ChanBeDu/relevant_section_length · Datasets at Hugging Face

42,709

181,446

41716

Discharge summary

report

Admission Date: [**2125-1-9**] Discharge Date: [**2125-1-13**] Date of Birth: [**2056-8-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2125-1-9**] Coronary artery bypass grafting times 3 with a reverse saphenous vein graft from the aorta to the left anterior descending coronary artery; reverse saphenous vein graft from aorta to the first obtuse marginal coronary artery; reverse saphenous vein graft from the aorta to the posterior descending coronary artery History of Present Illness: 68 year old male who was initially seen in [**2124-5-5**] with a 6 month history of symptoms. At that time, he reported chest pain, chest tightness and shortness of breath with minimal exertion relieved with rest. He was referred for a stress ECHO on [**4-20**], [**2124**] which was abnormal and at that time, he was noted to have thrombocytopenia for which he was sent for evaluation. He was treated with chemotherapy and prednisone therapy. His platelets are currently considered stable for antiplatelet therapy. Currently, he reports that symptoms have resolved since losing 30 pounds. He was referred for cardiac catheterization for further evaluation. He was found to have coronary artery disease upon catheterization and is now being referred to cardiac surgery for revascularization. Past Medical History: Hyperlipidemia Coronary artery disease Mild cardiomyopathy Spinal stenosis Chronic back pain d/t being hit by a truck 10 years ago Fatty liver Sleep apnea-diagnosed, however, resolved since weight loss Chronic Interstitial pulmonary fibrosis-will be followed by routine CT scans Thrombocytopenia- s/p bone marrow biopsy [**2124-4-21**], chemo therapy x 4 treatments and prednisone therapy Skin cancer s/p excision Social History: Race:Caucasian Last Dental Exam:has 3 native teeth with upper and lower plates, has not seen a dentist in a "long time" Lives with:Wife Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90642**] Occupation: Telephone technician Cigarettes: Smoked no [] yes [x] Hx:2ppd x 20 years, quit 35 years ago Other Tobacco use:denies ETOH: < 1 drink/week [x] [**3-13**] drinks/week [] >8 drinks/week [] Illicit drug use: Marijuana use 30 years ago. Family History: Premature coronary artery disease- Brother with heart transplant @ age 62 Physical Exam: Pulse:53 Resp:18 O2 sat:99/RA B/P Right:127/84 Left:133/84 Height:5'9" Weight:215 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [] Neuro: Grossly intact [x] Pulses: all palpable Discharge Exam: [**2125-1-13**] VS: T:99.2 HR: 80-100 SR BP: 99-120/60-70 Sats: 95 RA Weight: 99.9 kg General: 68 year-old male in no apparent distress HEENT: normocephalic mucus membranes moist Neck:supple no lymphadenopathy Card: RRR no murmur Normal S1,S2 Resp: late crackles 1/4 up bilateral GI: obese, soft non-tender/non-distended Extr: warm [**2-6**]+ edema Incision: sternal and left lower extremity clean dry intact Neuro: awake, alert oriented. Pertinent Results: [**2124-1-10**] Echo: PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. The right atrium is moderately dilated. 3. No atrial septal defect is seen by 2D or color Doppler. 4. The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with normal free wall contractility. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 7. Mild (1+) mitral regurgitation is seen. POST CPB: On infusion of phenylephrine. A pacing for slow sinus. Preserved biventricular systolic function with LVEF = 50 %. MR is trace, AI is 1+. The aortic contour is normal post decannulation. CXR: [**2125-1-12**]: IMPRESSION: PA and lateral chest Only mild residual interstitial pulmonary edema remains, postoperative widening of the cardiomediastinal silhouette is stable, and there is moderate-to-severe bibasilar atelectasis, left greater than right. There is no pneumothorax. [**2125-1-13**] WBC-7.6 RBC-3.49* Hgb-10.0* Hct-29.3* MCV-84 MCH-28.6 MCHC-34.1 RDW-14.3 Plt Ct-150 [**2125-1-9**] WBC-15.1*# RBC-3.61* Hgb-10.3* Hct-30.4* MCV-84 MCH-28.4 MCHC-33.7 RDW-13.8 Plt Ct-75* [**2125-1-13**] Glucose-183* UreaN-14 Creat-0.7 Na-135 K-3.4 Cl-99 HCO3-27 [**2125-1-9**] UreaN-12 Creat-0.7 Na-142 K-3.8 Cl-111* HCO3-26 Brief Hospital Course: Mr. [**Known lastname 90643**] was a same day admit after undergoing pre-operative work-up at the time of his cardiac cath. On [**1-9**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta-blockers and diuretics and diuresed towards his pre-op weight. Later on this day he was transferred to the step-down unit for further recovery. Chest tubes and epicardial pacing wires were removed per protocol. His pain was well controlled with Tramadol. Foley replaced for 1 Liter of urinary retention, flomax was started x 24 hours subsquently removed and he voided. Blood sugars were less than 150. He was followed by Physical therapy who recommended rehab. He continued to make steady progress and was discharged to [**Male First Name (un) 4542**] [**Hospital 6252**] Nursing and Rehab Center in N.[**Hospital1 1562**]. Medications on Admission: ATENOLOL 50 mg daily LISINOPRIL 2.5 mg daily SIMVASTATIN 20 mg daily ASPIRIN 81 mg daily MULTIVITAMIN 1 Tablet daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 12. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 5 days. 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: Hyperlipidemia Mild cardiomyopathy Spinal stenosis Chronic back pain d/t being hit by a truck 10 years ago Fatty liver Sleep apnea-diagnosed, however, resolved since weight loss Chronic Interstitial pulmonary fibrosis-will be followed by routine CT scans Thrombocytopenia- s/p bone marrow biopsy [**2124-4-21**], chemo therapy x 4 treatments and prednisone therapy Skin cancer s/p excision Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Please call to schedule follow-up appointments with Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 66291**] Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23239**] in [**5-9**] weeks [**Telephone/Fax (1) 24047**] **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:[**2125-1-13**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.13" ]

icd9pcs

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10490

Discharge summary

report

Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-28**] Service: CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 79 year old female with no prior history of coronary artery disease who complains of substernal chest pain around 11:00 p.m. the night prior to admission on [**2142-2-24**]. EMS was called to the scene and did an electrocardiogram in the field which showed ST segment elevation approximately 3.0 millimeters in II, III and aVF. At the time, the patient was watching television and developed sudden onset chest pain and left shoulder pain. She denied any shortness of breath, did have some nausea, no vomiting, did have some diaphoresis at the time. The patient was given three Baby Aspirin, 4 milligrams Morphine Sulfate, sublingual Nitroglycerin without relief. The patient's chest pain was ten out of ten on arrival to the Emergency Department. Heparin and intravenous Nitroglycerin were started in the Emergency Room with some relief of the pain. The patient's chest pain was then five out of ten and only in her back, chest, no diaphoresis, however, she continued to have ST segment changes in II, III and aVF. Right sided leads in the field were flat for V4 changes. The patient's cardiac risk factors include her age, hypertension and extensive tobacco use. PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Seizure disorder times approximately two years, status post multiple falls treated with Dilantin. 3. Neuropathy, unclear etiology. 4. History of pneumonia. 5. Hypothyroidism. 6. Depression. 7. Status post appendectomy. 8. Status post cholecystectomy. 9. Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. 10. Status post bilateral knee replacement. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Dilantin 100 milligrams p.o. t.i.d. 2. Doxepin 50 milligrams one to two tablets p.o. q.h.s. 3. Levothyroxine 0.5 milligrams p.o. q.d. 4 Remeron 10 milligrams p.o. q.d. 5. Ambien p.r.n. SOCIAL HISTORY: The patient has significant tobacco use history with more than 60 years of smoking one to two packs per day. No significant alcohol use. The patient lives alone, however, lives in the same building with her son who is very involved in her care. FAMILY HISTORY: Brother died of myocardial infarction at age 73. Sister had myocardial infarction at age 68. PHYSICAL EXAMINATION: Vital signs reveal temperature 95, pulse 96, blood pressure 110/70, respiratory rate 14, 95% in room air. In general, the patient is comfortable lying in bed in no acute distress, pleasant and conversational. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The oropharynx is clear. The mucous membranes are moist. The neck reveals no lymphadenopathy, no elevated jugular venous distention. The lungs are clear to auscultation bilaterally. The heart is regular rate and rhythm, normal S1 and S2, no S3 or S4. There is a small ejection murmur at the left sternal border. The abdomen is soft, nontender, nondistended, positive bowel sounds throughout. Extremities revealed no edema. Distal pulses are dopplerable. LABORATORY DATA: At the time of admission, complete blood count revealed white count 8.1. with 81 neutrophils, 0 bands, 11 lymphocytes, hematocrit 33.9, platelets 201,000. Prothrombin time 13.4, partial thromboplastin time 78, INR 1.2. Sodium 143, potassium 4.7, chloride 107, bicarbonate 25, blood urea nitrogen 23, creatinine 0.7, glucose 125. CK 60. Chest x-ray no acute cardiopulmonary process. Echocardiogram from [**2142-2-25**], revealed no significant effusion or tamponade. Cardiac catheterization from [**2142-2-25**], selective coronary arteriography of the right dominant system revealed two vessel coronary artery disease, the left main coronary artery was normal. Left anterior descending had a 50% lesion at the origin of the first septal branch. The left circumflex had a 70% lesion in its midportion. The dominant right coronary artery was totally occluded in its midportion with extensive clot burdened throughout its midportion. Initial hemodynamic measurements revealed normal systemic pressure with an opening central pressure of 120/64. Intervention on occluded mid right coronary artery using Reolytic thrombectomy (angiojet) and stenting times one with excellent angiographic results and timi free flow. The procedure was complicated by significant bradycardia, transient atrial fibrillation and hypotension requiring temporary pacing and intra-aortic balloon insertion. Blood pressure recordings are not available following placement of the intra-aortic balloon pump. At the completion of the case, her augmented diastolic pressure was 100 on a one to one setting. After the intra-aortic balloon pump was placed, the patient was transiently in atrial fibrillation. At the time of transfer to the CCU, she had spontaneously converted to a normal sinus rhythm. An urgent echocardiogram was performed in the Catheterization Laboratory to rule out effusion/tamponade (following placement of the temporary pacing wire). The study was limited but the right ventricle was well visualized with no significant effusion and no evidence of tamponade. FINAL DIAGNOSES: 1. Two vessel coronary artery disease. 2. Acute inferior myocardial infarction managed by acute stenting of right coronary artery. 3. Plavix ordered times four weeks. 4. Intra-aortic balloon pump placement. 5. Temporary pacing wire placement via the right femoral vein. HOSPITAL COURSE: The patient was admitted to the CCU service. 1. Cardiovascular - Rhythm - The patient was placed on telemetry, maintained normal sinus rhythm. No significant events during hospitalization. The patient's CKs were drawn during hospitalization with a peak CK of 1315 and a CK upon admission of 60. The patient's cholesterol levels were also checked. Total cholesterol was 135, LDH 55, HDL 65, cholesterol/HDL ratio 2.1, triglycerides 73. Pump - The patient remained hemodynamically stable. Intra-aortic balloon pump and Dopamine discontinued on [**2142-2-25**], without complication. Coronary artery disease - The patient was continued on Aspirin, Plavix. Beta blocker and ace inhibitor were started, however, due to blood pressure the patient was continued only on the beta blocker. Ace inhibitor was discontinued. 2. Peripheral vascular - The patient developed hematoma status post cardiac catheterization. Pressure was applied postcatheterization. Hematoma remained stable and began to resolve. The patient's hematocrit remained stable until [**2142-2-27**], at which time it was noted to be 25.0, down from 30.0. 3. Hematology - The patient was noted with mild anemia upon admission. Baseline hematocrit was 33.0. Postcatheterization, the patient did not require blood products, however, on [**2142-2-27**], the patient's hematocrit was noted to be significantly lower at 25.0 from 30.0 the day prior. There was no clear source of bleeding. The patient's hematoma was stable and the patient was occult blood negative. The patient was transfused one unit of packed red blood cells on [**2142-2-27**]. 4. Infectious disease - The patient is status post recent urinary tract infection previously treated with antibiotics prior to admission. Urinalysis sent on [**2142-2-25**], was negative for evidence of infection. 5. Neurologic - The patient with a history of seizure disorder on Dilantin at home. Phenytoin level was sent which was subtherapeutic at 3.1 The patient was given a bolus of Dilantin 300 milligrams times one. 6. Physical therapy - The patient was evaluated by physical therapy consult on [**2142-2-27**], who recommended cardiac rehabilitation and home physical therapy after discharge. 7. FEN - The patient was placed on a cardiac diet and maintained good p.o. during hospitalization. DISCHARGE STATUS: Stable. DISCHARGE MEDICATIONS: 1. Atenolol 25 milligrams p.o. q.d. 2. Aspirin 325 milligrams p.o. q.d. 3. Plavix 75 milligrams p.o. q.d. times thirty days until [**2142-3-25**]. 4. Dilantin 100 milligrams p.o. t.i.d. 5. Colace 100 milligrams p.o. b.i.d. 6. Combivent inhaler. 7. Flovent inhaler. 8. Synthroid 150 mcg p.o. q.d. 9. Doxepin 50 milligrams one to two tablets p.o. q.h.s. 10. Vicodin two tablets p.o. q4-6hours p.r.n. back pain. The patient is to follow-up with [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**], her primary care physician. [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 5456**] was contact[**Name (NI) **] by telephone by myself and informed of the [**Hospital 228**] hospital course. In addition, a packet of materials was sent to [**First Name8 (NamePattern2) **] [**Doctor Last Name 5456**] on his fax number including hospital laboratory values, test results and discharge medications. [**First Name8 (NamePattern2) **] [**Last Name (Titles) 34604**] telephone number is [**Telephone/Fax (1) 34605**], fax number [**Telephone/Fax (1) 34606**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 27618**] MEDQUIST36 D: [**2142-2-27**] 17:59 T: [**2142-2-27**] 18:18 JOB#: [**Job Number 34607**]

[ "244.9", "414.01", "427.31", "285.9", "458.2", "410.41", "305.1", "780.39", "715.90" ]

icd9cm

[ [ [] ] ]

[ "36.06", "88.56", "36.01", "88.42", "37.61", "37.22", "88.53" ]

icd9pcs

[ [ [] ] ]

2304, 2399

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144, 1333

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29471

Discharge summary

report

Admission Date: [**2179-12-11**] Discharge Date: [**2179-12-12**] Date of Birth: [**2155-10-15**] Sex: F Service: MEDICINE Allergies: Peanut Attending:[**First Name3 (LF) 398**] Chief Complaint: lip swelling Major Surgical or Invasive Procedure: none History of Present Illness: This is a 24 yo female with a PMH significant for prior allergic reaction in the past thought to be due to peanuts, who presents with persistent and worsening facial swelling. The patient originally presented to the ED 1 day PTA with lip swelling several hours after eating her lunch. She states that she had noted a bump on her lower left lip prior to eating, and then she proceded to eat steak, eggs, fruit, bagel/cream cheese. The pts lip swelling was felt to be due to either an allergic reaction or trauma, and she was discharged with benadryl and penicillin. The pt took 4 tablets of Benadryl 25 mg po after she returned home, as well as 1 penicillin. She awoke this am with worsening lip swelling, but denies any n/v/d, f/c/s, respiratory distress, odynophagia, tongue swelling, chest pain, palpitations, or headache. . In the ED, the pt was given solumedrol 80 mg IVx1, Pepcid 40 mg IVx1, epinephrine 1 mg IV x3, and Benadryl 50 mg IV x1 without relief of symptoms. The pt was transferred to MICU green for monitoring. Past Medical History: --h/o similar allergic reaction 4 years ago after eating honey nut cheerios, hospitalized in [**Location (un) 47**]. Allergic reaction was felt to be due to peanuts. Pt has not seen an allergist. Social History: Lives in [**Location **]; ocassional ETOH, no illicit drug use, no tobacco use Family History: Mother--asthma, allergy to [**Name (NI) 26204**]; no h/o angioedema in family Physical Exam: Vitals: afebrile, BP 128/62 P 111 R 15 Sat 99% RA Gen: overweight female lying in bed watching TV, NAD HEENT: lip swelling with lower lip>upper lip and R lip >L lip, BL cheek swelling, OP visible without tongue swelling, Neck: supple, no JVD CV: tachy, grade 2/6 SEM LUSB without radiation Lungs: CTAB, no w/r/r Ab: soft, NTND, NABS Extrem: no c/c/e, full dp/pt pulses Neuro: MAFE, appropriate affect Skin: no hives/urticaria Pertinent Results: [**2179-12-11**] 08:45AM GLUCOSE-79 UREA N-9 CREAT-0.7 SODIUM-137 POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [**2179-12-11**] 08:45AM estGFR-Using this [**2179-12-11**] 08:45AM WBC-10.6 RBC-4.27 HGB-13.1 HCT-39.6 MCV-93 MCH-30.6 MCHC-33.0 RDW-13.2 [**2179-12-11**] 08:45AM NEUTS-61.1 LYMPHS-32.2 MONOS-4.3 EOS-1.3 BASOS-1.0 Brief Hospital Course: This is a 24 yo female with a PMH significant for prior allergic reaction in the past thought to be due to peanuts, who presents with angioedema. . #Angioedema: Pt has a prior h/o possible peanut allergy. She has not seen an allergist in the past. The patient has no clear history of eating any peanuts or other allergens. Of note, her symptoms did worsen after taking penicillin, so she may have a [**Month/Day/Year 26204**] allergy (esp. given her h/o eczema and FH of atopy)in addition. She was started on Pepcid 40 mg IV q 12 hr, Benadryl 50 mg IV q 6 hr, Solumedrol 40 mg IV q 6 hr upon admission. The patients angioedema improved by the following morning. C1 esterase inhibitor levels, C2, and C4 levels were sent to evaluate for complement mediated angioedema (pending). Tryptase levels were sent to evaluate for mast cell mediated angioedema (pending). By the morning after admission, the patient's angioedema had decreased significantly. She was discharged with a prescription for Epi pens and benadryl. The patient will need to seen an allergist after discharge for formal evaluation of her angioedema. Until then, she should avoid peanuts and penicillin. Medications on Admission: Ortho tri cyclen Lo Discharge Medications: 1. Epinephrine 1 mg/mL Solution Sig: One (1) pen Injection once a day as needed for shortness of breath or wheezing. Disp:*5 epi pens* Refills:*0* 2. Benadryl 25 mg Capsule Sig: [**1-18**] Capsules PO once as needed for allergy symptoms. Discharge Disposition: Home Discharge Diagnosis: angioedema Discharge Condition: stable, no respiratory difficulty, satting 99% room air Discharge Instructions: Please avoid peanuts and penicillin at this time. Return to the ER for recurrent lip swelling, difficulty swallowing, difficulty breathing, or any other concerning symptoms Followup Instructions: Please follow up with an allergist in the next week.

