOOD PT-15.4* PTT-29.3 INR(PT)-1.4* [**2165-7-5**] 07:42AM BLOOD Glucose-94 UreaN-27* Creat-1.2 Na-135 K-3.9 Cl-106 HCO3-21* AnGap-14 [**2165-6-30**] 07:05AM BLOOD ALT-63* AST-111* LD(LDH)-269* AlkPhos-125 TotBili-2.9* [**2165-7-2**] 04:25AM BLOOD ALT-53* AST-120* LD(LDH)-303* AlkPhos-114 TotBili-1.5 [**2165-7-2**] 04:25AM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.1* Mg-1.9 Iron-27* [**2165-7-2**] 04:25AM BLOOD calTIBC-131* VitB12-1899* Folate-11.9 Ferritn-665* TRF-101* HELICOBACTER PYLORI ANTIBODY TEST (Final [**2165-7-3**]): POSITIVE BY EIA. BILAT LOWER EXT VEINS US IMPRESSION: Bilateral greater saphenous vein thrombosis. No extension into the deep veins. EGD: Excavated Lesions: A single non-bleeding 15 mm ulcer was found on the anterior wall of the first part of the duodenum. Impression: Grade 2 esophagitis in the lower third of the esophagus compatible with reflux esophagitis Ulcer in the first part of the duodenum Brief Hospital Course: Patient presented to ED with melena and was found to have marked drop in hemocrit in one day (from 31 to 26.2). Prior to admission, patient had chemo-embolization with adriamycin of his hepatocellular carcinoma. Patient was found to have guaiac positive stool. He was fluid resuscitated in the ED and started on a PPI. GI was consulted and then he was sent to the ICU for further management. While in the ICU, patient remained hemodynamically stable. Because of concern for variceal bleed given history of Hep B cirrhosis, empiric octreotide therapy was started and CTX x 1 dose was given for SBP prophylaxis. GI performed an EGD which revealed a 15mm nonbleeding ulcer in the first part of the duodenum. Octreotide and CTX were stopped and PPI gtt was started. Patient remained hemodynamically stable after the procedure. Pt's H. pylori serology was found to be positive, and thus he was started on triple therapy with Amoxicillin, clarithromycin, and pantoprazole x 14 days. . # HCC: Locally advanced, s/p chemoembolization. - outpatient follow up . # HBV cirrhosis: Chronic HBV infection. - Continued Tenofovir Disoproxil Fumarate 300 mg PO daily . # Rash: Pt was found to have a diffuse pruritic rash over his body, with high suspicion for drug rash from Albumin provided during the previous hospitalization. Derm was consulted due to the extensive nature of the rash, and he was started on triamcinolone with benefit. . # LE edema: Chronically edematous. Related to underlying liver disease and venous damage from RFAs. Pt had LENI's on his legs, which were negative for DVT, however, he was found to have bilateral greater saphenous vein thrombosis that did not extend into the deep venous system. He was not anticoagulated due to his recent GI bleed. . # HTN: On Clonidine and lisinopril at home - Continued home clonidine 0.1 mg PO BID - continued lisinopril . # Diabetes: - continued holding metformin and continue ISS for now . # DVT PPX: Pt received DVT prophylaxis with pneumatic boots given recent bleed . Pt was screened by physical therapy, and was found safe for discharge to home. Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks: apply to rash. Do not apply to face, groin or axillae. . Disp:*1 jar* Refills:*0* 6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8 hr as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 12 days. Disp:*48 Tablet(s)* Refills:*0* 8. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 12 days. Disp:*24 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): After 4 weeks, may decrease to 1 tab po q day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: [**Month (only) 116**] purchase over the counter. 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation: [**Month (only) 116**] purchase over the counter. 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating: [**Month (only) 116**] purchase over the counter. Discharge Disposition: Home Discharge Diagnosis: # Acute blood loss anemia # Duodenal ulcer/H.pylori serology positive # Hepatocellular carcinoma # Chronic Hepatitis B # Liver cirrhosis # Drug rash # Hypertension, benign # T2DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with bleeding from your duodenum (upper GI tract). You were found to have a bleeding ulcer, and you were treated with medications to help stop the bleeding. You were found to have an infection in your stomach, which puts you at risk for ulcers, so you have been started on treatment for this. Followup Instructions: Name: [**Last Name (LF) 32199**],[**First Name3 (LF) 3078**] H. Location: [**Hospital3 8233**] Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**] Phone: [**Telephone/Fax (1) 8236**] Appointment: Thursday [**2165-7-11**] 3:30pm