[ "995.1", "E930.0" ]

icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

4105, 4111

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282, 289

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3842, 4082

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Discharge summary

report

Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-21**] Date of Birth: [**2173-1-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3977**] Chief Complaint: LLQ/flank pain. Major Surgical or Invasive Procedure: Picc line placed, then removed at discharge. History of Present Illness: Mr. [**Known lastname **] is a 21 y.o. man w/ a history of AIHA s/p splenectomy ([**3-/2194**]) on prednisone, PE and portal vein thrombosis (on warfarin), and IgA deficiency, who presented with 3 days of nausea/vomiting and suprapubic/LLQ pain accompanied by dark urine. He noted that his vomiting began 3 days ago at night. He did not see what his vomit looked like at that time. He then had another episode the next morning, which he said appeared "brown." Altogether, he notes vomiting more than 10 times in the last three days, with some of the vomit appearing to be "coffee-ground" in nature. He felt as if having a bowel movement would make him feel less nauseous, but he had one earlier today but it did not help him. He said his stool was hard, brown, and non-bloody. One day ago he began having LLQ/suprapubic pain which was stabbing in nature and would radiate to his back and left flank. He would not be able to get comfortable due to this pain, which he said would range from [**2192-4-16**]. He said in this setting his urine began looking like "cola," and it would hurt him when he urinated. He noticed what looked like blood in his urine as well. Of note, he was healthy until [**9-/2193**], when he visited [**Hospital1 **] to see a friend who just had a child and was noted to be jaundiced and unsteady. He was found to be profoundly anemic and was diagnosed with autoimmune hemolytic anemia (Coombs+) and IgA deficiency. He underwent a splenectomy 4/[**2193**]. He developed chest pain in [**4-/2194**], and he was found on OSH imaging to have bilateral PEs and portal vein thrombosis. He was also treated for pneumonia in this setting. He has been chronically SOB, especially on exertion, noting that he can only walk up 1 flight of stairs or walk about 20 yards without needing to rest. He says he wheezes in the setting of exertion. He has had chest pain ever since his PE diagnosis in [**Month (only) 116**], although the pain has decreased since then. He also noted fevers, chills, 50-60 lb weight gain since beginning prednisone in [**9-/2193**], weakness since beginning prednisone. He has chronic headaches. He denied dizziness and lightheadedness. He takes "8 tylenol on average" per vascular surgery note. He originally presented to [**Hospital3 **], where WBC 65.5 and Hct 19.5. 11% bands, 5% metamyelocytes, 122 nucleated RBCs. He received a CT abdomen/pelvis, which found persistent non-occlusive extrahepatic portal vein thrombosis, R hepatic lobe intrahepatic portal vein thrombosis, L renal swelling, fat stranding, and perinephric fluid. L mid-hydroureter w/ the distal L ureter appearing relatively collapsed. No apparent ureterolithiasis. He received hydrocortisone, ondansetron, Zosyn, and ceftriaxone. He was then transferred to the [**Hospital1 18**] ED for further management. In the ED, initial VS were: T 97.2, HR 90, BP 144/88, RR 18, O(2)Sat: 98%. WBC 26.5, HCT 18.6, ALT 51, AST 166, LDH 4070, Tbili 2.8, and Dbili 1.0. Haptoglobin <5. U/A significant for WBC 47, RBCs 36, but negative nitrite, trace leukocyte esterase, few bacteria, 0 epis. Hematology was consulted and recommended 1mg/kg solumedrol, PPI, checking H.pylori, giving 5 mg folate QD, IV heparin, and bone marrow bx/aspirate. Vascular surgery was consulted and recommended a renal US. A preliminary read of a Renal US indicated L renal vein thrombosis. Urology was consulted and did not feel that there was a focal arterial process to intervene upon. On arrival to the MICU, T99, HR 112, BP 117/68, RR 26, 94% on 2L NC. He was fatigued but not in any apparent distress. He was started on vancomycin/cefepime for his suspected pyelonephritis and ordered for 2U packed RBCs. Review of systems: (+) Per HPI. Also notes b/l hand tremor, b/l elbow pain, and acne formation on arms b/l. (-) Denies night sweats. Denies sinus tenderness, rhinorrhea or congestion. Denies cough. Denies rash. Past Medical History: Autoimmune Hemolytic Anemia Hx Bilateral PE ([**4-/2194**], on warfarin) Portal Vein Thrombosis IgA Deficiency Hx Pneumonia (1 time in setting of b/l PE [**4-/2194**] and treated [**Date range (1) 112318**]) Hearing Loss (since birth, has used hearing aid since age [**3-13**]) S/P Splenectomy [**3-/2194**] S/P Tonsillectomy S/P B/L Tympanostomy tube placement as child Social History: Mr. [**Known lastname **] lives with his grandfather in [**Location (un) 10072**], MA. He used to work at [**Last Name (un) 6058**] but can no longer work given the limitations from his illness. He has an 8 pack-year smoking history (1 pack/day since age 14), but he recently quit following his diagnosis of PE. He has [**2-9**] alcoholic drinks/week. He denies a history of recreational drug use. Family History: He notes that his grandfather, mother, father, aunt, cousin, and brother all have hematologic abnormalities. Great grandmother w/ breast cancer, grandfather w/ skin cancer. Physical Exam: ADMISSION EXAM: Vitals: T: 99, HR: 119, BP: 124/60, RR: 25, 94% on 3L General: Alert and oriented x3 , fatigued HEENT: Sclera icteric, MMD, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, nl S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: soft, TTP in LLQ, non-distended, bowel sounds present, no organomegaly GU: TTP in Left Flank, nauseous when palpating suprapubic region Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly intact strength/sensation upper/lower extremities, gait deferred, coordination grossly intact Pertinent Results: ADMISSION LABS: [**2194-6-12**] 03:19AM BLOOD WBC-37.1* RBC-2.59* Hgb-7.9* Hct-21.6* MCV-83 MCH-29.5 MCHC-36.3* RDW-25.5* Plt Ct-178 [**2194-6-11**] 10:00PM BLOOD WBC-33.0* RBC-2.39* Hgb-6.8* Hct-19.9* MCV-83.0 MCH-27.4 MCHC-34.2 RDW-25.7* Plt Ct-145* [**2194-6-11**] 04:29PM BLOOD WBC-44.3* RBC-2.32* Hgb-6.8* Hct-19.7* MCV-85 MCH-29.2 MCHC-34.4 RDW-26.1* Plt Ct-143* [**2194-6-11**] 04:17AM BLOOD WBC-47.3* RBC-2.20* Hgb-6.4* Hct-18.7* MCV-85 MCH-29.0 MCHC-34.1 RDW-25.6* Plt Ct-126* [**2194-6-10**] 04:55PM BLOOD WBC-44.6* RBC-2.40* Hgb-7.0* Hct-20.4* MCV-85 MCH-29.2 MCHC-34.3 RDW-26.3* Plt Ct-125* [**2194-6-10**] 10:32AM BLOOD WBC-35.0* RBC-2.44* Hgb-7.2* Hct-20.8* MCV-85 MCH-29.6 MCHC-34.7 RDW-25.4* Plt Ct-122* [**2194-6-10**] 02:46AM BLOOD WBC-36.0* RBC-2.30* Hgb-6.8* Hct-19.6* MCV-85 MCH-29.6 MCHC-34.6 RDW-27.0* Plt Ct-115* [**2194-6-9**] 02:45PM BLOOD WBC-26.5* RBC-2.19*# Hgb-6.4*# Hct-18.6*# MCV-85# MCH-29.1 MCHC-34.2 RDW-30.5* Plt Ct-140* [**2194-6-10**] 02:46AM BLOOD Neuts-81* Bands-2 Lymphs-5* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* NRBC-66* [**2194-6-9**] 02:45PM BLOOD Neuts-80* Bands-0 Lymphs-7* Monos-4 Eos-1 Baso-1 Atyps-0 Metas-2* Myelos-5* NRBC-85* [**2194-6-10**] 02:46AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+ Macrocy-2+ Microcy-2+ Polychr-1+ Spheroc-OCCASIONAL Stipple-1+ Tear Dr[**Last Name (STitle) 833**] [**2194-6-9**] 02:45PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-NORMAL Macrocy-1+ Microcy-3+ Polychr-3+ DISCHARGE LABS: [**2194-6-12**] 03:19AM BLOOD PT-13.0* PTT-64.2* INR(PT)-1.2* [**2194-6-11**] 10:00PM BLOOD PT-13.0* PTT-62.9* INR(PT)-1.2* [**2194-6-11**] 04:28PM BLOOD PT-12.9* PTT-84.9* INR(PT)-1.2* [**2194-6-11**] 07:30AM BLOOD PT-13.0* PTT-45.2* INR(PT)-1.2* [**2194-6-11**] 01:42AM BLOOD PT-13.5* PTT-66.4* INR(PT)-1.3* [**2194-6-10**] 04:55PM BLOOD PT-13.8* PTT-58.6* INR(PT)-1.3* [**2194-6-10**] 10:32AM BLOOD PT-13.8* PTT-60.3* INR(PT)-1.3* [**2194-6-10**] 02:46AM BLOOD PT-14.4* PTT-55.1* INR(PT)-1.3* [**2194-6-9**] 02:45PM BLOOD Fibrino-426* [**2194-6-9**] 02:45PM BLOOD Ret Man-29.6* [**2194-6-12**] 03:19AM BLOOD Glucose-149* UreaN-15 Creat-1.5* Na-132* K-4.1 Cl-96 HCO3-19* AnGap-21 [**2194-6-11**] 04:28PM BLOOD Glucose-106* UreaN-17 Creat-1.3* Na-134 K-3.8 Cl-97 HCO3-23 AnGap-18 [**2194-6-11**] 04:17AM BLOOD Glucose-181* UreaN-16 Creat-1.3* Na-131* K-4.2 Cl-96 HCO3-24 AnGap-15 [**2194-6-10**] 11:03AM BLOOD Glucose-134* UreaN-18 Creat-1.3* Na-131* K-5.0 Cl-100 HCO3-21* AnGap-15 [**2194-6-10**] 02:46AM BLOOD Glucose-162* UreaN-19 Creat-1.3* Na-133 K-5.2* Cl-100 HCO3-22 AnGap-16 [**2194-6-9**] 02:45PM BLOOD Glucose-141* UreaN-18 Creat-1.3* Na-136 K-5.5* Cl-100 HCO3-25 AnGap-17 [**2194-6-12**] 03:19AM BLOOD ALT-47* AST-91* LD(LDH)-3994* AlkPhos-104 TotBili-2.9* [**2194-6-9**] 02:45PM BLOOD ALT-51* AST-166* LD(LDH)-4070* AlkPhos-117 TotBili-2.8* DirBili-1.0* IndBili-1.8 [**2194-6-12**] 03:19AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.0* Mg-2.1 [**2194-6-12**] 06:02AM BLOOD UricAcd-5.1 [**2194-6-11**] 04:28PM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3 [**2194-6-10**] 02:46AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 [**2194-6-9**] 02:45PM BLOOD UricAcd-6.9 Iron-52 [**2194-6-9**] 02:45PM BLOOD calTIBC-341 VitB12-640 Hapto-<5* Ferritn-118 TRF-262 [**2194-6-12**] 06:02AM BLOOD Osmolal-280 [**2194-6-10**] 02:46AM BLOOD b2micro-2.7* IgG-673* IgA-<5* IgM-63 [**2194-6-12**] 06:02AM BLOOD Vanco-15.1 [**2194-6-9**] 02:59PM BLOOD Lactate-1.1 [**2194-6-12**] 03:19AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [**2194-6-9**] CXR: IMPRESSION: No acute cardiopulmonary process. . [**2194-6-9**] RENAL U/S: IMPRESSION: Reversal of diastolic flow in the two identified separate left main renal arteries and overall decreased vascularity in the left kidney is most consistent with left renal vein thrombosis, including no identifiable flow in the left main renal vein. . [**2194-6-16**] MR ABD IMPRESSION: 1. Unchanged thrombus within the left renal vein with absent enhancement and restricted diffusion of the left renal medullary pyramids compatible with infarction. 2. Blood clot noted within the left collecting system and ureter. 3. Hemosiderin deposition within the renal cortices bilaterally, likely secondary to intravascular hemolysis. 4. Unchanged portal venous thrombus. . [**2194-6-18**] Tagged RBC scan for accessory spleen eval. IMPRESSION: Inconclusive study due to inadequate RBC damaging. A sulfur colloid could be used to try to identify accessory splenic tissue. . [**2194-6-20**] RENAL FUNCTION SCAN- IMPRESSION: 1- Absence of blood flow and decreased renal uptake noted in the left kidney and adequate blood flow noted in right kidney. 2- Left kidney shows approximately 10% of the total renal function and the right kidney shows 90%. . DISCHARGE LABS: [**2194-6-21**] 05:22AM BLOOD WBC-25.0* RBC-3.89* Hgb-11.3* Hct-33.2* MCV-85 MCH-29.0 MCHC-34.1 RDW-24.6* Plt Ct-393 [**2194-6-20**] 06:00AM BLOOD WBC-26.8* RBC-3.94* Hgb-11.3* Hct-33.2* MCV-84 MCH-28.8 MCHC-34.1 RDW-25.5* Plt Ct-332 [**2194-6-18**] 05:20AM BLOOD Neuts-85* Bands-0 Lymphs-1* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* NRBC-173* [**2194-6-20**] 06:00AM BLOOD Glucose-304* UreaN-13 Creat-1.0 Na-135 K-4.7 Cl-95* HCO3-28 AnGap-17 [**2194-6-21**] 05:22AM BLOOD UreaN-17 Creat-0.9 [**2194-6-21**] 05:22AM BLOOD LD(LDH)-1661* [**2194-6-20**] 06:00AM BLOOD ALT-55* AST-25 LD(LDH)-[**2145**]* AlkPhos-88 TotBili-1.0 [**2194-6-20**] 06:00AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.0 Mg-2.2 [**2194-6-19**] 06:00AM BLOOD calTIBC-319 Hapto-<5* Ferritn-181 TRF-245 [**2194-6-10**] 02:46AM BLOOD b2micro-2.7* IgG-673* IgA-<5* IgM-63 Brief Hospital Course: 21 y.o. man with PMH of AIHA s/p splenectomy, IgA deficiency, PE, and portal vein thrombosis (on warfarin) who presented w/ n/v, suprapubic/LLQ pain, found to have renal vein thrombosis as well as a markedly elevated WBC (37.1 this AM), the underlying etiology of which is not clear. However, his diagnosis is related to either a warm auto-immune hemolytic process and/or paroxysmal nocturnal hemoglobinuria processes. . Briefly, the patient was started on hi dose steroids and danazol and now has stabilized his blood counts. Rituximab was initially considered for concern of refractory hemolytic anemia as supported by Coomb's positive studies. However, he developed C Diff in the interim and Rituximab therapy was deferred. During the workup for his hypercoaguable state, flow cytometry studies suggested he had PNH cells. Therefore the use of rituximab came into question as he may have a better diagnosis of PNH to explain his hemolytic anemia and thrombosis. He is clinically stable and his Hgb is stable for several days now at time of discharge. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the hematology service will follow this patient as an outpatient and met the patient several times. . Attention was given to his complicated discharge plans including ensuring he will have his medications when he returns home and close followup. Other details below. . 1. Warm AIHA: Positive DAT IgG+, C3b negative. HIV and hepatitis B/C serologies negative. Panagglutinating antibody by routine method [solid phase], autoanti-c in [**Last Name (un) 101**]. BMB showed an appropriate erythroid hyperplasia, no lymphoma. Beta2-glycoprotein-1 negative. [**Doctor First Name **] negative. Flow for PNH show acquired PNH phenotype. Bone marrow cytogenetics normal. - Received 3 units PRBC [**6-9**], [**6-10**], [**6-13**] - D/c methylprednisolone [**2194-6-20**]. - Change to po steroids ([**2194-6-20**])- prednisone 120 mg daily (1 mg/kg daily). Dr [**Last Name (STitle) **] from hematology will manage next dose change. - Cotinue danazol, dose increased from 200 to 400mg [**Hospital1 **] on [**2194-6-13**]. This will be continued as outpatient. - Initially planned for rituximab 375mg/m2. However, given new information regarding PNH, this plan may change. NO RITUXUMAB FOR NOW. Eculizumab may be indicated (outpatient therapy). Need to confirm dx of PNH. Antibody therapy deferred at this time. - Folic acid repletion of cell turnover. - [**2194-6-18**] tagged RBC (heat damaged) scan looking for accessory spleen as contributor to AIHA; was inconclusive on study because of technical issues. Consider repeat if need to assess for accessory spleen. - Haptoglobin [**2194-6-19**] still low. . 2. Abdominal/back pain: Due to renal vein thrombosis, renal infarction, and portal vein thrombosis. Pain service consulted. CT at OSH showed renal vein thrombosis, renal infarction, and unclear if accessory spleen is present. - D/C hydromorphone PCA pump on [**2194-6-18**]. - Was on OxyContin 40mg [**Hospital1 **]. Oxycodone breakthru pain. - Change to Morphine sulfate long and short acting due to insurance. - Lidocaine patch. Consider d/c. - D/C Heparin gtt on [**2194-6-18**]. Warfarin failure unclear, but possible. INR 1.3 with renal vein thrombosis. However he has been compliant and has not had low INRs previously. Transition to enoxaparin 1mg/kg [**Hospital1 **] on [**2194-6-18**] PM. Check anti-Xa levels to ensure adequate anticoagulation in this high risk patient. - Blood cultures from [**Hospital3 **] NGTD. - Consider scheduled acetaminophen. - Avoid NSAIDs with anti-coagulation and steroids. . 3. Chronic PE, acute left renal vein thrombosis, portal vein thrombosis: Unknown hypercoagulable state, though flow cytometry shows acquired PNH; beta2-glycoprotein-1 negative, anti-cardiolipin Ab neg; JAK2 negative. - Urology following. Repeat U/A normal. - Heparin gtt d/c'd, started on enoxaparin as discussed above. - Discontinued telemetry [**2194-6-18**]. - Consider further workup of coagulopathy as needed as outpatient. . 4. Acute Kidney Injury - Left renal medullary infarct. As discussed above. - Cr normal now in fact after acute kidney injury. - Nephrology consulted for management of ongoing renal infarction. - MR kidney shows patent left renal arteries, but evidence of medullary infarct. No progression of clot in renal vein per se. - MAG3 renal scan for quantification of remaining renal function shows 10% of total function through left kidney. done Friday [**6-20**]. - Patient will have renal follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]. - Left ureteral blood clot, seen on MRI. Since minimal function remaining, no urgent intervention at this time. . 5. Hi dose steroid-related Issues: - HYPERGLYCEMIA - steroids induced. on insulin sliding scale. - Started on insulin sliding scale [**2194-6-19**]. Insulin will not be continued as outpatient given COMPLEX medication situation. - Will start on glipizide today [**2194-6-20**]. - PCP (SS Bactrim daily) and HSV PROPHYLAXIS (acyclovir) - Patient was educated carefully on these medications. Patient demonstrated understanding of these matters. . 6. Hx Tachycardia: Due to severe anemia, chronic PE, and diarrhea (volume depletion). Stable today. Non-issue at this time. - Monitor clinically. . 7. Leukocytosis: Unclear etiology, possibly due to splenectomy and steroids. Extreme leukocytosis reported (then corrected daily in OMR) is an error due to the automated counter mistaking nucleated RBCs for WBCs. Resolving C. diff diarrhea. BM bx consistent with AIHA. -monitor. No fever. . 8. Hx Thrombocytopenia: Mild, suspect ITP ([**Doctor First Name **] syndrome) given autoimmune predisposition. Resolved with steroids. . 9. Nucleated RBCs: Due to asplenia and extreme erythropoiesis during acute hemolysis. Physiologic. . 10. Diarrhea: C. diff PCR POSITIVE. Stool culture negative. - No response to metronidazole; changed to PO vancomycin on [**2194-6-16**], will have 1 week course post discharge. - Much improved, was getting better several days ago. - Does not have celiac disease; workup done (TTG IgG and anti-gliadin Ab) given its association with IgA deficiency and his chronic GI complaints. TTG IgA not useful because of IgA deficiency. Also at risk for giardiasis. *TISSUE TRANSGLUTAMINASE AB is negative. Anti-gliadin ab negative. . 11. Hx Pruritus: Suspect this was due to indirect hyperbilirubinemia from hemolysis. No acute issues at discharge. - Continue with diphenhydramine PRN. - Added fexofenadine early on in course. Will d/c now ([**2194-6-19**]). . 12. IgA deficiency: Rare infections (recent pneumonia, current C. difficile colitis). No need for treatment for this diagnosis. - Was on nystatin during early during course. No thrush at this time. D/c on [**2194-6-19**]. . 13. GI PPx: PPI with steroids use. Bowel regimen with narcotic analgesia held for diarrhea. . # Lines: PICC placed [**2194-6-14**]. D/c'd at discharge. . # CODE: FULL. . # Contact: Grandparents. Not close with parents who live in [**State 85653**] and Mid-West. Medications on Admission: Warfarin 10 mg PO QD Prednisone 20 mg PO QD Acetaminophen PRN Discharge Medications: 1. morphine 15 mg tablet Sig: One (1) tablet PO every four (4) hours as needed for acute pain. Disp:*90 tablet(s)* Refills:*0* 2. enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) MG Subcutaneous Q12H (every 12 hours). Disp:*1 Month supply* Refills:*11* 3. morphine 30 mg tablet extended release Sig: One (1) tablet extended release PO twice a day: Total morphine ER dose 45 mg [**Hospital1 **]. . Disp:*60 tablet extended release(s)* Refills:*0* 4. morphine 15 mg tablet extended release Sig: One (1) tablet extended release PO twice a day: Total morphine ER dose 45 mg [**Hospital1 **]. . Disp:*60 tablet extended release(s)* Refills:*0* 5. danazol 200 mg capsule Sig: Two (2) capsule PO BID (2 times a day). Disp:*120 capsule(s)* Refills:*2* 6. folic acid 1 mg tablet Sig: Five (5) tablet PO DAILY (Daily). Disp:*150 tablet(s)* Refills:*2* 7. senna 8.6 mg tablet Sig: Two (2) Tablet PO at bedtime: For constipation prophylaxis while on pain meds. . Disp:*60 Tablet(s)* Refills:*2* 8. pantoprazole 40 mg tablet,delayed release (DR/EC) Sig: One (1) tablet,delayed release (DR/EC) PO Q24H (every 24 hours): For stomach ulcer prevention with steroid use. . Disp:*30 tablet,delayed release (DR/EC)(s)* Refills:*2* 9. diphenhydramine HCl 25 mg capsule Sig: One (1) capsule PO Q6H (every 6 hours) as needed for pruritis. 10. vancomycin 125 mg capsule Sig: One (1) capsule PO Q6H (every 6 hours) for 7 days: for treatment of c.diff diarrhea. Take for 7 days only. . Disp:*28 capsule(s)* Refills:*0* 11. prednisone 50 mg tablet Sig: Two (2) tablet PO DAILY (Daily): Total daily dose is 120 mg per day. . Disp:*60 tablet(s)* Refills:*2* 12. prednisone 20 mg tablet Sig: One (1) tablet PO once a day: Total daily dose is 120 mg per day. . Disp:*30 tablet(s)* Refills:*2* 13. acyclovir 400 mg tablet Sig: One (1) tablet PO twice a day: For HSV prophylaxis while on hi dose steroids. . Disp:*60 tablet(s)* Refills:*2* 14. sulfamethoxazole-trimethoprim 400-80 mg tablet Sig: One (1) Tablet PO DAILY (Daily): For PCP prophylaxis while on high dose steroids. . Disp:*30 Tablet(s)* Refills:*2* 15. glipizide 5 mg tablet Sig: 0.5 tablet PO DAILY (Daily): For Steroid induced hyperglycemia. Can skip dose if not eating well. See med instructions. . Disp:*15 tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: 1. Abdominal pain. 2. Back pain. 3. Autoimmune hemolytic anemia (low red blood cells due to your own immune system). 4. C. diff colitis (bowel infection). 5. Renal vein thrombosis (blood clot in vein coming from kidney). 6. Portal vein thrombosis (blood clot in vein going to liver). 7. Pulmonary embolism (PE, blood clot in lung). 8. Question of PNH (Paroxysmal Nocturnal Hemoglobinuria) 9. Left Kidney Infarct and Dysfunction 10. Steroid-induced hyperglycemia 11. IgA Deficiency 12. Clostridium Difficile Diarrhea 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 for abdominal pain and severe anemia (low red blood cell count). The anemia was a flare of your autoimmune hemolytic anemia, a condition were your own immune system attacks your red blood cells. The abdominal pain was likely due to a blood clot in the vein coming from the kidney as seen by a CT scan. For the anemia, you were started on high-dose steroids and danazole. You were also given red blood cell transfusions. Your blood disease stabilized with this regimen and you are currently doing very well. There was concern that you may also have another condition called PNH (paroxysymal noctural hemoglobinuria). However, this remains to be determined. Importantly, you will have follow up with our hematologists here for this complicated condition. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will be taking care of you once you leave the hospital. You will have a visit with him within one week. See below for [**Last Name (NamePattern1) 648**] details. . During the hospitalization, you developed diarrhea and were found to have an infection of your colon called "C. diff" colitis, a type of bacterial infection. This was treated with antibiotics (vancomycin)and you will need to complete a one week course of this at home. . Your left kidney was injured from the blood clot in the left renal vein and it has lost most of its function. You were seen by our kidney doctor, Dr [**Last Name (STitle) 16449**] [**Name (STitle) 1366**], and he will follow your care as an outpatient. You will be alright with one right kidney for now, but you will need to be monitored closely by a kidney doctor over time. An [**Name (STitle) 648**] with them will be arranged for you over the next 4-6 weeks, as your blood issues are the priority currently. . You will also need to take several new medications, including the following with explanations: 1. Lovenox - this is a blood thinner which is used by injection to treat your blood clots. You will remain on this for at least several months. Your hematologist will discuss further plans at your next visit. 2. Prednisone - This is an anti-immune system medication which has helped treat your blood disease as discussed above. You will be on a high dose of this medication for at least 3-4 weeks. Your hematologist will discuss further plans at your next visit. 3. Glipizide - Diabetes treatment. The steroids that you are using, such as prednisone, can cause high blood sugar levels in the blood. This medication will better control diabetes. 4. Acyclovir - Herpes prophylaxis. Prednisone can also reactivate herpes, which most of use have been infected with and have under control. However, long term prednisone can increase risk of shingles, a complication of herpes. Acyclovir is an anti-viral medication that will decrease the risk of shingles. 5. Bactrim - Prednisone can also predispose you to an infection called PCP, [**Name Initial (NameIs) **] lung infection. Prednisone lowers the immune system. Bactrim is an antibiotic that decreases the risk of this PCP lung infection. 6. Morphine pain pills - You will be on a pain regimen of long acting and short acting pain meds. This medication should be decreased over time as your pain resolves. You may want to contact your PCP or hematologist to help with this matter. The goal will be to get you off of pain medications completely. These medications can cause constipation so you will also need to take laxatives and stool softeners. 7. VANCOMYCIN ORAL LIQUID - This is an antibiotic that you will take for 7 more days at home for treatment of your C.difff diarrheal infection. Though your symptoms are better, to complete the treatment course, 7 days of addition medication is needed. Then you can stop taking vancomycin. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2194-6-26**] time to be determined With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 9645**] (PLEASE CALL TO CONFIRM; BUT DR [**Last Name (STitle) **] OFFICE WILL ALSO BE NOTIFIED TO CONTACT YOU AS WELL) Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] - Kidney Doctor [**First Name (Titles) **] [**Last Name (Titles) 648**] will be made for you for 4-6 weeks. Please contact your PCP as well to arrange for follow up so that he is updated in your care. A copy of a discharge summary will be faxed. GENERAL: Please call [**Telephone/Fax (1) 2756**] during weekday business hours 8am-5pm and ask for DR [**First Name (STitle) **] [**Doctor Last Name **] (INPATIENT ONCOLOGY HOSPITALIST) if there are any questions during this time of transition prior to your meeting with Dr [**Last Name (STitle) **]. Afterwards, all questions should be directed to Dr [**Last Name (STitle) **].

[ "289.81", "276.50", "V58.61", "584.9", "288.60", "593.81", "287.31", "V58.65", "008.45", "416.2", "453.3", "279.01", "V45.79", "790.29", "283.0", "283.2", "276.2", "389.9", "452" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

21123, 21174

11565, 18703

319, 365

21734, 21734

5961, 5961

25697, 26851

5132, 5307

18815, 21100

21195, 21713

18729, 18792

21885, 25674

10702, 11542

5322, 5942

4111, 4304

264, 281

393, 4092

5977, 7407

21749, 21861

4326, 4698

4714, 5116

18,033

158,494

3942+3943+55532

Discharge summary

report+report+addendum

Admission Date: [**2112-4-24**] Discharge Date: [**2112-5-2**] Service: This patient is being transferred to the Medicine [**Hospital1 **] and out of the [**Hospital Ward Name 12573**] Intensive Care Unit. CHIEF COMPLAINT: Unresponsiveness. HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female with a history of recent pneumonia. He has been at a nursing home since [**4-11**]. She was made comfort measures only and started on a Morphine drip and Scopolamine. On [**4-23**] she developed short of breath and progressive unresponsiveness. The family was not aware of the CMO status and requested a code status change to Full Code and transfer to the emergency department. In the emergency department she was found to be hypotensive to 90/60 with heart rates in the 120 to 160's. She was afebrile to 102 degrees rectally. Upon Foley placement pus returned. She was intubated for airway protection and was found to have gastric contents in the airway. She received 7 liters of normal saline with one liter of urine output. Ceftriaxone and Clindamycin. She was started on Levophed for blood pressure support. PAST MEDICAL HISTORY: Significant for Diabetes type 2, hypertension, remote history of polymyalgia rheumatica (no steroid use times many years, positive elevated CRP). History of falls. History of pneumonia treated with Amoxicillin and Clarithromycin and changed to Ceftriaxone and Azithromycin and then changed to Levaquin over a period of two weeks, glaucoma with right eye blindness, hyperthyroidism, last TSH was 1.5. MEDICATIONS: At the nursing home includes: 1. Scopolamine 2. Morphine. 3. Captopril. 4. Aspirin. 5. Glyburide. ALLERGIES: No known drug allergies. FAMILY HISTORY: Unknown. SOCIAL HISTORY: She is Vietnamese speaking. She has recently been living in a nursing home after she suffered a fall at her home. Prior to her fall she was walking with her walker and talking and was quite interactive with her family members, this is per her family members. [**Name (NI) **] grandson [**Name (NI) 915**] speaks English and both her son and grandson are very involved in her care appropriately. PHYSICAL EXAMINATION: She was 94.6 degrees axillary. Blood pressure 126/80, heart rate 56, breathing 18, sating 98% on AC 400x18x5x70% In general she is an elderly female intubated and sedated. HEAD, EYES, EARS, NOSE AND THROAT: Oropharynx is clear, moist mucous membranes. She has a surgical mid-dilated pupil on the left and her cornea of the right eye is completely white. She has good skin turgor. Her lungs are clear to auscultation anteriorly. Her heart is regular rate and rhythm, no murmurs, rubs or gallops. Abdomen is soft, mildly distended, nontender. Good bowel sounds. No rebound. Extremities: No edema, faint pulses, cold feet and hands. Neurological: She moves all extremities. Slightly hypertonic in he lower extremities. Poor rectal tone. Genitals: Rectal area with a rash. LABORATORY: White count 7.7 with 14% bands, hematocrit 30.7, her baseline is 35 to 36, platelets 221, MCV 96. Her electrolytes were sodium 153, potassium 4.7, chloride 123, bicarbonate 16. BUN 99, creatinine 2.9, glucose 614. Calculated serum osmolarity 367, serum osmolarity 362. Her lactate was 5.1. Calcium 6.5, corrected 7.9, magnesium 2.3, phos 6.1, ALT 68, AST 94, amylase 145, lipase 91, alk phos 55, T-bili 0.5, INR 1.8, PTT 36.7, albumin 2.3. Her arterial blood gases on 100% O2 was 7.09/49/244 with an AA- gradient of 407. Her urine osmolality was 423, urinalysis, yellow, cloudy 1.016 with a pH of 5.0. She had moderate leukocyte esterase, large blood, negative nitrates, 100 protein, 250 glucose, 21 to 50 red blood cells, more than 50 white blood cells, many bacteria, 0 to 2 EPI's. Her head CT showed no bleed or acute stroke. Chest x-ray showed right subclavian line was in place. Endotracheal tube was 7 cm above the carinii, question of an infiltrate on the right. Blood cultures were taken. HOSPITAL COURSE: 1. Sepsis. Likely secondary to an urinary tract infection. She is also found to have gastric content in her airway, presumed aspiration pneumonia. She also had a left shift and was febrile in the Emergency Room. She was started on Ceftriaxone and Vancomycin since she is from a nursing home based on the sepsis protocol. She was on Ceftriaxone from [**4-23**] to [**4-29**] and Vancomycin [**4-24**] to [**4-29**]. Flagyl for the aspiration pneumonia from [**4-24**] to [**4-29**] and Ciprofloxacin was started on [**4-27**] for persistent urinary tract infection based on her urinalysis. Additionally she was also started on intravenous Fluconazole for yeast in her urine and sputum. The Fluconazole was started on [**2112-5-2**]. Per the sepsis protocol a Court Stem test was done and she was a nonresponder, thus she was given intravenous stress steroids from [**4-24**] to [**2112-4-30**]. She was originally placed on Levophed for blood pressure support however, this medication was weaned off the day after admission on [**2112-4-23**]. Her hypothermia resolved as well the day of admission. Culture Data: Her blood cultures from [**2112-4-24**] showed no growth. She had several urine cultures that were positive for yeast, she had her Foley changed and urine culture after Foley change was again positive for yeast and thus is this why Fluconazole was started. Additionally she has several sputum cultures that showed rare growth of yeast. 2. Respiratory failure. Was thought to be multifactorial, combination of hypoventilation and while she was on a Morphine drip at the nursing home her mental status changes. She had hypoxia with a large A gradient and aspiration. Mechanical ventilation was used until [**4-30**] until she was extubated after approximately three days of diuresis. She was evaluated by physical therapy for chest physical therapy to the left lung base. She did well post extubation. 3. acute renal failure. Her creatinine was 2.9 upon admission, her baseline was approximately 1.5. This acute renal failure resolved after intravenous hydration. She had a renal ultrasound that showed no hydronephrosis. She had a CT scan during her hospitalization course and Mucomyst was given prior to the CT scan to protect her kidneys. 4. Her hyperglycemia. Hyperosmolar, nonketonic coma was likely secondary to her urinary tract infection. She was originally placed on an insulin drip, was given intravenous fluids but has now since been weaned off to regular insulin sliding scale. This issue is now resolved. 5. Mental status change. Likely secondary to the Morphine and hypernatremia. She was not given morphine. Her head CT showed no bleed, no acute stroke. She was ruled out for myocardial infarction and she is now responding to verbal commands in her native language. 6. Hypernatremia. Her sodium upon admission was 159, corrected for hyperglycemia, this is now resolved likely secondary to no access to fluids at the nursing home. Her free water deficit was calculated along with her volume deficit. She was given D5 with 2 amps of bicarbonate as well as several free water boluses. Her sodium returns to normal after several days. 7. Anemia/GI bleed. Her hematocrit upon admission was 30 and her baseline of 35 with an MCV of 96. She is guaiac positive upon admission as well as gastric occult blood positive. She actually had an nasogastric lavage upon admission to the Intensive Care Unit which cleared after 350 cc's of normal saline. Gastrointestinal was consulted and on [**4-25**] she underwent an esophagogastroduodenoscopy. There was no acute bleed. She was found to have oral thrush and was started on Nystatin swish and swallow. She was changed to Lansoprazole q day and she will likely need a colonoscopy as an outpatient. Her B12 and Folate levels were normal. Her stools continued to be guaiac positive and her hematocrit monitored. She has been stable at a hematocrit of 30. 8. Transaminitis. Not suspicious for obstruction, likely secondary to sepsis. No pancreatitis. On [**2112-4-27**] she was found to have a tympanic belly with some mild distension and thus she underwent STT of the abdomen which was essentially unremarkable. 9. Leukocytosis and bandemia. Her white count rose to 20 with 18% bands and thus CT of the abdomen and pelvis was obtained to also rule out peri-nephric abscesses which there were none. Her urinalysis was still showing signs of infection however as mentioned there was no abscess, diverticulosis or diverticulitis on her CT. Her Foley was changed and culture data was followed. Her white count did trend down after adding Ciprofloxacin for greater coverage for her urinary tract infection. He should complete a 10 day course of Ciprofloxacin. Currently this is [**5-2**] and it is day seven of 10. 10. Coagulopathy. High INR and PTT but normal platelets. This could be possibly secondary to nutritional deficits. She was recently on antibiotics for pneumonia and had reported diarrhea from the nursing home. Her DIC labs were drawn. She had a normal fibrin blood product, very high D. Dimers. On [**4-30**] she was noted to have an enlarged left upper extremity and thus an ultrasound was performed which is negative for deep vein thrombosis however, was a difficult study as several veins were not visualized. 11. Hypocalcemia. We originally held off on repleting calcium given her high phosphate however, once her phosphate became normalized we did replace her calcium. 12. Hypokalemia. We had replaced her potassium as needed based on q day lyte checks. 13. Acid base status. Her arterial blood gases upon admission was 7.09, 49 and 244. The primary respiratory acidosis secondary to hypoventilation was metabolic acidosis, both anion gap, lactic acidosis and non-anion gap diarrhea. Her vent settings were changed in order to improve her pH and these values essentially. Her arterial blood gases improved and her respiratory status improved such that we were able to extubate her on [**2112-4-30**]. 14. Nutrition. She was maintained on tube feeds while intubated. Tube feeds were held the night prior to extubation. She is now currently taking food and Nutrition was consulted and recommended Boost pudding three times a day. She is having difficult with p.o. intake. This apparently was a problem we learned later on at the nursing home as well. We should consider possibly starting Megace or Remeron to increase her appetite. The family may feel aggressive enough to place a Percutaneous endoscopic gastrostomy tube for nutrition. Currently her son is bringing in food from home and she is sitting upright eating the food with minimal cough. 15. Hypertension. She is still 10 liters positive for her length of stay seeing as how she got a lot of intravenous fluids when admitted on the sepsis protocol and it is difficult for her to swallow her Captopril pills so she is currently getting intravenous Hydralazine as well as Captopril when she cake them. Consider adding a standing diuretic. The patient will take her p.o.'s. 16. Diabetes Type 2. She is continued on a regular insulin sliding scale and fingersticks four times a day. She was originally on Glyburide. 17. Prophylaxis. She is maintained on pneumo boots, PPI and subcutaneously Heparin. 18. Lines. She has a right Triple lumen catheter in a subclavian position that was placed on [**2112-4-24**] by surgery. We are currently attempting to get peripheral Intravenous's so that we can pull the triple lumen catheter. 19. Code status. She is currently "Do Not Resuscitate" (no defibrillations, no chest compression) however, the family would like to reintubate her should she have another episode of respiratory failure. 20. Communication. Her family visited daily. Her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) **] at [**Hospital3 **] was E-mailed on [**2112-4-29**], her phone number is [**Telephone/Fax (1) 8236**]. The patient is currently being transferred to the floor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 9789**] MEDQUIST36 D: [**2112-5-2**] 14:21 T: [**2112-5-2**] 16:27 JOB#: [**Job Number 17523**] Admission Date: [**2112-4-24**] Discharge Date: [**2112-5-12**] Service: ACOV service ADDENDUM: This is addendum to previously dictated discharge summary. Upon transfer from the Intensive Care Unit her acute renal failure, hyperosmolar nonketogenic coma, hyperglycemia, hyponatremia, transaminitis, urosepsis and acute renal failure all had resolved. Anemia/GI bleed: While in the unit the patient had been evaluated by the gastroenterology team and received esophagogastroduodenoscopy without a source of bleeding. This was done because she had hematemesis and guaiac positive stools. Overnight on her second night back on the medicine floor patient's hematocrit dropped from 29.6 to 26.4 and she was transfused one unit of packed red blood cells with appropriate jump to approximately 30. However, during the night after her transfusion patient had multiple episodes of bright red blood per rectum. Her repeat hematocrit was 25. A repeat hematocrit was 25.8. In addition the patient became hypotensive with a systolic blood pressure in the 70s. An EKG at that time did not reveal any new ischemia. She was not hypoxic. She was bolused with intravenous fluid and she was receiving blood. Her systolic blood pressure responded and increased to the 120s. Gastroenterology was reconsulted and the patient had a bleeding scan. Bleeding scan was positive for a bleeding right lower quadrant. The patient was readmitted to the Intensive Care Unit. She had a colonoscopy that showed a nonbleeding grade 1 internal hemorrhoid, a single nonbleeding diverticulum with large opening in the cecum. (This is the likely source of the positive red blood cell scan.) There were also multiple diverticula with large openings in the descending colon and sigmoid colon, and 15 cm from the anal verge there was a section of colon that had edematous mucosal tissue adjacent to several diverticula with large openings. One diverticulum had a large maroon organized clot within it. The patient had no more episodes of hypotension or GI bleed. She received 4 units of packed red blood cells and 2 units of FFP for her lower GI bleed. Her hematocrit remained stable between 30 and 34 throughout her hospitalization. GI: Patient was treated with fluconazole for a yeast urinary tract infection. Nutrition: Upon coming out of the Intensive Care Unit the first time the patient had speech and swallow study that showed aspiration with thin liquids and with drinking out of a straw. Their recommendations at that time were cup sips of nectar thick liquid and pureed diet with aspiration precautions, crush meds in yogurt or other puree. Patient had poor p.o. intake and she was readmitted to the Intensive Care Unit for her GI bleed. Upon coming out of the Intensive Care Unit the second time the patient had a re-evaluation and appeared to be aspirating even purees and thick liquids. She had been placed on tube feeds in the Intensive Care Unit and these were continued. We had lengthy discussions with the family and they decided that they would prefer the patient eating versus a PEG. All the risks and benefits of p.o. feeding versus PEG feeding were addressed. The patient has a tendency to pull out tubes from her body including her nasogastric tube. The family understands the risk that she will continue to aspirate if she eats and drinks p.o. fluids. Therefore the patient was given nectar thick liquid and pureed food. The family made the patient DNR/DNI. When she develops an aspiration pneumonia in the future they want her treated with antibiotics but not intubated. The patient required repletion with potassium. She is being discharged on 20 mEq potassium a day, with the intention of checking a potassium at least once a week. The patient has poor intravenous access and requires a central line for intravenous fluids. Her central line will be pulled prior to going to the nursing home. Therefore, if the patient requires antibiotics in the future she will likely need a new central line placed. A bedside evaluation by the intravenous team could not place a midline or a PICC. Altered mental status: The patient's status improved throughout the rest of her hospitalization. She became aware of her surroundings and appeared to interact with family members and seemed to understand wheat they were saying. Occasionally she would speak herself. Hypertension: Patient was maintained on metoprolol. Her blood pressure was well controlled with a high in he 150s after she returned the second time from the Intensive Care Unit. Diabetes: Patient's fingersticks showed glucose levels in the 200 while she was on tube feeds. After she was off of tube feeds her fingersticks were much lower. In the nursing home she should have fingersticks checked and given insulin as needed. At this time she can be evaluated to see if she needs further diabetic medication. Stage 1 decubitus ulcer of the sacrum: The patient was treated with vitamin C and zinc over an approximately two week time. Please treat ulcer appropriately. During the hospitalization she was given Duoderm dressing changed approximately every three days. Hyponatremia: Patient developed hyponatremia while on tube feeds. This is likely secondary to the SIADH from her pneumonia. This was treated by decreasing the amount of free water in her tube feeds. Once the patient pulled out nasogastric tube her tube feeds were discontinued and her sodium was within normal limits. Code status: Patient is DNR/DNI. I spoke at length with the grandson, [**Name (NI) 915**], who is the health care proxy and his father with the use of an interpreter. The family does not want unnecessary procedures to the patient but they want to be asked if an intervention is considered. They do not want a PEG placed at this time. They want her to be able to eat if she reaches for the food knowing that she will aspirate this food and will develop recurrent aspiration pneumonia. When this occurs they want her treated with antibiotics. The patient is not be resuscitated with chest compressions or intubation. The patient is Cantonese speaking. She responds well to her family members. Often she does not want to eat when fed by other people other than family members. In addition, she appears to enjoy Asian food over hospital food. The patient is being discharged to an extended care facility. DISCHARGE CONDITION: Aware of surroundings occasionally