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2137-1-26**] Discharge Date: [**2137-1-28**] Date of Birth: [**2089-5-13**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: Acute onset of dysarthria and right sided weakness Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: This is a 47 year-old man with PMH only known to have Afib (on Coumadin) who presents with acute onset of right-sided weakness today. The time of onset is unclear from the transfer notes, but his initial Head CT was performed at 20:00. He was found to have a large left thalamic hemorrhage, with extension and filling into the left lateral ventricle and some blood in the right lateral ventricle, with midline shift. He was intubated at [**Hospital6 3105**]. He was found to have an INR of 1.8 (on coumadin for Afib), and was given FFP and Vitamin K. His SBP was approximately 200 and he was given 10mg labetalol, with a drop in his HR to 56. He was medflighted to [**Hospital1 **], and on arrival he was on propofol for sedation, and his pupils were found to be fixed and dilated bilaterally. Past Medical History: Atrial fibrillation on coumadin Hypertension Congestive Heart Failure Social History: Unknown Family History: Unknown Physical Exam: BP: 181/81 HR: 88 R 17 O2Sats 100% on ventilator Gen: Intubated and sedated obese male HEENT: MMM, no injuries, no bruits CVS: S1/S2, hyperdynamic precordium, no murmur Resp: Vented breaths in all fields Abd: soft, non-distended Neurologic: (examined 5 minutes off propofol, had to be put back on for repeat HeadCT) -Mental Status: Intubated, sedated, some flexion of legs in response to sternal rub -Cranial Nerves: Eyes midline at rest, Pupils 6mm and fixed, no oculocephalics, no corneals, +gag, face symmetric (as best can tell while intubated) -Motor: tone normal, had some intermittent knee flexion movements without stimulation, but also in response to noxious stimuli. No movement b/l UE. -Reflexes: 2+ symmetric throughout, b/l toes mute Pertinent Results: on admission: [**2137-1-26**] 10:00PM BLOOD WBC-18.1* RBC-6.02 Hgb-17.2 Hct-51.2 MCV-85 MCH-28.5 MCHC-33.5 RDW-13.9 Plt Ct-295 [**2137-1-26**] 10:00PM BLOOD PT-18.4* PTT-44.5* INR(PT)-1.7* [**2137-1-27**] 04:51AM BLOOD Glucose-188* UreaN-18 Creat-1.9* Na-139 K-3.0* Cl-100 HCO3-33* AnGap-9 [**2137-1-27**] 04:51AM BLOOD ALT-26 AST-30 CK(CPK)-348* [**2137-1-27**] 04:51AM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.6* Cholest-197 [**2137-1-27**] 04:51AM BLOOD %HbA1c-6.0* eAG-126* [**2137-1-27**] 04:51AM BLOOD Triglyc-249* HDL-39 CHOL/HD-5.1 LDLcalc-108 [**2137-1-26**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2137-1-27**] 12:49AM BLOOD Type-ART Temp-36.7 pO2-160* pCO2-54* pH-7.31* calTCO2-28 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2137-1-26**] 10:10PM BLOOD freeCa-1.03* [**2137-1-28**] 08:41AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2137-1-28**] 08:41AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019 [**2137-1-28**] 08:41AM URINE RBC-2 WBC-13* Bacteri-FEW Yeast-NONE Epi-1 Labs prior to death: [**2137-1-28**] 04:28AM BLOOD WBC-11.5* RBC-4.68 Hgb-13.7* Hct-40.9 MCV-87 MCH-29.2 MCHC-33.4 RDW-14.4 Plt Ct-199 [**2137-1-28**] 04:28AM BLOOD PT-14.6* PTT-30.9 INR(PT)-1.4* [**2137-1-28**] 04:28AM BLOOD Glucose-89 UreaN-25* Creat-3.0*# Na-147* K-4.2 Cl-109* HCO3-30 AnGap-12 [**2137-1-28**] 04:28AM BLOOD Calcium-7.8* Phos-4.8*# Mg-1.9 REPORTS EKG: Atrial fibrillation with a controlled ventricular response. Prolonged Q-T interval. Non-specific intraventricular conduction delay. Poor R wave progression. Non-specific ST-T wave changes. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 57 0 112 508/502 0 60 -64 CXR: Single supine AP portable view of the chest was obtained. Endotracheal tube is seen, terminating approximately 5.9 cm above the level of the carina. Nasogastric tube is seen coursing below the level of the diaphragm, distal aspect not included on the images. There are low lung volumes. Bibasilar opacities are seen, which could be due to aspiration or infection. There is also mild pulmonary vascular congestion. The cardiac silhouette is mildly enlarged. No pneumothorax is seen. There is slight blunting of the left costophrenic angle which is most likely due to overlying soft tissue, though a trace pleural effusion cannot be excluded. NCHCT [**2137-1-26**]: Large left thalamic parenchymal hematoma with intraventricular and subarachnoid extension. Moderate surrounding edema and 8-mm rightward shift of midline structures. Left uncal herniation and diffuse cerebral edema. There is extension of parenchymal hemorrhage into the left midbrain and that there is both downward transtentorial and early cerebellar tonsilar herniation. NCHCT [**2137-1-27**]: Large left thalamic intraparenchymal bleed with surrounding edema and intraventricular extension, similar to the prior study. Stable rightward shift of midline structures by approximately 8 mm. Stable left uncal herniation and diffuse cerebral edema. Brief Hospital Course: Mr. [**Known lastname 92479**] was admitted to the neuro-Intensive care unit for the management of his anticoagulation-related left intraparenchymal CNS hemorrhage. In the setting of this massive hemorrhage, his admission neurologic examination was very poor including dilated and nonreactive pupils, absent VORs or corneals and a poor gag/cough. He was seen by neurosurgery who deferred intervention given the poor prognosis overall. He received one dose of 100g of mannitol, but this did not improve his neurologic examination. His blood pressure was controlled with a nitroprusside drip. He was seen by our supervising physician the following day, and at that point he had been off all sedating medications for almost four hours. He had no spontaneous or purposeful movements, and his only intact brainstem reflex was a low spontaneous breathing rate (approximately [**8-9**]/min). His family was made aware of the gravity of the situation. They were emotionally overwhelmed, and asked for an extra day to make their decision. In the interim, Mr. [**Known lastname 92479**] had problems with low BPs (down to the 80s/90s systolic) and developed a new elevated WBC with low grade fever, acute on chronic renal failure (Cr 1.5-3.0) and became slightly oliguric. On the 30th of [**Month (only) 404**], the daughter and wife of Mr. [**Known lastname 92479**] agreed to switch to CMO status and we pushed ahead with a terminal extubation. Prior to extubation, the priest was called to perform a prayer. He was given 2mg of morphine as a palliative measure. He passed approximately 45 minutes later. The family declined autopsy. Medications on Admission: Coumadin Simvastatin KCl Lasix Discharge Medications: N/a DECEASED Discharge Disposition: Expired Discharge Diagnosis: CNS intraparenchymal hemorrhage Discharge Condition: N/a DECEASED Discharge Instructions: N/a DECEASED Followup Instructions: N/a DECEASED [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2137-1-29**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

7007, 7016

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34770+57943

Discharge summary

report+addendum

Admission Date: [**2168-8-24**] Discharge Date: [**2168-8-29**] Date of Birth: [**2101-4-27**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2168-8-24**] Coronary Artery Bypass times 4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PLV) History of Present Illness: Mr. [**Known lastname 14710**] is a 67 year old gentleman who presented to [**Hospital1 18**] [**Location (un) 620**] with exertional chest pain while mowing his lawn. He was transferred to [**Location (un) 86**] and underwent a cardiac catheterization which revealed coronary artery disease. Past Medical History: Type 2 DM Hypertriglyceridemia- Diagnosed 30+ yrs ago. . Hypertension BPH s/p tonsillectomy s/p hernia repair Social History: Mr. [**Known lastname 14710**] lives in [**Hospital3 **] but has a home in [**Location (un) 620**]. He is retired and lives with his wife who works part time. Former smoker. Family History: Mr. [**Known lastname 14710**] has no family history of myocardial infarction or heart disease. His uncle died of a pulmonary embolism at 39 years of age. Physical Exam: At the time of discharge Mr. [**Known lastname 14710**] was found to be awake, alert, and oriented. His heart was of regular rate and rhythm. His lungs were clear to auscultation bilaterally. His sternum is stable and his mediastinal incision is clean, dry, and intact. His abdomen was soft, non-tender, and non-distended. Pertinent Results: [**2168-8-28**] 01:00PM BLOOD WBC-6.5 RBC-2.86* Hgb-8.7* Hct-24.2* MCV-85 MCH-30.6 MCHC-36.2* RDW-14.3 Plt Ct-292# [**2168-8-24**] 03:15PM BLOOD WBC-8.5 RBC-3.30*# Hgb-10.2*# Hct-29.2*# MCV-89 MCH-30.9 MCHC-34.9 RDW-13.8 Plt Ct-211 [**2168-8-29**] 05:45AM BLOOD Glucose-168* UreaN-22* Creat-1.1 Na-133 K-4.0 Cl-100 HCO3-25 AnGap-12 [**2168-8-24**] 03:15PM BLOOD UreaN-19 Creat-0.9 Cl-115* HCO3-24 [**Known lastname **],[**Known firstname 569**] A [**Medical Record Number 79651**] M 67 [**2101-4-27**] Radiology Report CHEST (PA & LAT) Study Date of [**2168-8-27**] 12:20 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2168-8-27**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79652**] Reason: eval pneumothoraces [**Hospital 93**] MEDICAL CONDITION: 67 year old man s/p CABG REASON FOR THIS EXAMINATION: eval pneumothoraces Final Report HISTORY: Status post CABG, to evaluate for pneumothorax. FINDINGS: In comparison with the study of [**8-26**], there is no definite evidence of pneumothorax. However, a posterior rib greatly obscures the area in the left apex where the pleural line was previously seen. Mild bilateral pleural effusions and bibasilar atelectatic changes. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: SAT [**2168-8-27**] 3:41 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 569**] [**Hospital1 18**] [**Numeric Identifier 79653**] (Complete) Done [**2168-8-24**] at 12:38:36 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2101-4-27**] Age (years): 67 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Congenital heart disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Right ventricular function. Valvular heart disease. ICD-9 Codes: 745.5, 440.0, 396.9 Test Information Date/Time: [**2168-8-24**] at 12:38 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW06-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 0.0 cm Left Ventricle - Fractional Shortening: 1.00 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. Dynamic interatrial septum. PFO is present. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Torn mitral chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Trivial mitral regurgitation is seen. There is no pericardial effusion. A bubble study was done to rule out a PFO. A left to right shunt could be demonstrated with contrast with valsalva POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolic function. 2. No change in valve structure and function. Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician ?????? [**2163**] CareGroup IS. All rights reserved. Imaging Lab Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname 14710**] underwent a coronary artery bypass graft times four on [**2168-8-24**] with Dr. [**Last Name (STitle) 914**]. The patient tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was extubated by post-operative day one and his vasoactive drips were weaned. He was transferred to the surgical step-down floor. His chest tubes and wires were removed. Stopped The remainder of his postoperative course was essentially unremarkable. He progressed well and on POD#5 he was discharged to home with VNA services. He was instructed on all neccessary follow up appointments. Medications on Admission: aspirin 81mg daily metformin 750mg TID atenolol 50mg daily lisinopril glyburide gemfibrozil buproprion Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 7. Metformin 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: coronary artery disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please see Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]), please call for appointment. Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP) 1-2 weeks ([**Telephone/Fax (1) 57279**]), please call for appointment. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] (cardiology) in [**1-20**] weeks, please call for appointment. Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]). Completed by:[**2168-8-29**] Name: [**Known lastname **],[**Known firstname 2147**] A Unit No: [**Numeric Identifier 12793**] Admission Date: [**2168-8-24**] Discharge Date: [**2168-8-29**] Date of Birth: [**2101-4-27**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1543**] Addendum: Prior to his discharge, as BP tolerate, Mr.[**Known lastname 8860**] was restarted on an ACE-I and dosage will require reevaluation as an outpt, and as BP tolerates. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 709**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2168-8-29**]