with family members, not ambulating, coughing with meals. Creatinine is 0.6, hematocrit stable at 33.2, taking in small amounts of food, nectar thick liquids and puree with diaper in place and a stage 1 decubitus on her sacrum. DISCHARGE INSTRUCTIONS: Patient speaks Cantonese. If she develops fevers, altered mental status or hypoxia [**Name8 (MD) 138**] M.D., check CBC, straight catheterization or urinalysis and urine culture, and get a chest x-ray. If there is evidence of an infection patient should be treated with oral antibiotics. She is unable to take oral antibiotics. She may need intravenous antibiotics. Because she is a difficult peripheral stick she may need to come to the emergency department for intravenous antibiotics. She should be treated with aspiration precautions. Her diet is thick liquids and pureed solids. Please allow family members to feed her if they wish. Please have the patient sit fully upright during meals. Give her one small spoonful of food and have her swallow twice. Then give her a small amount of sips thick liquid not through a straw. She may then repeat. Please leaver her upright for 1/2 hour after meals. She should have her head of the bed at greater than 30 degrees. If she refuses food please do not force her to eat. Please show tape patient q.i.d. and change dressings to the stage 1 ulcers on the sacrum every three days as per protocol. Suggest use of Duoderm. If there is foul smell coming from her back please assess for infection and treat appropriately. Have patient sit up as much as possible during the day. Continue to change diapers every couple of hours. She should not sit in wet diapers especially with an ulcer. Crush pills if possible and try putting in applesauce or puree. Continue with subcutaneous heparin. Patient is DNR/DNI. Family wants patient to be comfortable. Please deal with issues as they arise and address the family for their input in the case of possible interventions. Currently they want the patient to be brought to the Emergency Room if needed. They want her to receive her medications and be treated for infections. Please check fingersticks q.i.d. and use Humalog insulin sliding scale as directed. Check potassium once a week. Health care proxy and family contact is [**Name (NI) 915**] [**Name (NI) **], cell number is [**Telephone/Fax (1) 17524**]. FINAL DIAGNOSES: Upper GI bleed. Lower GI bleed. Urosepsis. Hyponatremia. Urinary tract infection, yeast. Aspiration pneumonia. Hypotension. Adrenal insufficiency. Hyperosmolar and nonketogenic coma. Acute renal failure from hypotension. Altered mental status. Diabetes. Hypokalemia. Anemia. Transaminitis from shock liver. Stage 1 decubitus ulcer on sacrum. Hyponatremia. RECOMMENDED FOLLOW UP: With Dr. [**Last Name (STitle) 17525**] as needed. DISCHARGE MEDICATIONS: Acetaminophen 325 one to two tablets p.o. or p.r. q 4 to 6 hours p.r.n. for fever or pain, miconazole powder b.i.d. p.r.n., metoprolol 25 mg p.o. b.i.d., hold for systolic blood pressure less than 100 or heart rate less than 60. Please crush pills if able to. Lansoprazole 30 mg 1 capsule 1 p.o. q day, ascorbic acid 500 mg p.o. b.i.d. for one week time, zinc sulfate 220 mg 1 capsule p.o. q day for one week, Humalog insulin sliding scale, potassium chloride 20 mEq packet, one packet p.o. q day in applesauce or puree, check potassium weekly. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 17526**] MEDQUIST36 D: [**2112-5-12**] 17:24 T: [**2112-5-12**] 17:28 JOB#: [**Job Number 17527**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 2822**] Admission Date: [**2112-4-24**] Discharge Date: [**2112-5-13**] Date of Birth: [**2021-9-22**] Sex: F Service: ADDENDUM: Of note, the patient had left upper extremity swelling during her hospitalization. She had two left upper extremity ultrasounds. One was the first time she was in the Intensive Care Unit that was a limited study but did not reveal a deep vein thrombosis. She also had one on the General Medicine Floor that did not reveal the deep vein thrombosis. The swelling in the left arm decreased during hospitalization but is still swollen on discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**] Dictated By:[**Last Name (NamePattern1) 2823**] MEDQUIST36 D: [**2112-5-13**] 07:47 T: [**2112-5-13**] 07:56 JOB#: [**Job Number 2824**]

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Discharge summary

report

Admission Date: [**2128-1-13**] Discharge Date: [**2128-1-17**] Date of Birth: [**2054-7-7**] Sex: F Service: MEDICINE Allergies: Lactose / Sulfa (Sulfonamide Antibiotics) / Codeine / Penicillins / prednisone / clindamycin Attending:[**First Name3 (LF) 106**] Chief Complaint: Presented to [**Hospital3 7571**]Hospital complaining chest pressure, nausea and vomiting. Transferred to [**Hospital3 **] for percutaneous intervention of NSTEMI(non-ST myocardial infarction). Major Surgical or Invasive Procedure: Cardiac Catheterization([**2128-1-13**]). Central line placement on right femoral vein([**2128-1-14**]). History of Present Illness: This is a 73 year old female with a past medical history notable for nonobstructive coronary artery disease, prior history of atrial fibrillation (not on coumadin), hyperlipidemia, and cutaneous lupus who was transferred from [**Hospital3 7571**]Hospital for catheterization following an NSTEMI. . Patient initially presented to [**Hospital3 7571**]Hospital on [**2128-1-11**] with several hours of indigestion, nausea, and chest pressure with ECG demonstrating 1mm ST depressions in V3-V6. Troponin I has trended as follows: 0.06.> 1.99 -> 0.94. CK: 128-> 137. CKMB: 3.4-> 11.1. She was transferred to [**Hospital1 18**] for further workup and catheterization. . Here at [**Hospital1 18**], she underwent BMS(Bare metal stent) deployment in the mid-distal LCx but with no reflow following stenting. She was given IC nicardipine bolus 400 mcg and intracoronary nitroglycerine 700 mcg X 1 with improved distal flow. Following stent deployment, she developed transient hypotension with SBPs in the 60s and she was subsequently given 700cc NS and 600cc D5 1/2 NS. She was also started on peripheral dopamine, titrated to max doses (20). A stat echo was performed and reported to be without tamonade or perforation. Dopamine was successfully weaned and her hypotension resolved prior to transfer to CCU. She is being admitted to the CCU for hemodynamic monitoring. She was reported to be in sinus rhythm with rates in the 70s and most recent SBP of 103/63 prior to transfer. . Of note, during the case, she also received bivalirudin bolus (45mg IV X 1) and gtt, 100mcg IV fentanyl, integrillin gtt, prasugrel 60mg PO X 1, versed 1mg IV X 1, and zofran 4mg IV X 1. . On the floor, patient is without acute complaints. She reports that she has had a "bad reaction" to statins in the past but cannot recall the exact reaction. . 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 current chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: hyperlipidemia questionable prior history of Afib, not on coumadin cutaneous lupus gastroesophageal reflux disease anxiety Social History: Sparing tobacco use, stopped 38 years prior. Denies ETOH. Denies current use of illicits. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: VS: 95.5, 150/68, 72, 19, 100%RA. GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Groin: Mild oozing at cath access sites. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ ON DISCHARGE: VS: Tmax: 96.8; HR: 114/79; BP: 95; RR:22 GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Groin: No signs of hematomas. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: FROM [**Hospital3 **]HOSPITAL: Troponin I: 0.06.> 1.99 -> 0.94. CK: 128-> 137. CKMB: 3.4-> 11.1. WBC: 6.9, Hct: 39.6, Plt: 198 Na: 130, K: 3.1, Cl: 92, CO2: 28, BUN: 20, Creatinine: 1.06, Glucose: 99, Calcium: 9.5 . Cholesterol: 192, TG: 29, HDL: 87, ESR: 12, CRP: < 0.5, TSH: 2.85. . Chest radiograph ([**2128-1-12**]) [**Hospital3 7571**]Hospital: No acute process. . ECG: OSH [**2128-1-11**]: Incomplete right bundle branch block, rate of 100, normal axis. Left atrial abnormality. 1mm ST depressions in V3-V6. . ON ADMISSION TO [**Hospital1 18**] [**2128-1-13**] ADMISSION LABS: [**2128-1-13**] 05:45PM BLOOD WBC-6.5 RBC-4.14* Hgb-12.3 Hct-35.1* MCV-85 MCH-29.7 MCHC-35.0 RDW-12.8 Plt Ct-190 [**2128-1-13**] 05:45PM BLOOD Neuts-76.5* Lymphs-17.0* Monos-4.7 Eos-1.3 Baso-0.4 [**2128-1-13**] 05:45PM BLOOD PT-15.4* PTT-80.1* INR(PT)-1.4* [**2128-1-13**] 05:45PM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-134 K-3.8 Cl-103 HCO3-21* AnGap-14 [**2128-1-13**] 05:45PM BLOOD CK(CPK)-101 [**2128-1-13**] 05:45PM BLOOD CK-MB-9 [**2128-1-13**] 09:39PM BLOOD CK-MB-14* MB Indx-9.7* . LABS THROUGHOUT HOSPITAL COURSE: HCT TREND: 31([**2128-1-17**]) <-- 30.4([**2128-1-14**]) <-- 35.1([**2128-1-13**]) CK TREND: 262([**2128-1-17**]) <-- 101([**2128-1-13**]) CKMB TREND: 15([**2128-1-17**]) <-- 9([**2128-1-13**]) LABS ON DISCHARGE DAY [**2128-1-17**]: WBC: 6.1 HGB: 10.8 HCT: 31 Na: 139 K: 4.2 CL:105 HCO:29 GLU: 94 BUN: 18 CREATININE: 1.1 . STUDIES: . Admission ECG: [**Hospital1 18**] [**2128-1-13**] at 4:30PM: Incomplete right bundle branch block, rate of 75, normal axis, normal intervals. Left atrial abnormality. No TWI or ST changes concerning for active ischemia. . ECHOS: ([**2128-1-13**])There is an anterior space which most likely represents a prominent fat pad. However, a small anterior effusion cannot be excluded with certainty. There are no echocardiographic signs of tamponade. No right ventricular diastolic collapse is seen. ([**2128-1-14**])The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal-mid anterior septum. The remaining segments contract normally (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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CATH REPORT: ([**2128-1-13**]) 1. One vessel coronary artery disease. 2. Moderate systemic arterial hypertension at the start of the case. 3. Successful PCI of OM3 long tapering lesion. 70-80% stenosis treated using a 3.0 x 26 mm Integrity bare metal stent. Complicated by no-reflow, but eventual improvement with administration of IC nitroglycerin and nicardipine. 4. Negative emergent echocardiogram to outrule pericardial effusion/tamponade. 5. Successful closure of LFA 8 Fr access using Angioseal. RFA and RFV sheaths sutured in place and to be removed in CCU. CT ABD & PELVIS W/O CONTRAST: ([**2128-1-14**]) Moderate left retroperitoneal hematoma with extension into the rectus sheath. A filling defect within the left external iliac vein is concerning for an external iliac thrombosis. An ultrasound may be obtained to determine changes in phasicity between the left and right common femoral vein to confirm these findings. FEMORAL VASCULAR US LEFT ([**2128-1-14**]) No deep vein thrombosis identified within the distal portion of the left external iliac vein and no DVT seen in the left common femoral vein. UNILAT LOWER EXT VEINS LEFT ([**2128-1-14**]) No evidence of DVT in the left lower extremity. MICROBIOLOGY: ([**2128-1-13**])No MRSA isolated ([**2128-1-15**]) ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Sensitive to all antibiotics tested. [**2128-1-15**] 10:17 am URINE Source: Catheter. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 73 year old female with a PMH notable for nonobstructive coronary artery disease, prior history of atrial fibrillation (not on coumadin), hyperlipidemia, and lupus who was transferred from [**Hospital3 7571**]Hospital for catheterization following an NSTEMI. S/p DES to LCX and admitted to the CCU for hemodynamic monitoring after an episode of hypotension in the cath lab requiring dopamine. . # Hypotension: Broad differential, but clinical presentation initially was most likely consistent with vagal episode. Patient found to have >1L CC of urine output once foley placed. Patient briefly required peripheral dopamine in cath lab in response to BP with systolics in the 60s but dopamine was quickly weaned without problems and pt was transported to CCU. At that time, TTE without evidence of tamponade, depressed LVEF, or perforation. REPEAT TTE [**2128-1-14**] showed very mild focal left ventricular dysfunction c/w CAD and borderline pulmonary artery systolic hypertension. Patient did not complain of abdominal or back pain following the procedure which argued against RP bleed. Pt did state she felt extremely thirsty and had not had anything to eat or drink since 9pm the evening prior. Her BPs responded to gentle hydration and remained stable in the 90s-low100s systolic overnight following the procedure. Home beta blocker was held. HCT remained relatively stable overnight so less concern for bleed, although on [**2128-1-14**] AM pt was noted to have had a 3 point HCT drop from midnight labs, see abdominal wall hematoma below. In the setting of acute bleed BP dropped to as low as 40s systolic. Pt was started on dopamine and levophed and transfused with good effect on BP (up as high as 150s systolic) and quickly weaned from these medications. Patient is being discharged with stable blood pressure. #abdominal wall hematoma - the morning after admission it was noted that the pt had a HCT drop from 33.7 at midnight to 30.5. Pt had been on an integrillin drip since cardiac cath and intervention [**2128-1-13**] midday. Overnight pt had remained stable with BP in the low 90s-100s, received gentle hydration with IVF, and denied significant pain anywhere in the abdominal, back, or groin regions. pt had bilateral femoral catheterizations as she had become hypotensive following the initial catheterization and there was anticipation of possible need for intra-aortic balloon pump, although her pressures reponded quickly to dopamine and pump was never placed. The night following the procedure, frequent groin checks performed which showed present pulses, no hematoma, masses, evidence of bleeding, or audible bruits. Early morning after admission pt was noted to have some minor bleeding through the dressing of the left femoral catheter site but remained HDS and without complaints. Shortly after discovering this she suddenly developed large swelling over the area of the left groin catheter site and somewhat more proximally partially over the left pelvic and lower abdominal region. She became very pale and was crying out in pain with BPs down to the 40s systolic. Deep pressure was held over the site, pt had right wrist A-line and right femoral central line placed. With dopamine and levophed her BP responded with systolics as high as 150s, and pressors were quickly weaned. Pt recieved a total of 3 units pRBCs. Pt was alert and oriented throughout this episode. Patient was stable during the rest of the hospital stay. . # NSTEMI: Troponin elevation at OSH in the setting of precordial ST depressions. Now asymptomatic. S/p BMS to the LCX, initially with no reflow with response to IC vasodilatory medications. Now asymptomatic. Will continue at home with medical management as below. - aspirin 325mg PO daily - prasugrel 10mg PO daily - metoprolol 12.5mg PO BID - Atorvastatin 10mg PO daily Patient should follow up with PCP and cardiologist. . #UTI: Patient had UTI symptoms and had a culture positive for ESCHERICHIA COLI pan-sensitive. Should complete a course of 7 days of ciprofloxacin 500mg PO Q12h(last day is [**2128-1-23**]). . #Atrial fibrillation - pt not on coumadin, question of whether or not it was paroxysmal, history unclear. Pt was not started on coumadin for Afib during this hospitalization. . # HLD: Patient was started on Atorvastatin 10 mg PO/NG HS and should continue it at home . # SLE: Patient was continued on home plaquenil. On [**2128-1-14**] pt did complain of facial flushing and appeared to have erythematous facial rash in malar distribution, ESR and CRP were sent which were within normal limits. Medications on Admission: HOME MEDICATIONS: Per discharge paperwork. - aspirin 81mg PO daily - klonopin 0.5mg PO daily prn QHS - plaquenil 200mg PO BID - MVI - vitamin D 400mg PO daily - calcium, magnesium, and fish oil supplementation - lutein eye drops . MEDICATIONS AT TIME OF DISCHARGE FROM OSH AND TRANSFER TO [**Hospital1 18**]: - Aspirin 325mg PO daily - Klonopin 0.5mg PO qhs - Plavix 75mg PO daily - Lovenox 60mg SQ [**Hospital1 **] - Metoprolol 12.5mg PO BID - Plaquinal 200mg PO BID - SL NTG - Restasis eye drops Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 8. Probiotic 10 billion cell Capsule Sig: One (1) Capsule PO once a day. 9. metoprolol succinate 25 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:*0* 10. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice a day. 11. multivitamin Capsule Sig: One (1) Capsule PO once a day. 12. cholecalciferol (vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO once a day. 13. cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic twice a day. 14. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Primary: non-ST elevation myocardial infarction Secondary: retroperitoneal hematoma, Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 6382**], It was pleasure taking care of you at the [**Hospital1 827**]. You were admitted for a heart attack (non-ST elevation MI). We performed a procedure called cardiac catheterization, during which we found that you had blockage in the blood supply to your heart. Your blood pressure dropped slightly during the procedure, and you were transferred to our cardiac intesive care unit for further monitoring. During your second day in the CCU you developed a collection of blood in your abdomen and groin, and your blood pressure dropped. We placed a special line in your groin to give you medications, blood and fluids. Your blood pressure subsequently improved and you were [**Hospital 91757**] transferred to the general cardiology floor. You also developed an urinary tract infection during your hospital stay and were started on antibiotics, which you will need to continue taking twice a day for 6 more days (last date [**2127-1-23**]). We made the following changes to your medications: CHANGED: Aspirin from 81mg to 325mg daily STARTED: Atorvastatin once daily before bedtime Ciprofloxacin twice daily (continue until [**2128-1-23**]) Metoprolol once daily Oxycodone-Acetaminophen 1 tab if you have pain. You can take it up to 4 times a day Prasugrel once daily Pantoprazole once daily Please continue taking your other medications as usual. Please followup with your primary care practitioner and cardiologist, see below. Followup Instructions: Please followup with your primary care practioner. Please call their office on Monday [**2127-1-19**] and make an appointment to see them with 3 days to followup after your hospital stay. Please followup with your cardiologist. Please call their office on Monday [**2127-1-19**] and make an appointment to see them with 4 weeks to followup after your hospital stay. Completed by:[**2128-1-17**]