[ "V15.82", "250.00", "411.1", "401.9", "414.01", "600.00", "272.1", "V14.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11678, 11901

7645, 8336

288, 387

10068, 10075

1572, 2401

10586, 11655

1053, 1211

8489, 9916

2441, 2466

10021, 10047

8362, 8466

10099, 10563

6288, 7314

1226, 1553

238, 250

2498, 6239

415, 710

732, 844

860, 1037

7324, 7622

78,722

180,285

38422

Discharge summary

report

Admission Date: [**2124-6-22**] Discharge Date: [**2124-7-3**] Date of Birth: [**2087-2-27**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8587**] Chief Complaint: Overdose/Right arm compartment syndrome Major Surgical or Invasive Procedure: [**2124-6-22**]: R forearm compartment releases (volar / extensor) [**2124-6-23**]: R forearm I&D with wound partial closure [**2124-6-27**]: R forearm I&D with split thickness skin graft for wound closure History of Present Illness: Mr. [**Known lastname 85561**] is a 37 year old man who was found in a car for at least 8 hours, someone saw on way to work, then on way home. In his car were empty bottles of seroquel, zyprexa, temazepam. He was unresponsive at scene- was given 2mg narcan and taken to [**Hospital3 **]. While there, CT head was negative and labs were negative for tylenol/ASA. He received IV fluids given his high CK. He was then transferred to [**Hospital1 18**] ED for further management. On arrival, his pupils reacted only minimally and patient remained minimally responsive so he was intubated to protecting his airway. He was transferred to the [**Hospital1 18**] for further evaluation and care. Past Medical History: Schizophrenia Social History: Born and raised outside of [**Location 652**]. Parents divorced. Has one brother who lives locally. Completed fifth grade, did not attend high school, but was able to take some classes at a community college. Works with disabled individuals at [**Street Address(1) 85562**] Center. Never married, not in a relationship. Lives with his mother and his 14 year old son. Family History: None known for certain, though mother apparently had serious depression when she divorced. Physical Exam: Afebrile, VSS Hand Exam: Sensory to light touch: Complete loss of sensation in ulnar nerve distribution. Complete loss of sensation in median nerve distribution. Reduced sensation in radial nerve distribution on hand. Patient loses sensation medial to the first metacarpal on the dorsum of his hand. Motor: Complete loss of AIN branch of median nerve. Complete loss of ulnar nerve function: FDP of ring and little finger, lumbricals are not activated. Complete loss of PIN branch of radial nerve: extensors are not activated. Of note: there is some motion of fingers and hand that is hard to categorize into nerve patterns. This random motion is an improvement over the complete paralysis that this patient had during and immediately following the compartment syndrome. Pertinent Results: WBC-10.4 RBC-3.39* Hgb-9.8* Hct-30.1* MCV-89 MCH-28.8 MCHC-32.5 RDW-14.0 Plt Ct-254 Brief Hospital Course: Mr. [**Known lastname 85561**] presented to the [**Hospital1 18**] on [**2124-6-22**] via transfer from [**Hospital3 **] in the setting of suicide attempt by ingestion. . # Suicidal ideation s/p attempt?????? Patient initially intubated s/p ingestion for airway protection. Per report, with empty seroquel, tamazepam, and zyprexa bottles. Successfully extubated on [**6-23**], and patient denied any SI/HI. Placed on CIWA. Psychiatry consulted throught his hospital stay. . # Rhabomyolysis with compartment syndrome?????? Patient taken to OR upon admission for fasciotomy. He returned to the operating room on [**2124-6-23**] and underwent an I&D with partial closure and and VAC change. On [**2124-6-27**] he returned to the operating room and underwent a final I&D with split thickness skin graft placement. On [**2124-7-1**] his VAC was removed and an xeroform dressing was put over the graft to be changed daily. . # Pain control- He was started on MS Contin 30mg [**Hospital1 **] for pain control and oral dialudid for breakthrough pain working well. At 2 weeks after surgery ([**2124-7-11**]) MS Contin should be reduced to 15mg [**Hospital1 **] and then 2wks later ([**2124-7-25**]) should be reduced to 15mg Qhs for 2wks then will be off all long acting narcotics. Patient has been taken off IV antibiotics. He is tolerating PO pain meds and his pain is controlled on this PO regimen. He is medically stable and being discharged to a psychiatric facility. Medications on Admission: seroquel, zyprexa, temazepam Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*85 syringes* Refills:*0* 2. Morphine 15 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*120 Tablet Sustained Release(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. Disp:*120 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. Disp:*100 Tablet(s)* Refills:*0* 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomia. Disp:*100 Tablet(s)* Refills:*0* 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. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 11. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasms. Disp:*100 Tablet(s)* Refills:*0* 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Multiple ingestions/Overdose Right arm compartment syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Continue to be non-weight bearing on your right arm Continue your medication as prescribed If you have any increased redness, drainage, swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Physical Therapy: Activity: Activity as tolerated Right upper extremity: Non weight bearing Treatments Frequency: Xeroform dressing over graft site (arm) daily then lose kerlix wrap Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Completed by:[**2124-7-3**]

[ "799.02", "518.81", "969.4", "E950.3", "969.3", "728.88", "295.62", "311", "729.71" ]

icd9cm

[ [ [] ] ]

[ "83.45", "86.69", "83.14", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