[ "041.49", "272.4", "410.71", "414.01", "998.12", "458.29", "E879.0", "V49.86", "599.0", "427.31", "710.0" ]

icd9cm

[ [ [] ] ]

[ "00.66", "38.93", "38.91", "36.06", "00.45", "99.20", "88.56", "00.40" ]

icd9pcs

[ [ [] ] ]

16893, 16899

10248, 14819

545, 652

17052, 17052

5237, 5809

18695, 19095

3323, 3438

15369, 16870

16920, 17031

14845, 14845

6350, 9355

17203, 18202

3453, 3453

14863, 15346

4353, 5218

18232, 18672

312, 507

9390, 10225

680, 3054

5825, 6333

3467, 4339

17067, 17179

3076, 3200

3216, 3307

18,657

143,590

50692

Discharge summary

report

Admission Date: [**2121-2-24**] Discharge Date: [**2121-2-26**] Date of Birth: [**2036-2-24**] Sex: F Service: MEDICINE Allergies: Zestril Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: SOB, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 84 y/o F with hx of DM, CAD, CHF, COPD, afib, MM, HTN and CKD who presents today with worsening shortness of breath. Since the beginning of this year, she was admitted three times for the similar complains where her AMS resolves after her respiratory function is maintained. Each time, she improved after treating CHF and COPD exacerbation. She was sent from [**Location (un) **] Nursing home for SOB and altered mental status. Most recently, her amiodarone was stopped and she was suppose to start Digoxin based on last discharge summary. Nursing home staff is unsure of when the AMS or SOB started. . In the ED, initial vs were: T 100.0 P 140 BP 128/95 R 36 O2 100 sat. Pt was noted to be tachy to 130's in AF, mostly wheezing on exam not much crakles, lethargic, too SOB to talk. Patient was given Ipratropium Bromide Neb, Albuterol 0.083% Neb; solumedrol, Nitroglycerin (for HF); Acetaminophen (for a temp of 102.6 rectally); Piperacillin-Tazob and Vancomycin. Patient came in NRB, now on bipap. CXR c/w vascular congestion. No lasix was given. . On the floor, patient was on a none-rebreather, awake, in moderate distress. Past Medical History: 1. Obesity 2. Hypertension 3. Diabetes mellitus, type II 4. Hyperlipidemia 5. Coronary Artery Disease, s/p 2 anterior MI - 3 vessel disease: refused CABG - s/p stent of left circumflex, LAD, RCA 6. Ischemic and possibly valvular cardiomyopathy: EF of 35-40% in echo in [**6-25**], 3+ MR. 7. Atrial Fib with adm in [**7-31**] for RVR (anticoagulated) 8. Chronic kidney disease with baseline creatinine of 1.9 9. Anemia. 10. Multiple myeloma: monoclonal IgG kappa, being observed by Heme-Onc. 11. Osteoarthritis. 12. Gastroesophageal reflux disease. 13. Seizure disorder, on dilantin 14. Chronic bronchitis/COPD 15. Detrusor instability. 16. Frequent UTIs: in [**1-28**] Klebsiella pneumonia Social History: Used to live with daughter until recent hospitalization at NEBH with CHF exaccerbation. Currently living at [**Hospital3 2558**]. Now patient requires wheel chair for mobility, per daughter. Denies tobacco/alcohol. Family History: Sister with coronary artery disease. Physical Exam: Temp:100.0 HR:140 BP:128/95 Resp:36 O(2)Sat:100 normal Constitutional: Mild respiratory distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Crackles and expiratory wheezes throughout with poor air movement 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: Follows commands, moves all extremities Pertinent Results: [**2121-2-24**] 03:50PM BLOOD WBC-6.1 RBC-2.77* Hgb-8.6* Hct-26.4* MCV-96 MCH-31.2 MCHC-32.7 RDW-14.4 Plt Ct-378 [**2121-2-26**] 04:24AM BLOOD WBC-4.5 RBC-2.44* Hgb-7.8* Hct-24.5* MCV-100* MCH-32.0 MCHC-31.8 RDW-14.1 Plt Ct-267 [**2121-2-24**] 03:50PM BLOOD PT-16.2* PTT-28.7 INR(PT)-1.4* [**2121-2-26**] 04:24AM BLOOD PT-18.1* PTT-31.2 INR(PT)-1.6* [**2121-2-24**] 03:50PM BLOOD Glucose-221* UreaN-45* Creat-2.1* Na-138 K-4.9 Cl-103 HCO3-23 AnGap-17 [**2121-2-26**] 04:24AM BLOOD Glucose-119* UreaN-45* Creat-1.8* Na-141 K-3.6 Cl-107 HCO3-26 AnGap-12 [**2121-2-25**] 03:41AM BLOOD ALT-45* AST-61* LD(LDH)-247 CK(CPK)-99 AlkPhos-78 TotBili-0.2 [**2121-2-24**] 03:50PM BLOOD cTropnT-0.09* [**2121-2-25**] 03:41AM BLOOD CK-MB-2 cTropnT-0.05* [**2121-2-24**] 03:50PM BLOOD proBNP-[**Numeric Identifier 105464**]* [**2121-2-25**] 03:41AM BLOOD Albumin-2.9* Calcium-7.8* Phos-4.1 Mg-2.0 [**2121-2-26**] 04:24AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.0 [**2121-2-24**] 03:50PM BLOOD Digoxin-0.4* [**2121-2-24**] 03:50PM BLOOD Phenyto-12.3 [**2121-2-24**] 04:05PM BLOOD Lactate-2.8* [**2121-2-25**] 06:47AM BLOOD Lactate-1.1 CHEST (PORTABLE AP) Study Date of [**2121-2-25**] 5:13 AM FINDINGS: In comparison with the study of [**2-24**], there is continued enlargement of the cardiac silhouette with left ventricular prominence. Mild fullness of pulmonary vessels again is consistent with elevated pulmonary venous pressure. Elevation of the left hemidiaphragm is again seen with atelectatic changes above it in the retrocardiac region. Degenerative changes about both shoulders and the thoracolumbar spine are again seen. Brief Hospital Course: # Shortness of Breath - CXR on admission was suggestive of fluid overload vs infiltrate. She was on BiPap briefly in ED but quickly weaned to nasal cannula in the ICU. BNP was elevated (29,000's), making clinical presentation most consistent with acute on chronic hear failure, and thus she was diuresed. Subsequent CXR were unimpressive for an infectious cause. Cardiac enzymes were cycled and remained negative. She was initially started on treatment with vancomycin and zosyn for presumed healthcare-associated pneumonia. Antibiotics were eventually discontinued on HD2 given significant improvement in respiratory status after diuresis and little concern for infection. She remained stable from a respiratory standpoint with oxygen saturations in the high 90s% on room air. She was not labored or tachypneic with her breathing. . # Atrial fibrillation: Heart rate noted to be elevated to 130s on night of admission. She was continued on her outpatient medications. Metoprolol was initially held in setting of low blood pressures (see below) however, this was restarted as her pressures improved. She remained on coumadin and digoxin. She was found to have an INR of 1.4 that was subtherapeutic, we continued on her home dose coumadin given renal failure and concurrent antibiotics. On discharge the patient's metoprolol was uptitrated to allow for improved heart rate control. . # Acute on chronic renal failure: On admission, creatinine was elevated at 2.1 from baseline in 1.6. Thought to be pre-renal with a posible component from Multiple myeloma. Medications were renally dosed. Electrolytes were trended daily and creatinine eventually trending back down to her baseline. Creatinine was 1.6 on discharge. . # Coronary artery disease: Troponins were cycled and remained flat (0.09->0.05). Thought to be due to minimal component of demand ischemia from hypotension in setting of renal failure. Remained on aspirin, beta-blocker initially held in setting of low blood pressure but was then restarted. . # Hypotension: hypotensive on admission thought to be due to congestive heart failure vs. sepsis. Pressures improved after initial treatment of acute heart failure. Antibiotics eventually were discontinued. Home antihypertensives were initially held but were then restarted. . # Depressed mental status: She was, at times, sleepy and difficult to arouse from sleep. After discussion with the family and nursing facility, it was determined that this was her baseline mental status. . # Multiple myeloma - required no management during admission. Creatinine and electrolytes were trended daily. . # Anemia: Likely due to multiple myeloma. Remained stable at baseline. . # Seizure Disorder: no seizure activity noted during ICU admission. Dilantin level checked and found to be within normal limits. She was continued on dilantin at a dose of 250 mg [**Hospital1 **]. . # COPD/chronic bronchitis: remained on home nebulizer treatment, given a burst of steroids for her treatment that does not need to be continued upon discharge. Was successful at weaning down her O2 requirement. Medications on Admission: 1. Aspirin 81 mg PO DAILY (Daily). 2. Ranitidine HCl 150 mg PO DAILY. 3. Montelukast 10 mg PO once a day. 4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule PO once a week. 5. Senna 8.6 mg PO BID as needed for constipation. 6. Docusate Sodium 100 mg Capsule PO BID as needed for constipation. 7. Atorvastatin 20mg PO DAILY. 8. Metoprolol Tartrate 25 mg Tablet PO BID 9. Ferrous Sulfate 300 mg (60 mg Iron) PO once a day. 10. Multi-Vitamin W/Minerals Capsule PO once a day. 11. Ipratropium Bromide 0.02 % Solution 1 Inhalation Q6H. 12. Insulin Lispro sliding scale units 13. Dilantin Infatabs 250 mg PO twice a day. 14. Furosemide 40 mg PO DAILY 15. Warfarin 4 mg PO Once Daily at 4 PM. 16. Digoxin 0.125 mg twice a week (Tuesday and Saturday) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK ([**Doctor First Name **]). 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED). 10. Phenytoin 50 mg Tablet, Chewable Sig: Five (5) Tablet, Chewable PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,SA). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) 15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Congestive heart failure Bronchitis Discharge Condition: Level of Consciousness: Lethargic and not arousable. Mental Status: Confused - always. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with difficulty breathing. We believe that your difficulty was secondary to a viral illness and congestive heart failure. You were given medicine to help remove fluid and your symptoms improved. Medications changed during this admission: INCREASED furosemide to 40 mg [**Hospital1 **] to improve fluid removal INCREASED metoprolol to 37.5 mg [**Hospital1 **] to improve heart rate control Please follow-up with your appointments as listed below. Please call your cardiologist, Dr. [**Last Name (STitle) **], to schedule an appointment within 2 weeks. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please call Dr. [**Last Name (STitle) **] to schedule an appointment within 1-2 weeks. His office can be contact[**Name (NI) **] at ([**Telephone/Fax (1) 32215**]. Other Appointments within [**Hospital1 18**]: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2121-3-5**] 10:20 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2121-3-19**] 2:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2121-2-26**]

[ "491.22", "414.8", "584.9", "585.9", "203.00", "345.90", "428.23", "403.90", "428.0", "285.22", "250.00", "V45.82", "414.01", "427.31", "518.83", "278.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9881, 9951

4736, 7050

302, 308

10031, 10084

3099, 4713

10916, 11610

2437, 2475

8636, 9858

9972, 10010

7868, 8613

10212, 10893

2490, 3080

236, 264

336, 1475

10099, 10188

1497, 2188

2204, 2421

60,775

118,545

44059

Discharge summary

report

Admission Date: [**2146-3-27**] Discharge Date: [**2146-4-8**] Date of Birth: [**2105-6-29**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache and neck pain that goes down my spine Major Surgical or Invasive Procedure: [**2146-3-27**]: VPS removal [**2146-4-1**]: lumbar puncture [**2146-4-4**]: bedside I&D of chest wound History of Present Illness: This is a 40 year old white male who presented from an OSH with a VPS in place that was placed at [**Hospital1 18**] in [**2124**] after brain biopsy for benign tumors that were obstructing csf flow. Hereports that they are like "tuberous sclerosis" but that is not what it is. He reports that he had low grade temps to 99 at home with neck pain that goes down his spine. He did not have nausea or vomiting until Friday overnight. He also had slightly blurred vision. He went to the OSH when the pain had gotten to be enough. They did an LP and started abx after the LP had an elevated wbc. Past Medical History: benign brain tumors obstructive hydrocephalus Social History: He lives with his 2 children in a 3 bedroom apt. He is divorced. The nurse reports that his exwife died this past [**Month (only) 321**] of a drug overdose. He states he has some support with the children. He works as a xray tech. He travels regularly to nursing homes and prisons for his job. He smokes 1ppd and has cut back on this since being in the new apt. He drinks rarely. He denies drug use. Family History: non-contributory Physical Exam: On Admission: PHYSICAL EXAM: O: T: 97 BP: 111/64 HR: 72 R 18 O2Sats100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:[**3-7**] no photophobia / NCAT / shunt palpable in the right occipital region. Compresses easily and is slow to refill EOMis Neck: slight limit of passive rom [**1-6**] to discomfort. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ /scar from vps noted Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-5**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 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 [**4-9**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally At Discharge: He is neurologically intact. He had a right chest wall wound with two openings and iodoform packing. The margins are arthematous. Pertinent Results: Head CT [**2146-3-27**]: FINDINGS: The patient is status post recent ventricular shunt removal, with skin staples and a small amount of fluid and subcutaneous emphysema in the right parietal scalp subcutaneous soft tissues. There is no evidence of intracranial hemorrhage, edema, masses or mass effect. There is no pneumocephalus. The [**Doctor Last Name 352**]-white matter differentiation is normal. The ventricles and sulci are normal in caliber. The basal cisterns are normal. The imaged paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute intracranial pathology. 2. A small amount of fluid and air in the subcutaneous tissues of the right frontoparietal scalp, related to the recent shunt removal. EKG [**2146-3-28**]: Sinus rhythm. Non-specific anterior T wave flattening. No previous tracing available for comparison. Head CT [**2146-3-28**]: FINDINGS: A small amount of layering hemorrhage in the atrium of the left lateral ventricle (2:14) and some hyperdensity within an asymmetrically enlarged choroid plexus within the left lateral ventricular body, indicating hemorrhage, have not significantly changed since the recent study. No new intracranial hemorrhage is detected. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricular size is unchanged since the prior study, without evidence of interval onset of hydrocephalus. The basal cisterns are normal. No extra-axial fluid collection is seen. A small amount of subcutaneous emphysema and fluid in the right frontoparietal scalp has improved since the prior study. The paranasal sinuses and mastoid air cells are clear. The orbits are unremarkable. IMPRESSION: 1. Stable small intraventricular hemorrhage layering in the atrium of the left lateral ventricle with small hemorrhage in the choroid plexus within the left lateral ventricular body, also unchanged. 2. No new hemorrhage or hydrocephalus. MRI Brain [**2146-3-29**]: IMPRESSION: 1. Status post removal of left ventricular shunt catheter, with a small amount of hemorrhage in the left lateral ventricle. 2. Mild enhancement within both lateral ventricles and along the track of the left frontal shunt catheter, can be secondary to reactive inflammation or infection. 3. Subtle isointense mass in the right periventricular region causing mild compression of the foramen of [**Last Name (un) 2044**]. The previously described left lateral ventricular mass is difficult to delineate given the asymmetric enlargement and hemorrhage within the left lateral ventricle choroid plexus. Followup both lesions (nature uncertain) to assess stability/ progression. US Right chest wall [**4-2**] 1cm fluid collection at VP shunt removal site with extensive surrounding induration. Super-infection cannot be determined by ultrasound. CT head [**2146-4-7**]: IMPRESSION: 1. Stable ventricular size without evidence of interval onset hydrocephalus. 2. No residual evidence of intraventricular hemorrhage. No new intracranial hemorrhage is detected. 3. Stable lesion right foramen of [**Last Name (un) 2044**] ( possible subependymal giant cell astrocytoma in the setting of underyling tuberous sclerosis) unchanged from MRI of [**2146-3-29**]. Brief Hospital Course: This is a 40 year old man who was admitted to [**Hospital1 18**] with meningitis. He was taken to the OR for removal of the entire VP shunt system with Dr. [**Last Name (STitle) **]. An external drain was not place as it was felt that the patient did not require another VP shunt. ID was consulted and CSF cultures were still pending from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. He was started on Vancomycin, Cefepime, and Ampicillin. On [**3-29**], the ampacillin was d/c'd and Vanc was increased to 1250mg. AJH was called for CSF results and no growth has been seen. ID requested a lumbar tap to reassess CSF. On [**4-1**] a LP was performed and CSF was sent for evaluation. CSF continued to show elevated WBC however it was improved from prior. He had an evolving collection underneath his right chest wall at the area of his chest incision. It was monitored and a ultrasound was ordered to evalaute which was consistent with post-op seroma. He remained stable on the floor while awaiting ID recs and and culture results on [**4-3**], on [**4-4**] the remainder of his staples were removed and the collection at his right chest wall looked to be improving. Later in the day he noted exudate from his chest incision and subsequently approximately 30cc of drainage was expressed by our team. As a result of this general surgery was consulted who performed an I and D of the wound at the bedside. ID continued to follow and gram stain from this chest collection showed gram negative rods. [**Date range (1) 94578**] he remained stable while awaiting further culture results in order to better target treatment. Nursing performed daily dressing changes of chest wounds and a wound care consult was requested. CT head was done to ensure that he does not have enlarging venricles prior to discharge. Home services were established and coordinated and he was discharged on [**4-8**]. Medications on Admission: Advil prn Discharge Medications: 1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q 12H (Every 12 Hours) for 14 days: 14 days from [**4-4**]. Disp:*20 bags* Refills:*0* 2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q6H (every 6 hours) for 14 days: 14 days from [**4-4**]. Disp:*40 bags* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. Tablet(s) 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*7 Patch 24 hr(s)* Refills:*0* 9. 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. Discharge Disposition: Home With Service Facility: Amedisys Home care Discharge Diagnosis: Meningitis VP shunt infection Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in four weeks. ??????You will need a CT scan of the brain without contrast. Infectious Disease - [**2146-4-12**] 11:45a ID,[**Doctor Last Name **] [**Doctor First Name **] LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST (SB) Tel: [**Telephone/Fax (1) 457**] - Vanco trough. CBC w/diff, LFTs, BMP once weekly and fax results to [**Telephone/Fax (1) 1419**] * You need to follow up with ACS for your chest wound. They recommend an appointment in [**12-6**] wks. This can be made by calling [**Telephone/Fax (1) 94579**]. Completed by:[**2146-4-12**]

[ "682.2", "998.13", "V12.41", "320.9", "041.49", "996.63", "E878.8", "305.1", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "86.04", "03.31", "02.43" ]

icd9pcs

[ [ [] ] ]

9599, 9648

6414, 8337

355, 461

9733, 9733

3175, 6391

10712, 11425

1597, 1615

8397, 9576

9669, 9712

8363, 8374

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1659, 2070

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268, 317

489, 1087

2362, 3010

1644, 1644

9748, 9860

1109, 1157

1173, 1581

23,092

188,404

49169

Discharge summary

report

Admission Date: [**2129-7-18**] Discharge Date: [**2129-7-24**] Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female with a past medical history remarkable for hypertension, hypercholesterolemia, noninsulin dependent diabetes mellitus, who presents with increased dyspnea on exertion for the past one year. Patient has noted worsening of this condition in the past two to three months with dyspnea resolving at rest. Patient also had one episode of chest pain which radiated into left arm in early [**Month (only) 547**] which resolved spontaneously at rest. Baseline murmur has been noted on cardiac exam for several years. In evaluating this cardiac symptom, patient underwent a cardiac catheterization on [**2129-6-1**] which revealed aortic valve area of .84 and severe aortic stenosis with severe mitral regurgitation 3+. Patient's right ventricular end-diastolic pressure was noted to be 18, left ventricular end-diastolic pressure 34, ejection fraction to be 62%, with left anterior descending with mild diffuse disease and right coronary artery 40% occluded. Cardiac echocardiogram which was performed on [**2129-5-16**] suggested similar results with peak gradient of 77 and aortic valve area of .67 with mild left ventricular hypertrophy and moderate mitral regurgitation and pulmonary hypertension. Given these findings, patient was referred to Cardiothoracic Surgery Service for aortic valve replacement, as well as mitral valve replacement. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Noninsulin dependent diabetes mellitus. 4. Pneumonia. 5. Osteoarthritis. 6. Obesity. 7. Bilateral lower extremity varicosities. 8. Fungal dermatitis. 9. Bilateral cataracts. PAST SURGICAL HISTORY: 1. Thyroidectomy in [**2086**]. 2. Cholecystectomy in [**2091**]. 3. Uterine cancer with XRT therapy in [**2106**]. 4. Hysterectomy in [**2106**]. 5. Total knee replacement [**2123**] - bilateral. 6. Left cataract surgery in [**2126**]. 7. Bilateral vein stripings. PATIENT'S MEDICATIONS AT HOME: 1. Zantac 75 q.d. 2. Iron q.d. 3. Colace 100 q.d. 4. Aspirin 81 mg q.d. 5. Glyburide 1.25 q.a.m. 6. Atenolol 25 mg q.d. 7. Synthroid 115 mcg q.d. 8. Triamterene 37.5 mg. 9. Hydrochlorothiazide 25 mg q.d. 10. Multivitamins. ALLERGIES: Penicillin which leads to rash. FAMILY HISTORY: Mother who died with breast cancer. Father who died of emphysema and lung cancer. Occupation: Retired. Currently living with husband with no prior tobacco or ethanol usage. PHYSICAL EXAMINATION: Vital signs: Temperature 98.6. Pulse: 85. Blood pressure 108/44. Respiratory rate 18. Oxygen saturation 97% on room air. Head, eyes, ears, nose and throat: No evidence of cervical lymphadenopathy, sclerae are anicteric, cranial nerves II through XII are intact. Mucous membranes moist. No evidence of oral ulcers. Chest: Clear to auscultation bilaterally. Sternotomy site without any evidence of drainage, erythema, nor click on palpation. Abdomen: Soft, nondistended, nontender with positive bowel sounds, no hepatosplenomegaly and no inguinal lymphadenopathy noted. Extremities: Mild lower extremity edema, no evidence of rash. PERTINENT LABORATORIES: On [**2129-7-23**], white blood cell count was 8.5, hematocrit 34.5, platelets 136,000. Sodium 138, potassium 3.6, chloride 98, bicarbonate 29, BUN 25, creatinine .9, glucose 69, calcium 7.5, phosphorus 3.1, magnesium 2.0. HOSPITAL COURSE: [**Known firstname **] [**Known lastname **] is an 86-year-old female with a past medical history remarkable for hypertension, hypercholesterolemia, noninsulin dependent diabetes mellitus who presents with severe aortic stenosis and mitral regurgitation. For these reasons, patient underwent a successful preoperative evaluation by Cardiothoracic Surgery Service and underwent an uncomplicated aortic valve replacement (21 mm c.e. bioprosthetic valve) and mitral valve repair (26 mm Cogsgrove annuloplasty band) on [**2129-7-18**]. Postoperatively, the patient maintained normal sinus rhythm sedated on propofol and pressure maintained with mild amount of >......<. On postoperative day number one, patient exhibited labile hemodynamics and was maintained on apaced rhythm, as well as SIMV ventilator setting. By postoperative day number two, the patient was transfused two units of packed red blood cells and extubated with discontinuation of pacer, since patient maintained normal sinus rhythm. At this time, chest tubes were also removed without incident. On postoperative day number three, patient was initiated on po Lopresor, as well as Lasix for diuresis and patient was transferred to the floor since no further evidence of labile blood pressure nor respiratory instability were noted. By postoperative day number four, patient was evaluated by the Physical Therapy Service to determine whether the additional rehabilitation service would be required prior to patient returning back home. The evaluation yielded the conclusion that discharge to rehabilitation would provide the best environment for quick recovery. By postoperative day number six, on [**7-24**], the decision was made to discharge the patient to a rehabilitation facility. By this time, cardiac medications were properly re-titrated. CONDITION OF DISCHARGE: Good. DISCHARGE STATUS: To a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement (21 mm c.e. bioprosthetic valve). 2. Mitral valve repair (26 mm Cogsgrove annuloplasty band). DISCHARGE MEDICATIONS: 1. Albuterol nebulizer solution q. 6 hours prn wheeze. 2. Atenolol 75 mg po q.d. 3. Dilaudid 2-4 mg po q. 4-6 hours prn pain. 4. Lasix 40 mg po q.d. times seven days. 5. After the initial seven days, patient is to be revaluated by a physician who will determined whether further diuretic will be necessary. Patient is also to take potassium replacement 40 mEq po b.i.d. during the duration of above Lasix administration. 6. Protonix 40 mg po q.d. 7. Captopril 6.25 mg po t.i.d. 8. Levothyroxine sodium 115 mcg po q.d. 9. Glyburide 1.25 mg po b.i.d. 10. Aspirin 325 mg po q.d. FOLLOW-UP: 1. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) **] in seven days. 2. Patient is to follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2129-7-23**] 08:40 T: [**2129-7-23**] 15:19 JOB#: [**Job Number 103145**] cc:[**Last Name (STitle) 103146**]

[ "416.8", "396.2", "250.00", "272.0", "512.1", "401.9", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "35.33", "34.04" ]

icd9pcs

[ [ [] ] ]