5788, 5858

2734, 4207

358, 569

5962, 5962

2626, 2711

6579, 6800

1725, 1818

4286, 5765

5879, 5941

4233, 4263

6113, 6370

1833, 2607

6388, 6465

6487, 6556

279, 320

597, 1286

5977, 6089

1308, 1324

1340, 1709

26,999

181,461

32572

Discharge summary

report

Admission Date: [**2147-10-16**] Discharge Date: [**2147-10-20**] Date of Birth: [**2083-9-5**] Sex: F Service: MEDICINE Allergies: Fentanyl / Compazine / Dilaudid Attending:[**First Name3 (LF) 3556**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: History of Present Illness (adapted from Med Consult Note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] and Neurology Note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]): 64 F with HCV, initially admitted to [**Hospital6 20592**] with mental status changes and fever. Per her husband, she was found speaking "gibberish" and groaning, not following commands. On the way to the hospital, they had stopped at a railroad crossing, at which time she tried to exit the vehicle, and needed to be restrained. . Of note, she had presented to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15131**], at [**University/College **] Mass on [**10-11**] with a herpetic-rash on the right side of her face and back. These were cultured and grew MSSA, and treated with Bactroban and Keflex. . Her review of systoms is otherwise negative. Specifically, she has had no recent travel history, any hiking or any recent sick contacts or unusual exposures. According to the husband, the patient was fine about 1 week ago. . At [**Location (un) **], a head CT showed bilateral subarachnoid hemorrhages. In addition, her laboratory values were significant for a plt 62, Hct 28, Cr 1.6, and TBili 2.2. Of note, in [**2147-4-18**], her plt was 231 and Hct 33. Her creat in [**2146-5-19**] was 0.7. . Of note, her [**Location (un) **] labs also included a tox screen that was positive for benzos, amphetamines, and opiates. . She was transferred to the neurosurgery service here at the [**Hospital1 18**]. Here, she was loaded with dilantin, a R radial A-line placed, and CT imaging performed of her head and neck. This showed subarachnoid hemorrhages in her right frontal, left frontal, and left parietooccipital lobes. In addition, a 2-mm aneurysm from the supraclinoid internal carotid artery was visualized, as well as a subcentimeter lesion along the left parietotemporal lobe likely representing a meningioma. An LP was also performed, which showed 450 RBCs, 110 WBCs, with 81% polys and 14% bands. She was given vanco, ceftriaxone, ampicillin, and acyclovir. . Her course here is also significant for finding of a cool, cyanotic right hand after placement of the right radial A-line. Past Medical History: Hepatitis C, according to husband pt has been treated with an incomplete course of Interferon in the past at [**Hospital3 2358**] unsuccessfully; he denies any h/o cirrhosis but he is a poor historian Anemia (unclear baseline or etiology) Fibromyalgia Depression s/p tubal ligation s/p D&C s/p tonsillectomy Social History: married, lives with husband; former ER nurse, abruptly ended job, but never gave an explanation to husband or family; no Etoh; h/o IVDU Family History: noncontributory Physical Exam: On admission: Vitals - Tm 102.1, Tc 98.1, BP 116/68, HR 113, RR 32, O2 sat 100%, wt 54.2 kg AC 450x20/0.4/5.0 General - Intubated and sedated HEENT - Sclera anicteric, PERRL, C-collar in place CV - tachy, but regular; [**1-24**] syst mur best heard at apex Chest - Course ventilated breath sounds, but grossly CTAB Abd - no stigmata of chronic liver diseasea; NABS, soft, NT/ND, no g/r; no hepatosplenomegaly; R femoral A-line c/d/i Ext - no edema; R hand, and bilat L>R feet cool and cyanotic appearing Skin - no patechia; ? [**Last Name (un) 1003**] & Oslers lesions on L hand Pertinent Results: AP Chest ([**10-16**]) - The tip of an endotracheal tube projects approximately 2.9 cm above the carina. The proximal sideport of a nasogastric tube is below the diaphragm though the tip courses below the confines of the radiograph. The cardiomediastinal silhouette is unremarkable, and the lungs are grossly clear without evidence of overt edema. There is no evidence of pleural effusion or pneumothorax. . CTA Head/Neck ([**10-16**]): Several foci of subarachnoid hemorrhage in the right frontal, left frontal, left parietooccipital lobes are noted. There is minimal associated edema without evidence of mass effect or infarction. A 5-mm extra-axial lesion (2, 18) along the left parietotemporal lobe may represent a meningioma. The carotid and vertebral arteries and their major branches are patent with no evidence of stenosis. There is a 2-mm aneurysm in the posterior margin of the supraclinoid internal carotid artery. . CT Head ([**10-17**]): New 4 mm hemorrhage within the left posterior thalamic region. In conjunction with evidence of one and possibly two infarcts within the left parietal lobe region, as well as the rather posteriorly situated area of subarachnoid blood, it seems unlikely that the left supraclinoid internal carotid artery aneurysm is cause for any of the hemorrhagic or ischemic lesions seen. Trauma could certainly account for the subarachnoid hemorrhage but would seem less likely as a cause of the thalamic hemorrhage. Brief Hospital Course: 64 F with Staph Aureus bacteremia including endocarditis, pneumonia, and meningitis. . Bacteremia/septic shock - GPC cultures growing from blood, urine, and sputum, with wbc in CSF and vegetations on mitral valve. Possibly stemming from recent MSSA skin lesion. PT started on gentamycin, vancomycin and acyclovir, but was switched to nafcillin as cultures showed MSSA. C/s ID for appropriate antibiotic use. Gave fluid bolluses to maintained BP, but eventulally ussed pressors to continue to support BP . Respiratory failure - Intubated in ED for airway protection respiratory alkalosis. Morphine for comfort while intubated . Endocarditis: Pt with heart murmer and evidence for Mitral regurg and vegitations seen on TTE. Clinical signs of septic emboli throught body. TEE was performed to better define extent of disease, and cardiology and CT surtery were consulted. Pt's family decided to not consider surgery in acute period, so daily EKG's were performed to monitor cardiac progress . AMS: Pt presented with AMS and evidence of SAH on CT scan. Given Endocarditis, septic emboli are likely cause, but many other possible causes. Given elevated WBC on LP, could be encephalitis, and viral cultures are pending. Thrombocytopenia not severe enough to cause hemorage. There was concern for domestic abuse, but pattern of injury does not suggest trauma, and other more likely causes. Repeat head CT from [**10-18**] shows no new hemorrhage. Pt showed signs of flaicd paraysis. Given ICH nsgy and neuro recommended to trasnfuse platelets to goal of 70 and continue dilantin for seizure prophylaxis. We did not administer anticoagulants based on the concern for new or reoccurance of intracranial hemorrhage. . Thrombocytopenia: Given overal septic picture, likely from DIC. Baseline labs from [**4-24**] with plt in 230s. Schistocytes on smear reviewed overnight and an elevated LDH, along with mental status changes, fever, and renal failure raises concern for TTP; However, Hct stable and normal haptoglobin. Time course too rapid for HIT. Recent abx use for treatment of MSSA skin lesion may be precipitant for ITP. Cool extremities also raises consideration of arterial thrombi. Abdominal US showed no splenic enlargement, so sequestration is less likely. Heme was consulted to hep determine origin and possible treatments. . Acute renal failure: creat elevated from 0.7 last year; FeNa last night consistent with prerenal physiology. TTP also in the differential, as are arterial or septic thromboemboli. Pt was hydrated based on CVP, but eventually pt becam anuric. . Pt had thrombosis of R radial artery, and went to the OR with vascular surgery for venous graft. Post op the venous graft clotted as well due to the lack of anticoagulation due to ICH. Simutaneously extensive clot burden was extending in the legs and throughout the right arm. The option of amputation was discussed with the family, but was decided against given the poor prognosis. . Hepatitis C: per husband, no known h/o cirrhosis. Although she presented with elevated PT & PTT, only PTT is mildly elevated now. low albumin, elevated INR are suggestive of decreased functional capacity of the liver. This would also go along with a thrombocytopenia if there is splenomegaly from portal hypertension, and mental status changes. . DNR/DNI; As pt's status worsened shown by renal failure, increasing respiratory failure, requirement of pressors, and significant clot burdern, the pt's husband decided the patient would have wanted to be DNR. This decision was discussed again with step son, mother, and additional family members. [**Name (NI) **] interventions such as pressors and intubation were continued, but no additional treatments such as amputation were given. Pt eventually went in to sudden cardiac arrest, and ACLS was withheld in concordance with the patients DNR status. Medications on Admission: Clonazepam 0.5 [**Hospital1 **] Cymbalta 30 qd Oxycodone 40 tid Valium 5 prn Tinazidine 4 qd Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "995.92", "322.9", "584.9", "444.21", "424.0", "038.11", "571.5", "070.54", "785.52", "430", "482.41", "284.1", "421.0" ]

icd9cm

[ [ [] ] ]