2380, 2557

5414, 5551

5574, 6690

3491, 5393

2085, 2363

1780, 2064

2580, 3473

125, 1506

1528, 1757

740

184,078

14601+14602+14603

Discharge summary

report+report+report

Admission Date: [**2169-6-24**] Discharge Date: Date of Birth: [**2094-6-6**] Sex: F Service: CCU MED This is an interim report and will be completed by Dr. [**Last Name (STitle) **] [**Name (STitle) **]. NOTE: The following is an admission history and physical as noted by medical house staff, Dr. [**First Name (STitle) **] [**Name (STitle) 9835**], pager #[**Numeric Identifier 43061**]. DIAGNOSES: 1. Acute renal failure. 2. CHF. 3. Symptomatic shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 75 year old female with past medical history significant for diabetes mellitus, CAD status post CABG, peripheral vascular disease and hypercholesterolemia, who presents to [**Hospital 882**] Hospital on [**6-21**] with shortness of breath. Of note, on [**2169-4-26**] she was admitted to vascular surgery at [**Hospital6 1708**] for femoral popliteal bypass surgery. At that time preadmission creatinine was 1.5 and after bypass surgery she was in acute renal failure with her dye load and creatinine that had risen to 4. This was recovered to 2.0 during that admission. On [**2169-5-7**] she was readmitted with CHF and at that time diuresed. An echo revealed an ejection fraction of 50% with [**Date Range 1192**] MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR. Since that admission she has had progressive fatigue, malaise and decreased appetite with some dyspnea on exertion, PND and increased peripheral edema in the setting of decreased urine output. She was admitted to [**Hospital 882**] Hospital where she was found to have crackles and increased JVD with acute renal failure, BUN 80, creatinine 4.7. She also had anion gap acidosis with a question of pneumonia on chest x-ray. At [**Hospital1 882**], therefore, she was given IV Lasix in increasing doses with 500 mg of Diuril for potentiation. She was started on a furosemide drip at 20 mg per hour. She was given IV nitroglycerin without effect. On the day of transfer to [**Hospital1 1444**] she had received 500 cc of fluids over two hours with worsened respiratory status and some lateral ST segment depressions with elevated troponin. It is in this setting that the patient was transferred to [**Hospital1 69**]. PAST MEDICAL HISTORY: Hypertension. Diabetes mellitus with resultant retinopathy and neuropathy. Hypercholesterolemia. Peripheral vascular disease. CAD status post CABG in [**2160**] with LIMA to LAD, SVG to D1, OM1 and PDA. Hypothyroidism. CHF. Gout. ALLERGIES: Sulfa causes an unknown reaction. ACE inhibitors result in hyperkalemia. MEDICATIONS: At [**Hospital 882**] Hospital Lasix 20 mg continuous drip, hydralazine 20 mg IV q.six, Diuril 500 mg IV b.i.d., Lopressor 12.5 mg p.o. t.i.d., simvastatin 20 mg p.o. q.h.s., IV nitroglycerin at 200 mcg per minute. At home Lopressor 75 mg p.o. t.i.d., Isordil 20 mg p.o. t.i.d., Zocor 10 mg p.o. q.d., aspirin 325 mg p.o. q.d., Levoxyl 100 mcg p.o. q.d., albuterol and Atrovent p.r.n., hydralazine 50 mg p.o. t.i.d. SOCIAL HISTORY: No history of tobacco or ethanol use. Patient lives at home with her husband and son and is usually able to perform ADLs. Contact information for her includes her daughter, [**Name (NI) **] [**Name (NI) **] home phone number [**Telephone/Fax (1) 43062**], cell phone [**Telephone/Fax (1) 43063**]. PHYSICAL EXAMINATION: Vitals temperature 97.3, blood pressure 132/44, heart rate 88, respiratory rate 19, O2 saturation 97% on CPAP. In general, mild respiratory distress. HEENT PERRL, surgical pupils bilaterally, EOMI, anicteric, mucous membranes moist. Cardiovascular regular rhythm, normal rate, no murmurs. Elevated JVD. Pulmonary crackles [**2-12**] of the way up on the left and possibly [**1-11**] on the right. Abdomen positive bowel sounds, obese, soft, nondistended, nontender. Extremities 3+ edema. Dermatology left mid-abdominal healing injection site. Neuro CN II-XII intact. LABORATORY DATA: White count 15.7, differential 89 polys, 0 bands, 6 lymphs, 4 monos, hematocrit 27.0, MCV 91, platelets 309. PT 14, PTT 63, INR 1.4. Electrolytes sodium 120, potassium 4.5, chloride 85, bicarb 13, BUN 92, creatinine 5.3, glucose 236. CK 87. Anion gap negative 22. Calcium 8.5, phosphorus 7.5, magnesium 2.3. Urine no evidence of dysmorphic red blood cells or casts. EKG from outside hospital revealed sinus rhythm at 81 beats per minute, normal axis and intervals, ST segment depressions in aVL, 1, [**5-15**]. Chest x-ray bilateral effusion with cephalization and curly B lines. HOSPITAL COURSE: The following is as noted by [**Last Name (NamePattern5) 43064**], M.D., PhD. On arrival to the coronary care unit patient was found to be in acute respiratory distress and feeling nauseous with some bright red blood per rectum in the setting of a heparin drip given her elevated troponin at [**Hospital 882**] Hospital. Heparin was discontinued at this time with resolution of her GI bleed. She was started on Protonix 40 mg p.o. b.i.d. The nephrology service was consulted for urgent hemodialysis and renal Fellow, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27532**], saw the patient and after obtaining central venous access, he started hemodialysis with resultant removal of 4 liters of fluid. Subsequently patient was managed in the CCU with initially intermittent bolus dose of furosemide. However, this was with minimal effect and, therefore, she was converted to a furosemide drip titrated to urine output of greater than 100 cc an hour. Furosemide drip was increased to 40 mg an hour for one day with improvement in her urinary output and her overall volume status improved. However, given the possibility of increased ototoxicity at these doses, nephrology recommended decreasing the rate and starting Nitrocor bolus and drip, which was done. Over the next one to two days the patient's furosemide drip was decreased to 20 mg an hour with Nitrocor drip accompanying. She was also started on metolazone 5 mg p.o. b.i.d. to augment her renal response to furosemide. Patient had markedly good response to this regimen and over the next several hospitalization days diuresed a total of 10 liters at the time of this dictation. She had symptomatic relief with decreased shortness of breath and decreased oxygen requirement. On the day of this dictation Nitrocor and furosemide drips were discontinued and the patient maintained on IV furosemide at 100 mg b.i.d. with 5 mg of metolazone scheduled b.i.d. 30 minutes before furosemide. This regimen thus far has been adequate in maintaining a negative fluid balance. In addition, the patient was also started and titrated up on hydralazine for afterload reduction and oral nitrates for her preload. The patient's renal function continued to improve throughout the hospitalization and at the time of this dictation her creatinine had improved steadily to 2.9. The patient also had an episode of chest pain and shortness of breath with EKG consistent with ischemia, but no evidence of ST segment elevation. Cardiac enzymes revealed relatively normal CK with peak at 265 and MB index of 11, however, with troponin which peaked at greater than 50, which is the laboratory maximum. Given the patient's underlying medical conditions and after discussion with patient and family, it was decided to medically manage this non-ST segment elevation MI as to avoid catheterization at least in the setting of acute renal failure in an attempt to preserve renal function and avoid hemodialysis. Hematology. As noted, patient developed lower GI bleed in the setting of heparinization for a troponin leak as noted at [**Hospital 882**] Hospital. Heparin was discontinued on arrival to [**Hospital1 69**] and patient was started on Protonix 40 mg b.i.d. and transfused one unit of blood with appropriate rise in hematocrit. At the time of this dictation, patient's hematocrit was steadily improving and was up to 38. Infectious disease. Patient was started on a course of levofloxacin at [**Hospital 882**] Hospital for pneumonia. Therefore, we opted to continue a full course of seven days. She did well throughout the hospitalization without a temperature. She had no signs or symptoms of pneumonia. However, one day after discontinuation of levofloxacin, patient developed diarrhea and elevated white count to 21. Therefore, this is concerning for the possibility of pseudomembranous colitis. Therefore stool was sent for C.difficile and patient started on an empiric course of metronidazole 500 mg p.o. t.i.d. Overall, the patient's clinical condition is markedly improved as compared with her admission. Her acute renal failure is improving steadily as well as her CHF. She has had no recurrent episodes of chest pain concerning for ischemia in the past three to four days. She is making steady clinical improvement and we anticipate that she will be able to transfer to the medical floor the following day. Dr. [**Last Name (STitle) **] [**Name (STitle) **] will take over the care of the patient effective [**2169-7-2**] and he will complete the rest of this dictation. We anticipate, however, given the patient's clinical course, she will benefit from a cardiac regimen to include aspirin, beta blocker, ACE inhibitor once her creatinine function improves. She will further benefit from both preload and afterload reduction. Of course, she will need a diuretic regimen to maintain her fluid balance once she has achieved her dry weight. This will likely include metolazone and furosemide in some combination. We further anticipate that patient will benefit from a short course of rehabilitation. Thank you very much for the opportunity to participate in the care of this very pleasant patient. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern4) 43065**] MEDQUIST36 D: [**2169-7-1**] 21:21 T: [**2169-7-1**] 21:47 JOB#: [**Job Number 43066**] Admission Date: [**2169-6-24**] Discharge Date: [**2169-7-10**] Date of Birth: [**2094-6-6**] Sex: F Service: ADDENDUM: The rest of the [**Hospital 228**] hospital course will be covered systematically. 1. Cardiovascular: The patient was medically treated for coronary artery disease with enteric coated aspirin 325, Lipitor 10 mg, Hydralazine, Metoprolol, Isosorbide, and Norvasc. Doses have been titrated and weaned appropriately to maintain adequate blood pressure control. On discharge, her blood pressure medications include Hydralazine 100 mg p.o. q. six hours; Lopressor 50 mg twice a day; Imdur 60 mg p.o. three times a day; and Norvasc 5 mg p.o. q. day. These doses will likely have to change as the patient has had episodes of hypotension which required holding many of the blood pressure medications. During the course of the hospital stay, the patient had one episode of chest pain. EKG at the time showed no significant changes. The patient ruled out by cardiac enzymes. The patient had an echocardiogram done which showed an ejection fraction of 40%, hypokinesis of inferior and posterior walls, two plus mitral regurgitation. A Persantine MIBI was performed which revealed perfusion abnormalities of inferior lateral region induced by Persantine. Therapeutic options were discussed with the patient chose to continue with medical therapy. If patient continues with further episodes of clinical manifestation of coronary artery disease, more invasive intervention may be necessary down the line. The patient's congestive heart failure improved upon rigorous diuresis. Her diuretic regimen was weaned down and the patient is being discharged on Lasix 100 mg p.o. q. day. At baseline, the patient has bibasilar rales, left slightly greater than right, one-third of the way up. 2. Renal: The patient initially required hemodialysis with a creatinine of 5.7. The creatinine fell down to around 2.9 before stabilizing close to 3.0. On discharge her creatinine is 3.3. Her BUN also trended higher before stabilizing around 120. This was initially thought to be secondary to overly aggressive diuresis and is one of the reasons why the diuretic regimen was weaned down. The patient will likely need close renal follow-up on an outpatient basis as she has chronic renal failure and will likely require hemodialysis down the line. The patient was consulted by Renal and PTH was tested. Levels came back 160, which being less than 200, did not necessitate starting the patient on Rocaltrol. The patient was also started on Epogen 4000 units twice a week. Her iron levels were tested prior to starting, her iron being 36; she was started on iron sulfate 325 mg q. day. 3. Infectious Disease: The patient was started on a 14 day course of Flagyl for Clostridium difficile. Subsequent C. difficile stool toxins proved negative, however, the patient had showed clinical improvement with the antibiotics with her white blood cell count falling and diarrhea eventually going away. The patient remains on Flagyl; she is day nine of 14, and should receive five more days of metronidazole 500 mg three times a day. 4. Gastrointestinal: After having a lower GI bleed on admission, the patient was started on Protonix 40 mg twice a day. This dose was weaned to 40 mg q. day. The patient's hematocrit remained stable. Near the end of her hospital course, the patient was noted to still have guaiac positive stool. This may account for some of the rise in BUN that was noticed during the course of admission, however, the patient's hematocrit remained stable. GI had been consulted and recommended no intervention at this time. The patient may reserve further outpatient GI follow-up and possibly colonoscopy down the line. 5. Pain: The patient had been under a lot of pain during the course of admission. It was found that this pain was contributing to her tachypnea. Once the patient's pain management was better controlled with a Percocet regimen and topical ointment on rectal region ulcer, the patient's pain level decreased and the patient improved clinically. 6. Endocrine: The patient's sugar has been elevated during the course of admission. Her NPH regimen was gradually titrated up. On discharge, she is getting 4 units NPH in the a.m. and 16 units in the p.m., but still requires coverage with insulin sliding scale. The patient also has been getting Levothyroxine for her hypothyroidism and she will continue to get 100 micrograms p.o. q. day after discharge. The patient should be followed up with her primary care physician at the [**Name9 (PRE) 756**]. She has been given the choice of whether to follow-up with Cardiology and Renal at [**Hospital1 346**] or to follow-up at the [**Hospital1 756**]. On discharge, the patient is hemodynamically stable, alert and oriented times three, with a stable hematocrit. DISCHARGE DIAGNOSES: 1. Congestive heart failure with an ejection fraction of 40%. 2. Non-ST elevation myocardial infarction with a troponin of greater than 50. 3. Acute renal failure with creatinine of 5.7, requiring emergent hemodialysis. 4. Chronic renal failure with the creatinine stabilizing at 3.0. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg p.o. q. day. 2. Lipitor 10 mg p.o. q. day. 3. Hydralazine 100 mg p.o. q. six hours; hold for a systolic blood pressure less than 90. 4. Metoprolol 50 mg p.o. twice a day; hold for systolic blood pressure less than 100; heart rate less than 55. 5. Imdur 60 mg p.o. three times a day; hold for systolic blood pressure less than 100. 6. Norvasc 5 mg p.o. q. day. Hold for systolic blood pressure less than 90. 7. Lasix 100 mg p.o. q. day. 8. Protonix 40 mg p.o. q. day. 9. NPH 40 units a.m. and 16 units p.m. 10. Insulin coverage with sliding scale. 11. Iron sulfate 325 mg p.o. q. day. 12. Epogen 4000 units subcutaneously two times per week. 13. Colace 100 mg p.o. twice a day. 14. Percocet one to two tablets p.o. q. four to six hours p.r.n. for pain. 15. Levothyroxine 100 micrograms p.o. q. day. 16. Zolpidem 5 mg p.o. h.s. p.r.n. for sleep. 17. Calcium carbonate 500 mg p.o. three times a day with meals. 18. Flagyl 500 mg p.o. three times a day times five days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 9508**] MEDQUIST36 D: [**2169-7-10**] 12:44 T: [**2169-7-10**] 12:59 JOB#: [**Job Number 43067**] Admission Date: [**2169-6-24**] Discharge Date: [**2169-7-10**] Date of Birth: [**2094-6-6**] Sex: F Service: . ADDENDUM: Please mail a copy of the Discharge Summary to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name7 (NamePattern1) 1528**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 43068**]. His address is [**Location (un) 2274**], The [**Location (un) 1468**] Center, 26 City [**Doctor Last Name **] Mall, [**Location (un) 1468**], [**Numeric Identifier 43069**]. His phone number is [**Telephone/Fax (1) 43070**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 9508**] MEDQUIST36 D: [**2169-7-10**] 13:49 T: [**2169-7-10**] 14:13 JOB#: [**Job Number 43071**]

[ "578.9", "584.9", "428.0", "486", "403.91", "410.91", "276.2", "458.2", "424.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

14983, 15274

15297, 17429

4562, 14962

3361, 4544

526, 2243

2266, 3021

3038, 3338

72,323

159,176

53612

Discharge summary

report

Admission Date: [**2172-5-14**] Discharge Date: [**2172-5-18**] Date of Birth: [**2086-12-6**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: MVC Major Surgical or Invasive Procedure: none History of Present Illness: 85F s/p MVC w/ R SDH w/ shift, nasal bone fx, b/l rib fractures w/ contusions, and ?L globe FB, incidentally found to thrombocytopenic and anemic, likely advanced metastatic CA, possily breast. Past Medical History: PSH: Denies Social History: [**Doctor First Name **] Scientist, no EtOH or Alcohol, retired secretary (retired at age 78) Family History: NC Physical Exam: On admission: HR: 130 BP: 157/84 Resp: 20 O(2)Sat: 98% Normal Constitutional: The patient is awake, alert and responding appropriately to questions. She is comfortable and nontoxic in appearance HEENT: She has multiple facial abrasions and bruising along with raccoon eyes. Pupils are reactive to light She has a cervical collar in place, no stridor Chest: Lungs are clear bilaterally anteriorly Cardiovascular: Normal first and second heart sounds Abdominal: Her belly is soft and nontender. GU/Flank: No costovertebral angle tenderness Extr/Back: No extremity deformities Skin: No rash, Warm and dry Neuro: Speech fluent Pertinent Results: [**2172-5-18**] 10:25AM BLOOD WBC-8.7 RBC-3.13* Hgb-9.2* Hct-29.9* MCV-95 MCH-29.5 MCHC-30.9* RDW-18.5* Plt Ct-44* Plt Ct-44* Glucose-164* UreaN-19 Creat-0.7 Na-138 K-3.9 Cl-107 HCO3-23 AnGap-12 Calcium-9.1 Phos-3.4 Mg-2.104/26/12 02:40PM BLOOD WBC-11.8 Hct-19.8 Plt Ct-<5 [**2172-5-17**] 07:45AM BLOOD Plt Ct-52* WBC-9.0 RBC-2.61* Hgb-7.5* Hct-24.5* MCV-94 MCH-28.5 MCHC-30.4* RDW-18.2* Plt Ct-52* Glucose-96 UreaN-20 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-25 AnGap-14 [**2172-5-14**] 06:00PM Hct-21.8* [**2172-5-14**] 10:30PM Hct-22.0* [**2172-5-15**] 03:00AM Hct-24.5* [**2172-5-15**] 07:02AM Hct-20.6* [**2172-5-14**] 02:40PM Plt Ct-<5 [**2172-5-14**] 06:00PM Plt Ct-7 [**2172-5-15**] 03:00AM Plt Ct-52 [**2172-5-15**] 07:02AM Plt Ct-115 [**2172-5-15**] 03:00AM Glucose-201* UreaN-20 Creat-0.7 Na-137 K-4.2 Cl-104 HCO3-23 [**2172-5-14**] CT mx/fac - IMPRESSION: 1. Left frontal rounded hyperdensity suspicious for a hemorrhagic mass lesion such as a metastasis and right subdural hematoma, better visualized on the reference CT examination from [**2172-5-14**] at 12:37 p.m. from [**Hospital6 2561**]. 2. Minimally displaced comminuted nasal bone fracture with neighboring soft tissue contusion. 3. 1-mm hyperdense focus abutting the lateral aspect of the left globe (3:31) may represent a foreign body. 4. Intact globes. No retrobulbar soft tissue abnormalities. 5. Moderate ethmoid and trace maxillary and sphenoid sinus disease. 6. Mild rotation of C1 on C2, as seen on the reference CT C spine. Correlate clinically and consider MRI to exclude rotatory subluxation. [**2172-5-14**] CT chest/abd/pel - IMPRESSION: 1. Acute bilateral anterior rib fractures with subjacent mild pulmonary contusions. 2. 3.1 x 2.6 cm enhancing right lower outer breast mass, suspicious for malignancy, with left supraclavivular, bilateral axillary, mediastinal, and retroperitoneal lymphadenopathy. 3. 3 mm right upper lobe nodule warrants attention to this region on followup examinations. 4. Trace bilateral pleural effusions. 5. Multiple sub-cm hypodensities within the liver, not fully characterized on this exam. An MRI can be obtained for further evaluation. [**2172-5-14**] CT head - IMPRESSION: 1. Superior right parietal intraparenchymal hematoma is more diffuse than on the prior study with increased edema and new 4-mm leftward shift of normally midline structures. 2. A more inferior right parietal and the left frontal intraparenchymal hematomas are unchanged. Edema in the lower right parietal region has increased since [**72**]:37pm with new 4 mm leftward shift of normally midline structures and complete effacement of the right lateral ventricle occipital [**Doctor Last Name 534**]. If clinically indicated and feasible, MRI could be performed to evaluate for underlying mass lesions in the setting of right breast mass and lymphadenopathy seen on CT Torso [**2172-5-14**]. 3. New intraventricular blood in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. 4. Unchanged left parafalcine and small right frontal subdural hematomas. [**2172-5-15**] CT head - In comparison to study obtained 10 hours prior, there is no significant change in small right frontal subdural hematoma, left parafalcine hematoma and intraventricular hemorrhage. Intraparenchymal areas of hyperattenuation with extensive vasogenic edema, likely represents a combination of traumatic injury and hypercellular/hemorrhagic intracranial lesion, which also appear unchanged since prior exam. Minimal improvement of leftward shift of normally midline structures. Brief Hospital Course: 85F s/p MVC w/ R SDH w/ shift, nasal bone fx, b/l rib fractures w/ contusions, and ?L globe FB, incidentally found advanced metastatic CA, likely breast was admitted to the TICU for management of her multiple injuries. The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist and it was established that she is DNR early in her hospitalization. N: Pt remained alert and oriented throughout her stay in the hospital. She underwent frquent neuro checks and repeat scans of her head. After developing n LUE/LLE paresis repeat CT was significant for a new 4mm shift and expansion of her IVH. Given her beliefs if was decided to follow her clinically and not intervene. Her paresis stayed stable through HD 2 and she was maintained on Decadron and dilantin through the remainder of her hospitalization. Upon discharge, Decadron and dilantin were discontinued as the extended care facility, which the patient elected for further care, does not administer medications. HEENT: Pt was evaluated by the plstic surgery team for her nasal bone fx. She was packed and the packing was maintained for 48 hrs. It was decided that the fx was not operative. CV: The patient was found to be tachycardic upon presentation. The tachycardia improved as she was resuscitated with crystal and blood products during her stay in the TICU. While on the floor, she remained stable from a cardiovascular standpoint. P: Pt remained comfortable on supplemental oxygen during her stay in the TICU. While on the floor, she was weaned to room air; incentive spirometry was encouraged and the patient remained stable from a pulmonary standpoint. GI: The patient was initially NPO. After discussing her multiple injuries with her HCP it was decided that she would be discharged to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Science facility for further care and so her diet was advanced to regular, which was well tolerated. GU: A foley was placed in the ED and the patient made adequate urine throughout her stay in the hospital. The foley was removed on HD 3 and she was voiding without difficulty. Rehab: The patient was evaluated by Physical Therapy who felt the patient was appropriate for acute rehabiliation (please see evaluation for details). Heme: The patient presented with a hct of 19 and plts <5. The pt was seen by the Heme/onc team who reported that the cause of her anemia and thrombocytopenia was from either primary hematologic process or secondary to diffuse metastatic disease likely from a breast primary; incidental findings of a large breast lesion, diffuse lymphadenopathy and a liver lesion were identified. They deferred further work up until her neurological issues were stabilized and the patient did not wish to discuss the above issues at that time. Of note, Heme/Onc addressed the above issues with the patient's son. She was transfused a total of 3 PRBCs and 4 Plts through HD 2. ID: She was not maintained on abx during this hospitalization. Palliative Care: Palliative care met with the patient's family on HD2 where patient's wishes including transfer to the Benevolent Association were addressed. Given the patient's religious beliefs a discussion about continuing care was had which she elected to continue medical care while in house, however, desired transfer to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Science facility. In the event that the patient should desire additional medical follow-up or intervention, contact numbers for Neurology and Oncology were provided. Additionally, should the patient deteriorate acutely and wish to receive medication treatment, she was instructed to return to the Emergency Department. Medications on Admission: None Discharge Medications: None Discharge Disposition: Extended Care Facility: Benevolent Association Discharge Diagnosis: Multi-trauma 1. Left frontal intraparenchymal hematoma and right subdural hematoma with 4mm shift 2. Minimally displaced comminuted nasal bone fracture 3. Rib fractures: Left 1st rib; Right 2nd, 3rd rib 4. Bilateral pulmonary contusions 5. Thrombocytopenia 6. Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital following a motor vehicle collision during which you sustained multiple injuries including a right subdural hematoma, left intraparenchymal hemorrhage, nasal bone fracture, multiple rib fractures and bilateral pulmonary contusions. Additionally, a lesions were identified within your breast and liver, which you did not wish to further discuss with Hematology/ Oncology. You subsequenlty recovered in the hospital and based on your wishes are now being discharged to the Benevolent Association. We understand, based on your beliefs, that you do not wish to take medications, which will not be provided at the Benevolent Association, however, shall you experience any deterioration and you wish to receive active medication treatment or hospital level care, please return to the Emergency Department. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2172-6-2**] at 2:45 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage If desired, please contact Neurosurgery at [**Telephone/Fax (1) 1669**] to schedule a follow-up appointment within 4 weeks. A repeat Head CT is recommended at this time. Also, if desired, please contact Oncology at [**0-0-**] to schedule a follow-up appointment with either Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 8494**]. Completed by:[**2172-5-25**]