[ "39.56", "96.72", "96.6", "88.72", "03.31", "99.05", "38.03", "96.04" ]

icd9pcs

[ [ [] ] ]

9266, 9275

5213, 9094

315, 327

9327, 9337

3729, 5190

9394, 9534

3097, 3114

9237, 9243

9296, 9306

9120, 9214

9361, 9371

3129, 3129

254, 277

355, 2595

3143, 3710

2617, 2927

2943, 3081

75,089

160,209

42566

Discharge summary

report

Admission Date: [**2128-2-13**] Discharge Date: [**2128-2-17**] Service: MEDICINE Allergies: Cipro Cystitis / Levaquin / Macrobid / Ampicillin Attending:[**First Name3 (LF) 905**] Chief Complaint: CC:[**CC Contact Info 92111**] Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy which showed esophagitis and an old healed ulcer but no sign of bleeding. History of Present Illness: [**Age over 90 **]-year-old female with past medical history of diverticulitis, peptic ulcer disease, anemia who presents with "hemoptysis". . The patient was in her usual state of health until 1 week prior to admission. At that time she developed severe epigastric pain which she attributed to acid-reflux. She also noted nausea which was intermittent and a sour taste. The day prior to admission she "coughed up" a half-dollar sized blood clot. She went to bed without any more symptoms. She awoke with lightheadedness. She denies any chest pain, palpitations, shortness of breath, abdominal pain, fevers, chills, cough, changes in bowel habits, blood in stool (notes dark stool but no different than baseline given takes oral iron). She presented to [**Hospital1 18**] EW for further evaluation. . Upon presentation to [**Hospital1 18**] EW, initial vitals were: T 98.7, HR 56, BP 200/70, RR 17, SaO2 100% ra. CXR was normal. Hct 20 (unsure of baseline). Coags with INR 1. NGL with coffee ground emesis. Cleared after 60cc NS. Rectal with brown, heme positive stool. GI was consulted and the patient was admitted to MICU for further work up. . Currently, she feels well and is without complaints. . ROS: Per HPI. Lost weight since [**Month (only) **]. . Past Medical History: - diverticulitis - peptic ulcer disease - glaucoma - cataract - hyperlipidemia - hypertension - anemia - in [**Month (only) 1096**] required 2u PRBC - anxiety - GERD Social History: Lives at home by self. Denies EtOH, Tobacco, Illicits. Family History: Brother with PUD Physical Exam: On Admission: VS: Temp: 98, BP: 233/67, HR: 74, RR: 17, O2sat: 100% RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, dry MM, op without lesions RESP: CTAB, with good air movement throughout CV: RR, nl rate, II/VI RUSB ABD: epigastric tenderness, LLQ tenderness, nondistended +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: warm NEURO: AAOx3. Cn II-XII intact. On Discharge: VS: Temp: 98.3, BP: 187/74 (120s-180s/50s-70s), 71 (60s-80s), 18 O2sat: 100% RA GEN: pleasant, comfortable, NAD, A&Ox3 HEENT: PERRL, EOMI, dry MM, op without lesions RESP: CTAB, with good air movement throughout CV: RR, nl rate, 2/6 SEM at RUSB ABD: soft, non-tender, non-distended, bowel sounds present, no masses, no hepatosplenomegaly EXT: no c/c/e SKIN: warm NEURO: AAOx3. Cn II-XII intact. Pertinent Results: Admission Labs: [**2128-2-13**] 06:10PM BLOOD WBC-4.9 RBC-2.17* Hgb-7.0* Hct-20.5* MCV-95 MCH-32.3* MCHC-34.2 RDW-16.2* Plt Ct-278 [**2128-2-13**] 04:15PM BLOOD Glucose-118* UreaN-65* Creat-2.4* Na-134 K-5.4* Cl-106 HCO3-20* AnGap-13 [**2128-2-14**] 04:46AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.3 Discharge Labs: [**2128-2-17**] 05:30AM BLOOD WBC-6.7 RBC-3.06* Hgb-9.6* Hct-28.0* MCV-92 MCH-31.5 MCHC-34.3 RDW-17.0* Plt Ct-303 [**2128-2-17**] 01:05PM BLOOD Na-134 K-5.2* Cl-108 [**2128-2-17**] 05:30AM BLOOD Glucose-96 UreaN-52* Creat-2.5* Na-138 K-5.6* Cl-110* HCO3-21* AnGap-13 [**2128-2-17**] 05:30AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0 Chest X-Ray: FINDINGS: No consolidation or edema is evident. The mediastinum is unremarkable. The cardiac silhouette is borderline enlarged. No effusion or pneumothorax is noted. A marked levoconcave scoliosis of the thoracolumbar spine is evident. IMPRESSION: No acute pulmonary process. Borderline cardiomegaly. Scoliosis. EGD: Mild esophagitis in the lower third of the esophagus Hiatal hernia Otherwise normal EGD to third part of the duodenum Brief Hospital Course: [**Age over 90 **]-year-old female with past medical history of diverticulitis, peptic ulcer disease who presents with upper GI bleed. 1. Upper GI Bleed: Based on low Hct, +NGL the patient likely has UGIB. No evidence of varices or liver pathology. Concern was for [**Doctor First Name 329**] [**Doctor Last Name **] tear or peptic ulcer disease as patient has known h/o esophagitis and gastritis from prior EGD. Unclear of how brisk bleed it as unsure of time course but remained hemodynamically stable in ICU. Transfused 2 units PRBC with subsequent stable HCts. She did not have any further evidence of active bleeding. She was continued on PPI drip in ICU. Patient remained stable and was called out to medicine floor. She was continued on IV PPI [**Hospital1 **]. She underwent upper endoscopy and was found to have mild esophagitis in the lower third of the esophagus and a hiatal hernia. The EGD was otherwise normal to the third part of the duodenum. GI recommended that as part of the complete anemia work-up the patient should have a virtual colonoscopy or barium enema done as an outpatient. This is in light of the incomplete colonoscopy done at that outside hospital due to colonic stricture. Ms. [**Known lastname **] will follow-up with her GI doctor as an outpatient. She was discharged home on a PO PPI. VNA will draw patient's CBC and fax it to her PCP prior to PCP visit. 2. Hypertension: Ms. [**Known lastname **] had SBP to 200s on admission then improved on IV hydralazine in the ICU. Lisinopril and atenolol was held in the setting of GIB and elevated creatinine. Per prior DC sumamry from [**2127-11-3**], she was supposed to stop ACE but admission note records her as being on lisinopril 40mg PO BID. Restarted norvasc as BP med that would not affect HR and kidneys. On the floor the patient was continued on norvasc and hydralazine. Metoprolol 12.5 mg [**Hospital1 **] was started in place of atenolol given that patient had an elevated creatinine. Lisinopril was held at discharge given patient's creatinine of 2.5 (at last admission at [**Hospital1 **] was 2.) 3. Acute on chronic renal failure: Patient with baseline creatinine of 1.8 - 2 during recent outside hospital stay, but during this hospitalization ranged 2.3 - 2.6. This is possibly secondary to pre-renal causes given recent GI bleed. Lisinopril was held during hospitalization. 4. Hyperkalemia: Patient had elevated potassium in the 5s (5.2 at discharge). Her ACI inhibitor was held. EKG did not show evidence of cardiac conduction abnormalities related to hyperkalemia. It is possibly secondary to decreased GFR. VNA will draw chemistry as an outpatient and fax results to patient's PCP so hyperkalemia can be followed. 5. GERD: Patient was on PPI drip and then IV PPI during hospitalization. She was dishcarged on PO PPI. 6. Glaucoma: Continued outpt eye drops 7. Anxiety: Continued home TID ativan for anxiety. 8. Code: DNR/DNI, confirmed with patient. Medications on Admission: - Atenolol 25mg daily - Lasix 20mg QOD - Aspirin 81mg daily - Lisinopril 40mg [**Hospital1 **] - Lipitor 10mg daily - MVI - omega-3 fatty acid - Dorzalamide eye drops - Ativan 0.5mg TID - Iron pill Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 8. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1) Capsule PO twice a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary: Acute blood loss anemia from unknown source Secondary: 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: It was a pleasure to participate in your care Ms. [**Known lastname **]. You were admitted to the hospital with bleeding that caused a low blood count and blood in your stomach. This may have been caused by bleeding in your upper GI tract, but the gastroenterologists did not see any bleeding on your upper endoscopy. You need to follow-up with your GI doctor as an outpatient to have a virtual colonoscopy or a barium enema. Please make the following changes to your medications: 1. STOP Atenolol 2. STOP Lisinopril until your kidneys recover (your primary care will let you know when it is ok to restart this) 3. STOP Lasix until your kidneys recover (your primary care will let you know when it is ok to restart this) 4. START Metoprolol 12.5 mg po BID 5. START Amlodipine 10mg po daily 6. START Hydralazine 25 mg by mouth Four times daily ( this will take the place of lisinopril until your primary care says it is ok to stop). 7. START Pantoprazole 40mg by mouth daily for stomach protection Please see below for your follow-up appointments. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Address: [**Street Address(2) **], STE 2W, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 2697**] Appt: [**2-24**] at 11am Name: [**Last Name (LF) **],[**Name8 (MD) **] MD Address: 92 [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 21622**] Phone: [**Telephone/Fax (1) 49449**] Appt: [**2-27**] at 2:30pm [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "584.9", "553.3", "585.3", "786.30", "272.4", "276.7", "578.9", "530.81", "365.9", "300.00", "403.90", "530.10", "285.29", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

8043, 8118

3910, 6882

287, 390

8239, 8239

2801, 2801

9498, 10008

1956, 1974

7130, 8020

8139, 8218

6908, 7107

8422, 8878

3111, 3887

1989, 1989

2386, 2782

8907, 9475

217, 249

418, 1677

2817, 3095

2003, 2372

8254, 8398

1699, 1867

1883, 1940

15,893

123,514

28437

Discharge summary

report

Admission Date: [**2188-9-8**] Discharge Date: [**2188-9-21**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: off pump CABG X 1 (LIMA > LAD) on [**2188-9-11**] History of Present Illness: 82 year old male with a history of 6 prior PCI's (in [**State 622**] and [**State 108**]) admitted for worsening chest pain to the floor s/p cath with tight LAD and diffuse LCx disease without intervention. He has had chest pain with minimal exertion for 1-2 weeks and was admitted [**9-5**] to [**Hospital 1474**] Hospital for worsening chest pain. The patient describes 1 week of sharp chest pain across his precordium into his R shoulder and his upper R back occurring only with exertion and different from his anginal pain. The patient ruled out for an MI with negative cardiac enzymes and was transfered for cardiac cath. In cath today, the patient had 90% mid LAD, diffuse LCx, diffuse RCA without intervention and an old acute marginal lesion. The patient was transferred to the floor chest pain free. Past Medical History: - HTN - CAD with 6 prior PCI, last in [**2185**]. - Brittle diabetes complicated by neuropathy. - Chronic anemia (treated with Procrit but has been off of it for 1 month) - mild CRI - Brain aneurism (4mm ACA) s/p coiling - CVA with no residual deficit 2 years ago - Prostate cancer s/p radiation therapy - Hx of peritonitis secondary to perforated sigmoid colon in past of unknown etiology with multiple obstructions since that time. - IBS - S/p appendectomy and cholecystectomy - Hypercholesterolemia Social History: Recently moved from [**State 108**] back to [**Location 27224**]. Lives alone. No smoking or alcohol x25 years. Prior to that smoked 1ppd x30-40 years. Family History: Mother died at 41 of MI? Physical Exam: VS 160/60 80 18 96% RA GEN: Well-appearing. NAD. HEENT: PERRL. Pink, moist oral mucosa without lesions. CV: Systolic ejection murmur in 2nd intercostal space. Pulm: CTA b/l laterally as patient not allowed to sit forward after cath. Abd: Obese, mild diffuse tenderness. Normoactive bowel sounds. Ext: 1+ edema in bilateral lower extremities. Strength 5/5. Peripheral pulses intact. Neuro: A&Ox3. Pertinent Results: [**2188-9-18**] 04:49PM BLOOD WBC-8.1 RBC-3.63* Hgb-11.1* Hct-31.5* MCV-87 MCH-30.6 MCHC-35.2* RDW-17.2* Plt Ct-163 [**2188-9-18**] 04:49PM BLOOD PT-12.4 PTT-24.5 INR(PT)-1.1 [**2188-9-19**] 11:00AM BLOOD Glucose-120* UreaN-56* Creat-1.8* Na-137 K-4.7 Cl-102 HCO3-25 AnGap-15Cardiology Report ECHO Study Date of [**2188-9-19**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Height: (in) 68 Weight (lb): 220 BSA (m2): 2.13 m2 BP (mm Hg): 128/57 HR (bpm): 59 Status: Inpatient Date/Time: [**2188-9-19**] at 14:52 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W046-0:32 Test Location: West Echo Lab Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *7.4 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: 35% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 2.67 Mitral Valve - E Wave Deceleration Time: 135 msec INTERPRETATION: Findings: This study was compared to the prior study of [**2188-9-9**]. LEFT VENTRICLE: Depressed LVEF. RIGHT VENTRICLE: Severe global RV free wall hypokinesis. AORTIC VALVE: No AS. MITRAL VALVE: LV inflow pattern c/w restrictive filling abnormality, with elevated LA pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: LV systolic function appears depressed. There is severe global right ventricular free wall hypokinesis. There is no aortic valve stenosis. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2188-9-9**], the LVEF and RVEF now appear reduced. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2188-9-19**] 16:24. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] CHEST (PORTABLE AP) [**2188-9-18**] 8:46 AM CHEST (PORTABLE AP) Reason: Eval pulm edema [**Hospital 93**] MEDICAL CONDITION: 82 year old man with CAD s/p Off-Pump CABG now w/ orthopnea REASON FOR THIS EXAMINATION: Eval pulm edema INDICATION: Status post CABG with orthopnea, to evaluate for pulmonary edema. PORTABLE AP CHEST. COMPARISON: [**2188-9-17**]. Moderate cardiomegaly. Aorta is unfolded. Left-sided pleural effusion remains stable. Left retrocardiac atelectasis also persist. There is no CHF. IMPRESSION: Moderate cardiomegaly with persistent left retrocardiac atelectasis and left-sided pleural effusion. DR. [**First Name (STitle) 29814**] [**Name (STitle) 65954**] [**Doctor Last Name **] Brief Hospital Course: Assessment: This is an 82 y.o. man s/p PCI x6 last in [**2185**] who presents with worsening chest pain, negative cardiac enzymes, with significant disease on cardiac cath. He was taken to the operating room on [**2188-9-11**] where he underwent a CABG x 1, off-pump. He was transsferred to the SICU in critical but stable condition. He was extubated by POD #1. He was transferred to the floor on POD #2.He did have some postoperative atrial fibrillation which converted to sinus rhythm with medication. He was seen in consultation by [**Last Name (un) **] for his DM management post op. On [**9-16**], he had a ventricular tachycardia arrest. He was taken to the cath lab where he received a stent to the RCA, for which he needs to stay on plavix for 12 months. He continued to recover and was transfered back the floor on [**2188-9-18**]. He was discharged to rehab in good condition on [**2188-9-21**]. Medications on Admission: Aspirin 325 QD Clopidogrel 75 QD Lopressor 50 [**Hospital1 **] Imdur 30 QD -> d/c'd at OSH Furosemide 20 QD Lisinopril 5 [**Hospital1 **] Simvastatin 20 QD Protonix 20 QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: Decrease dose to 200 mg PO daily after 7 day course complete. . 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital 39225**] & Rehab Center - [**Hospital1 1474**] Discharge Diagnosis: CAD HTN CRI IBS DM Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks no driving for 1 month Followup Instructions: with Dr. [**Last Name (STitle) 7047**] in [**1-11**] weeks with Dr. [**Last Name (STitle) **] in 4 weeks

[ "401.9", "410.91", "250.60", "V12.59", "427.5", "V58.67", "424.1", "585.9", "414.01", "V15.82", "V10.46", "427.31", "357.2", "564.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "00.45", "96.71", "00.40", "00.66", "37.23", "99.60", "36.15", "88.56", "96.04", "37.22", "88.57", "88.72", "36.06" ]

icd9pcs

[ [ [] ] ]

7833, 7918

5412, 6319

280, 332

7981, 7988

2342, 2673

8183, 8291

1883, 1910

6541, 7810

4797, 4857

7939, 7960

6345, 6518

8012, 8160

2699, 4588

1925, 2323

228, 242

4886, 5389

360, 1171

4620, 4760

1193, 1697

1713, 1867

83,419

170,823

38020

Discharge summary

report

Admission Date: [**2147-8-16**] Discharge Date: [**2147-8-22**] Date of Birth: [**2092-3-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: transferred from OSH for GI bleed evaluation Major Surgical or Invasive Procedure: Endoscopy on [**2147-8-21**] History of Present Illness: 55 yo F with hisotry of alcohol abuse transferred from OSH with GI bleed and small right frontal intraparenchymal contusion. She originally came to the OSH ED today after multiple falls at home for the 3 days prior to admission. Patient had been having dizzines, nausea, vomiting and abd pain. She reports vomitting blood. Found to have hct of 27. Got 1 unit of blood, IV protonix, and "GI cocktail" at OSH. NG lavage negative at OSH. . In the ED, initial VS: 99 100 140/80 20 100%RA. Patient was given 5mg of valium for CIWA and 60meq K and a banana bag. Had black stools that are guaic positive. Serum asa level of 5. Had taken 2 aspirin for headache. Repeat hct 27 checked while xfusion still going. finished 1/2 hour ago. VS prior to departing ED 104/68 81 15 99% on RA. CT head small right frontal intraparenchymal contusion and CT abd teratoma vs dermoid cyst. Neuro said NTD. GI will come by. . Currently, patient reported abdominal pain that was worse with inspiration. She report abd pain on right side that radiated to back. She confirms that she had episodes of hematemasis x 10, diarrhea with dark stools that were multiple and dizziness. She fell 2 days prior to admission resulting of LOC for 10 min per sons with a prodrome of dizziness. The patient says she feel so many times with her lightheadness that she could not count and she feels she would not be able to walk at this point. She has never had these symptoms before. Reports taking 5 aspirin in the past week but no motrin or tylenol. In addition, she has been intolerant of any PO intake for past 2 days. . She says last drink monday(48hrs) prior to admission. Never had seizures, intubations or DTs. She reports not having alcohol for month prior to her relapse on sunday. At her heaviest drinking she would drink 1 gallon of wine and a couple of shots of vodka nightly. She denied fever, chills, nausea, cough, or chest pain on admission. She reported difficulty when taking a deep breath but no real shortness of breath. Reports a 20-30lb unintentional weight loss with associate night sweats for past couple of months although she is vauge about these symptoms. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -alcohol abuse Social History: Denies tobacco and drugs. Endorses drinking few glasses wine and few shots vodka daily. No EtOH on Mon and admits to just one glass wine yesterday. Denied abuse at home Family History: Sister with meningitis and stroke. Other sister with learning delay. Daughter w/ stroke. Physical Exam: General Appearance: Well nourished, Anxious Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Bowel sounds present, Tender: Rupper and L quadrants, guarding Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm, multiple hematomas on back, abd, legs, and hip Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal, no pronator drift and downgoing toes Pertinent Results: [**2147-8-16**] 06:42PM GLUCOSE-103 UREA N-28* CREAT-0.6 SODIUM-143 POTASSIUM-3.4 CHLORIDE-111* TOTAL CO2-25 ANION GAP-10 [**2147-8-16**] 06:42PM CALCIUM-7.1* PHOSPHATE-1.4* MAGNESIUM-1.3* [**2147-8-16**] 06:42PM WBC-3.6* RBC-2.52* HGB-8.5* HCT-25.4* MCV-101* MCH-33.6* MCHC-33.4 RDW-19.4* [**2147-8-16**] 06:42PM PLT COUNT-126* [**2147-8-16**] 06:42PM PT-13.3 PTT-26.8 INR(PT)-1.1 [**2147-8-16**] 01:55PM GLUCOSE-102 UREA N-38* CREAT-0.8 SODIUM-141 POTASSIUM-3.0* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 [**2147-8-16**] 01:55PM estGFR-Using this [**2147-8-16**] 01:55PM ALT(SGPT)-23 AST(SGOT)-46* CK(CPK)-74 ALK PHOS-85 TOT BILI-0.6 [**2147-8-16**] 01:55PM LIPASE-79* [**2147-8-16**] 01:55PM cTropnT-<0.01 [**2147-8-16**] 01:55PM CK-MB-NotDone [**2147-8-16**] 01:55PM ALBUMIN-3.5 CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-1.3* [**2147-8-16**] 01:55PM ASA-5 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2147-8-16**] 01:55PM WBC-4.5 RBC-2.62* HGB-9.0* HCT-27.0* MCV-103* MCH-34.3* MCHC-33.4 RDW-18.1* [**2147-8-16**] 01:55PM NEUTS-68.5 LYMPHS-22.3 MONOS-8.6 EOS-0.4 BASOS-0.3 [**2147-8-16**] 01:55PM PLT COUNT-149* [**2147-8-16**] 01:55PM PT-13.0 PTT-25.1 INR(PT)-1.1 . [**8-16**] CXR FINDINGS: As compared to the previous radiograph, there is a newly placed nasogastric tube. The tube is in correct position, the side port is distal to the gastroesophageal junction. No evidence of complications, notably no pneumothorax. Otherwise, the radiograph is unremarkable. . [**8-16**] CT head without contrast IMPRESSION: 1. Small patchy hyperdense focus at the right frontal lobe, could be a small focus of intraparenchymal hemorrhage, or less likely beam hardening artifact. 2. Radiolucent line, with well-corticated margins at the right occipital bone, extending in the right foramen magnum, of indeterminate age. Brain MRI is more sensitive to evaluate for hemorrhage, if there is clinical concern. Discussed with Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**] at the time scan done. NOTE ADDED AT ATTENDING REVIEW: The small focus of hyperdensity in the right frtonal lobe appears unchanged since the outside CT, apparently acquired at 10:30 am on [**8-16**]. This stability, and specifically the absence of surrounding edema, raises the possibility that this is not acute hemorrhage related to a contusion. It may represent, for example, an occult vascular malformation. Images of the remainder of the brain also are unchanged with no evidence of hemorrhage. The occipital bone fracture is again seen, and appears identical to that on the prior CT. . [**8-16**] CT torso: 1. Findings most consistent with acute on chronic pancreatitis. However there is an abrupt change in caliper of the pancreatic duct in the bosy of the pancreas and an obstructing tumor while not seen on this single phase study cannot be entirely excluded. Further evaluation should commence with correlation with outside studies to evaluate stability of this finding. Further radiologic evaluation can be attempted with multiphase pancreas CT scan, or MRI/MRCP, although follow-up multi-phase CT after resolution of acute symptoms would be most useful. 2. Large ovarian dermoid . [**8-16**] CT C-spine IMPRESSION: 1. No fracture seen in the cervical spine. Multilevel degenerative changes in the cervical spine, most significant at level C5-C6 with posterior osteophytes impinging anteriorly on the thecal sac. CT is not sensitive for intrathecal details as MRI. 2. Radiolucent line through the right occipital bone extending in the foramen magnum ring, with well-corticated margins, of indeterminate age. No associated soft tissue swelling and no associated air-fluid levels. NOTE ADDED AT ATTENDING REVIEW: I agree with the above findings. Note that the occipital bone fracture crosses the midline superiorly and that it has the potential to compromise multiple dural sinuses if it is acute. . [**8-16**] Hip films: L greater troch non displ fx. . [**8-18**] MRI brain/cspine: . [**8-18**] Repeat head CT head Brief Hospital Course: 55 yo F with hisotry of alcohol abuse transferred from OSH with GI bleed and small right frontal intraparenchymal contusion. . # GIB: Given history thought most likely from GI bleed with upper source given hematemasis and melana. She had no history of cirrhosis but given alcoholism it was possible for her to have variceal bleed and there was a question of NSAID induced PUD. She received 1 units blood on way to [**Hospital1 **] and another unit in ICU for hct that had not bumped. GI was consulted but had to wait to do EGD until Cspine cleared. . She had an active T+S, q6hr hct that was spaced out to [**Hospital1 **] as hct stabilized, 2 PIV, NPO, once stabilized from GIB. Eventual EGD showed likely alcoholic gastritis. Hpylori antibodies were sent and showed?. She was originally placed on a protonix gtt and then switched to oral [**Hospital1 **] PP plan was made for further workup of her anemia as an outpatient by her primary care provider including [**Name Initial (PRE) **]. pylori serology. . # Trauma: Patient fell multiple times at home. Now has pinpoint cervical neck tenderness and multiple hematomas on legs, back, right hip, and abdomen concerning for more diffuse injuries. R frontal contusion, small inferior already found on OSH scan but will repeat. Noncon head CT showed like small right frontal contusion. Neuro consult followed. CT- non con C spine wihtout acute fracture but osteophytes that could be compressing on thecal sac. She was put in [**Location (un) 2848**] J collar until MRI cleared ligamentous injury. MRI brain needed to clear C-spine and rule out cord compression, CT torso showed acute on chronic pancreatits and questionable lesion at head of pancreas that could not rule out carcinoma. Plain film hip, pelvis showed nondisplaced right trochanteric fracture. Orthopedics was consulted, but because it was nondisplaced, she can be full weight bearing as tolerated and does not need surgical management. She was given tylenol and morhpine for pain. . # Abd pain: Diffuse abd pain with guarding mostly on R upper and low quadrants by exam most likely etiology was acute on chronic pancreatitis. No lab evidence to suggest cholecystits or alc hep. No fever to suggest infection. Given diarrhea, inflammatory vs ischemic colitis is possible. Lactate trended down. CT scan confirmed pancreatitis however was unable to rule out an obstructing tumor. Improved with NPO, IVF and morphine. A plan was made for further imaging as an outpatient by her PCP. . # AMS: Patient became more confused after 12 hours of admission at night not knowing where she was, tried to get out of bed, and confabulating. CT head was repeated. UA was sent. Thought [**12-19**] Wernike's/Korosokoff alcoholism. 1:1 sitter needed. Utox sent but meds c/w what had been given. Haldol was used to control confusion and aggitation. She was treated for Wernike's encephalopathy with 100mg IV thiamine for 5 days. An EEG did not reveal any pathology. . # Alcoholism: Reports last drink 48hours prior to admission. Family had never seen her not drunk in fact she had been drinking more recently because she inherited money from her father's death. Also with confabulating and history of unable to walk concern for Wernicke's encephalopathy although no eye findings. Received banana bag in ED and treatment as above. Put on CIWA but she required very minimal Valium. Continued MVI, folate and thiamine. Posey restraints were needed. Social work was consulted to establish outpatient support. Medications on Admission: None Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Please do not take more than 2 g/day. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastritis Sub-dural hematoma Secondary: Alcohol abuse Acute Pancreatitis Discharge Condition: Good. The patient's VS are stable, and she is able to ambulate with a walker. Discharge Instructions: You were admitted to the hospital because you had several falls and were found to have some internal bleeding from your gastrointestinal system. You were given intravenous fluids and blood transfusion, and an endoscopy revealed that you had an alcohol related gastritis. Imaging was done on your head and neck given the falls that you had, and a small bleed inside your head was found, but no other trauma. While you were here, we made the following changes to your medications: 1. We STARTED you on Pantoprazole 40mg [**Hospital1 **] 2. We STARTED you on folic acid 1mg daily 3. We STARTED you on thiamine 100mg daily Please return to the emergency room if you feel dizzy, light headed, have bleeding, feel like passing out, have shortness of breath, chest pain, abdominal pain, headache, fever, sweats, chills or any other symptoms you may be concerned about Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP). Date and time: Tuesday, [**8-29**] @ 10:50 am ( please arrive @ 10:30 for new patient paper work). Location: 1000 [**Last Name (LF) **], [**First Name3 (LF) **] [**Numeric Identifier 9121**]. Phone number: [**Telephone/Fax (1) 1144**] Special instructions if applicable: *** Patient must call MASS Health ( [**Telephone/Fax (1) 25370**]) to change PCP, [**Name10 (NameIs) **] primary site for care to the [**Hospital1 69**] prior to her visit for payment coverage for this appointment. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (Gastroenterology). Date and time: Wednesday, [**8-30**] @ 1:30 pm. Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 452**] 1. Phone number: [**Telephone/Fax (1) 463**] - You were found to have an abnormality of your pancreas, which needs further evaluation. You should have a MRI or MRCP of your abdomen in approximately 3 weeks. Please ask your PCP to arrange this.

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