[ "198.3", "802.0", "174.5", "V49.86", "861.21", "285.22", "E816.0", "807.03", "197.7", "287.5", "344.40", "348.5", "853.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8752, 8801

4951, 8668

306, 312

9112, 9112

1362, 4928

10149, 10838

698, 702

8723, 8729

8822, 9091

8694, 8700

9288, 10126

717, 717

263, 268

340, 535

731, 1343

9127, 9264

557, 571

587, 682

48,553

172,407

13747

Discharge summary

report

Admission Date: [**2152-2-8**] Discharge Date: [**2152-2-18**] Date of Birth: [**2096-4-3**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 3645**] Chief Complaint: Cervical stenosis Major Surgical or Invasive Procedure: Anterior/posterior cervical decompression and fusion History of Present Illness: see admit H&P Past Medical History: see admit H&P Social History: see admit H&P Family History: see admit H&P Physical Exam: see admit H&P Pertinent Results: [**2152-2-8**] 12:51PM TYPE-ART PO2-251* PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2152-2-8**] 12:51PM GLUCOSE-191* LACTATE-1.6 NA+-138 K+-3.9 CL--108 [**2152-2-8**] 12:51PM HGB-12.8* calcHCT-38 [**2152-2-8**] 12:51PM freeCa-1.07* [**2152-2-8**] 12:00PM TYPE-ART PO2-247* PCO2-36 PH-7.36 TOTAL CO2-21 BASE XS--4 [**2152-2-8**] 12:00PM GLUCOSE-173* LACTATE-1.7 NA+-139 K+-3.7 CL--111 [**2152-2-8**] 12:00PM HGB-12.7* calcHCT-38 [**2152-2-8**] 12:00PM freeCa-1.07* Brief Hospital Course: Patient underwent above procedures in staged fashion. Stage 1 was well tolerated. In the immediate post-operative period after Stage 2 (posterior fusion), patient developed respiratory compromise and possible aspiration, and was transferred to the ICU after intubation. The ICU team managed his pulmonary function with ventilator, diuresis and elevation to reduce tracheal edema. Once patient developed a cuff leak signaling improving edema, he was successfully extubated. He returned to the floor in stable condition and progressed well. He did not develop febrile temperatures nor any clinical signs of respiratory infection. Incisions maintained excellent appearance throughout hospitalization. Once pain was adequately controlled, once stable medically, and once patient was tolerating a diet, he was deemed stable for discharge. Given slow progress with PT, he was deemed most appropriate for transfer to [**Hospital3 **] facility. Medications on Admission: see admit H&P Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sertraline 50 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. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain,fever. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cervical stenosis 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: 1. Keep incision clean and dry 2. [**Month (only) 116**] shower, change dressing afterwards 3. no bath2 4. No bending, twisting, no lifting > 10 lbs 5. C-collar at all times. Physical Therapy: Continue to advance mobility. No bending, twisting, lifting. Treatments Frequency: keep incision clean and dry, may shower, change dressing afterwards. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2152-2-28**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2152-3-1**] 11:00 Completed by:[**2152-2-17**]

[ "250.00", "E878.8", "721.1", "799.1", "998.12" ]

icd9cm

[ [ [] ] ]

[ "81.63", "81.02", "81.03", "96.71", "96.04", "84.51", "80.51" ]

icd9pcs

[ [ [] ] ]

2774, 2844

1073, 2019

323, 378

2906, 2906

569, 1050

3459, 3837

505, 520

2083, 2751

2865, 2885

2045, 2060

3089, 3264

535, 550

3282, 3344

3366, 3436

266, 285

406, 421

2921, 3065

443, 458

474, 489

68,453

166,143

39621

Discharge summary

report

Admission Date: [**2136-9-19**] Discharge Date: [**2136-9-25**] Date of Birth: [**2072-12-4**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 3565**] Chief Complaint: upper GI bleed Major Surgical or Invasive Procedure: endoscopy intubation History of Present Illness: 63M with h/o DM, HTN, CAD s/p MI ([**2125**]), Fournier's Gangrene, PVD, Peripheral neuropathy, hypercholesterolemia, CKD, shock liver BIBEMS with 1 day of chest pain (which he alternately describes as stabbing and crushing with a slight pleuritic component), fatigue, weakness, and 10-12 episodes of vomiting blood since yesterday. He reported intermittent LUQ abd pain and L anterior chest pain with deep breathing - [**3-22**]. He was found on floor alert and oriented by EMS- states was on floor since 1500 yesterday. He was too weak to get up and walk. Denies any syncopal episode. Patient had mechanical fall in shower yesterday with headstrike - no loc, no head or neck pain. He also c/o back pain since fall, reports dizzy standing up. He reports slightly postural on scene. FSBS 250. Of note, he had a recent colostomy take down and was discharged home wiht VNA on [**2136-8-19**]. . In ED, initial vitals were 99.8 113 128/67 20 98% 2L Nasal Cannula. Exam was notable for rhonchi disfusely. Labs were notable for a wbc of 14, creatinine of 1.4, Hct 26.9. He got an EKG that showed SR@108 STD 1 aVL c/w prior, slightly worse STD V5 V6 (most likely demand ischemia given rate). Underwent NG lavage which did not clear after 500cc. He was given IVF and type and crossed 2 U. CT of head showed no acute intracranial bleed. CXR showed opacity on the left upper lobes, new since CXR on [**2136-8-19**]. GI was notified and will urgently scope. ACS is aware of the patient and will follow. He was transferred to MICU for urgent scope. He has 2 PIV for access and is stable at transfer. . On floor, he was noted to be in moderate distress, rigoring with frequent non-productive cough. Past Medical History: - Leriche syndrome,(also referred to as aortoiliac occlusive disease, is due to thrombotic occlusion of the abdominal aorta just above the site of its bifurcation) - CABG LIMA to LAD, left radial to OM1, VG to RCA ( extended endarterectomy )[**2124-12-1**] - Coronary stenting after bypass ([**Hospital1 **]; report requested) - Diabetic type II with peripheral neuropathy - Fournier Gangrene (necrotizing infection involving the soft tissue of scrotom)[**8-/2135**] s/p scrotectomy and diverting colostomy c/b ARDS and severe hypotension, renal and liver failure and s/p tracheostomy placement (now closed) - Peripheral neuropathy - Renal insufficiency- most recent creat 1.7 - Recent colostomy take down [**8-/2136**] Social History: Lives alone in a 2 family home with his elderly parents. 2 children Tobacco: 50 pack year smoking history; quit smoking 2 weeks ago. has been smoking intermittently over the last year. ETOH: Not since hospitalization. Family History: father has had [**Name (NI) 5290**] and CABG in at age 70. Physical Exam: Vitals: T: 98 BP: 154/80 P: 123 R: 18 O2: 92% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds, rhonchi, crackles b/l with L>R, no rales. CV: tachy, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2136-9-19**] 10:20AM BLOOD WBC-14.1*# RBC-3.05* Hgb-9.2* Hct-26.2* MCV-86 MCH-30.3 MCHC-35.3* RDW-15.7* Plt Ct-175 [**2136-9-19**] 10:20AM BLOOD Neuts-92.9* Lymphs-3.2* Monos-3.5 Eos-0.2 Baso-0.2 [**2136-9-19**] 10:20AM BLOOD PT-13.5* PTT-29.5 INR(PT)-1.2* [**2136-9-19**] 10:20AM BLOOD Glucose-217* UreaN-23* Creat-1.4* Na-135 K-3.6 Cl-100 HCO3-24 AnGap-15 [**2136-9-19**] 10:20AM BLOOD ALT-20 AST-38 CK(CPK)-906* AlkPhos-91 TotBili-1.0 [**2136-9-19**] 10:20AM BLOOD cTropnT-0.03* [**2136-9-19**] 10:20AM BLOOD Phos-2.9 Mg-1.9 [**2136-9-21**] 06:19AM BLOOD Vanco-21.0* [**2136-9-20**] 02:50AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 Intubat-NOT INTUBA [**2136-9-19**] 02:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2136-9-19**] 02:40PM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-150 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2136-9-19**] 02:40PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Micro [**2136-9-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY INPATIENT [**2136-9-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2136-9-20**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-FINAL INPATIENT [**2136-9-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2136-9-19**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2136-9-19**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2136-9-19**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2136-9-19**] URINE URINE CULTURE-FINAL INPATIENT [**2136-9-19**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] CT head [**9-19**] NON-CONTRAST HEAD CT PERFORMED ON [**2136-9-19**] CLINICAL HISTORY: Status post fall with head trauma, question ICH or fracture. TECHNIQUE: Non-contrast MDCT with axial, coronal, sagittal reformations. FINDINGS: Evaluation is slightly limited due to motion artifact in the lower cuts. There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. The ventricles and sulci appear stable and mildly prominent likely related to mild atrophy. Basilar cisterns are patent. Mild periventricular white matter hypodensity likely related to chronic microvascular ischemic disease. Paranasal sinuses are notable for minimal mucosal thickening. Mastoid air cells and middle ear cavities are well aerated. Bony calvarium is intact. IMPRESSION: No acute intracranial process. DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**] Approved: WED [**2136-9-19**] 1:40 PM Brief Hospital Course: 63M with h/o DM, HTN, CAD s/p MI ([**2125**]), Fournier's Gangrene, PVD, Peripheral neuropathy, hypercholesterolemia, CKD, shock liver BIBEMS with 1 day of chest pain (which he alternately describes as stabbing and crushing with a slight pleuritic component), fatigue, weakness, and 10-12 episodes of vomiting blood since day prior to admission. #UGIB- EGD in ICU showed duodenitis and duodenal ulcers. Hpylori was negative. Patient was placed on a PPI. He was transfused 2U on [**9-19**]. #Acute respiratory failure- Pt had LUL consolidation on admission, which progressed. He developed respiratory distress and was intubated on [**9-19**]. He was treated with Vanc, Levo, Zosyn. #Acute on chronic renal insufficiency- Cr steadily rose from day of admission, without clear etiology. Urine sediment evaluation by renal revealed ATN. This worsening in setting of development of shock (see below), to the point of consideration of RRT prior to change in goals of care. #Leukocytosis- WBC initially declined, but then began to rise abrubptly on [**9-22**] with accompanying fever. Source unclear- empiric treatment for [**Name (NI) **] initiated, although stool negative x1. CT Torso did not reveal any infectious source (except known pneumonia). RUQ TTP and rising LFT prompted RUQ u/s which was equivocal; HIDA was negative. IR was consulted re: possible perc drainage regardless, given clinical deterioration; they felt gallbladder not distended enough to perform. #Shock- On [**9-24**], in setting of above rising WBC in absence of clear new source, pt developed hypotension that was not fluid responsive and required escalating pressors overnight. This was thought to be most likely septic shock. TTE showed global hypokinesis, also consistent with sepsis. On [**9-25**], in setting of worsening shock and need for initiation of RRT if aggressive care was to be pursued, a family meeting was held. Pt's daughter and sister both expressed that pt would not want to continue aggressive care in this situation. Therefore, goals of care were redirected to comfort, with withdrawal of ventilator and pressors. Pt expired shortly thereafter. Medications on Admission: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY 2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS 4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID 6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY 8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. . Allergies: Sulfa (Sulfonamide Antibiotics) Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "96.04", "96.05", "45.13", "96.72", "38.93", "33.22" ]

icd9pcs

[ [ [] ] ]

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51,291

149,071

41360

Discharge summary

report

Admission Date: [**2159-8-9**] Discharge Date: [**2159-8-11**] Date of Birth: [**2090-5-18**] Sex: F Service: MEDICINE Allergies: Adult Low Dose Aspirin Attending:[**First Name3 (LF) 1899**] Chief Complaint: CHIEF COMPLAINT: Pericardial effusion REASON FOR CCU ADMISSION: Monitoring post pericardial drain placement Major Surgical or Invasive Procedure: Pericardial drain placement [**2159-8-9**] History of Present Illness: Ms. [**Known lastname 90050**] is a 69F with a history of recently diagnosed synchronous stage IIIB non-small cell lung cancer (adenocarcinoma by bronchial brushings) and renal cell carcinoma, currently s/p left nephrectomy and undergoing chemotherapy and radiation. She underwent CT scan of her chest for re-staging of her lung cancer on [**2159-8-6**], which demonstrated an increasingly large pericardial effusion (had been previously noted on PET scan in [**Month (only) 116**]). She has recently been experiencing worsening shortness of breath at home, which she notices only with exertion such as carrying a full basket of laundry. She has had some associated cough, but no sputum production. In addition, about 3 weeks ago she was seen at [**Hospital3 1443**] hospital for chest pain; she was ruled out for MI and planned for outpatient echocardiogram, which would have been today but she cancelled given her oncology appointments. She has not had a recurrence of the chest pain. She was seen today in clinic today by her oncologist Dr. [**Last Name (STitle) **], who noted her complaints of worsening dyspnea on exertion and referred her to the ED for echocardiogram to evaluate for possible tamponade. In the ED, echocardiogram showed brief right atrial collapse and impaired filling of the right ventricle consistent with early tamponade physiology. She was evaluated by interventional cardiology and taken to the catheterization lab for pericardial fluid removal. . She underwent pericardial drain placement with ~400 cc of bloody fluid removed, followed by rapid drainage of another ~150cc into the drainage bag. She tolerated the procedure well. Immediate post-procedure echo showed small residual pericardial effusion with no Fluid was sent for cytology. Her oncologist Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and updated with the events of the procedure. He requested transfusion of 2 units pRBCs for anemia. . On the floor, she reports feeling well. No current SOB at rest or chest pain (only very mild site tenderness with drain placement). . Of note, her cancer history is well-documented in OMR note by Dr. [**Last Name (STitle) **] dated [**2159-8-9**]. Briefly, she initially presented in [**Month (only) 404**] with hematuria, and further work up revealed both a large 9-cm renal mass and a RUL 9-cm mass with mediastinal nodes. Based on renal biopsy (RCC, clear cell type) and bronchial brushings (likely adenocarcinoma) these are two separate cancers. She has been treated with chemotherapy with cysplatin and paclitaxel (start date [**2159-7-12**]) and radiation therapy to the chest, in addition to unilateral nephrectomy in 4/[**2159**]. . On review of systems, she endorses bilateral chronic hip pain with walking (not new or changed), and dark stool secondary to iron use. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery (though had one GI bleed on aspirin in [**2154**]), myalgias, hemoptysis, black stools or red stools. She denies recent fevers, chills, nightsweats or rigors. No recent cold or flu symptoms. She denies exertional buttock or calf pain. She denies dysuria or other urinary symptoms. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea (sleeps with one flat pillow), ankle edema, palpitations, syncope or presyncope. All of the other review of systems were negative. Past Medical History: - Renal cell carcinoma (clear cell type by biopsy) s/p unilateral left nephrectomy [**4-/2158**] - Non-small cell lung cancer (likely adenocarcinoma by bronchial brushings) stage IIIB s/p cisplatin/paclitaxel (day #1 = [**2159-7-12**]) and radiation (ongoing) - Esophagitis secondary to chemo/radiation - Hypertension diagnosed > 30 years ago - Depression - Status post gastrointestinal bleed from GI ulceration from aspirin in [**2154**] - History of iron deficiency anemia - Status post rotator cuff repair in [**2156**] - History of sinusitis Social History: Lives at home with her husband. Continues to work part time at her husband's business (he owns an automotive parts supply shop). - Tobacco history: Former smoker of [**1-28**] packs per day until age 65 (~75 pack-year history) - ETOH: Recreational in past, none recent - Illicit drugs: None Family History: Mother died of stroke; father died of heart disease. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; no family history of lung or renal cancer; one maternal aunt had cancer of an unknown type. Otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: T=98.7 BP=100/69 HR= RR=16 O2 sat=97% on 4L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. No carotid bruits noted. CARDIAC: Distant S1S2, no distinct murmurs, rubs or gallops. Pericardial drain in place with ~150 cc of sanguinous fluid in bag. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. 2+ DP pulses SKIN: Erythematous rash over central anterior chest secondary to recent radiation treatment . DISCHARGE EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate. CARDIAC: Distant S1S2, no distinct murmurs, rubs or gallops. Dressing in place at the site of pericardial drain, c/d/i LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. 2+ DP pulses SKIN: Erythematous rash over central anterior chest secondary to recent radiation treatment Pertinent Results: LABS ON ADMISSION: [**2159-8-9**] 07:35AM WBC-14.5* RBC-2.93* HGB-7.8* HCT-24.1* MCV-82 MCH-26.7* MCHC-32.4 RDW-18.3* [**2159-8-9**] 07:35AM PLT COUNT-486* [**2159-8-9**] 12:20PM GLUCOSE-97 UREA N-27* CREAT-1.3* SODIUM-131* POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-24 ANION GAP-18 [**2159-8-9**] 12:38PM GLUCOSE-104 LACTATE-1.1 NA+-131* K+-5.0 CL--95* TCO2-25 [**2159-8-9**] 02:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050* [**2159-8-9**] 02:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM [**2159-8-9**] 02:45PM URINE RBC-15* WBC-6* BACTERIA-NONE YEAST-NONE EPI-2 TRANS EPI-<1 OTHER SIGNIFICANT LABS: . MICROBIOLOGY: - Pericardial fluid [**2159-8-9**]: Gram stain negative for organisms or PMNs. - Pericardial fluid culture [**2159-8-9**] (blood culture bottles): NO GROWTH - MRSA screen [**2159-8-9**]: PENDING IMAGING: . - ECHO [**2159-8-9**] (pre-procedure): Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is unusually small. with normal free wall contractility. There is a moderate sized pericardial effusion. The effusion appears circumferential. Stranding is visualized within the pericardial space c/w organization. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate circumferential pericardial effusion with most of the fluid located over the right atrium and inferolateral wall. There is relatively little fluid over the right ventricular free wall. There is variation in tricuspid inflows, along with brief right atrial collapse and impaired filling of the right ventricle consistent with early tamponade physiology. . - ECHO [**2159-8-9**] (post-procedure): Effusion is loculated. No significant respiratory variation in mitral/tricuspid valve flows. IMPRESSION: Limited study, Doppler images only. No significant variation in mitral inflows. Pericardial fluid amount is reduced. . - ECHO [**2159-8-11**] (post-procedure): Focused views s/p pericardial drainage. The estimated right atrial pressure is 0-5 mmHg. Overall left ventricular systolic function is normal (LVEF>55%). There is a residual small pericardial effusion along the infero-lateral wall and right atrium. The effusion is very small anterior to the right ventricle and significantly improved compared to the prior study dated [**2159-8-9**].There are no echocardiographic signs of tamponade. LABS ON DISCHARGE: Pericardial Effusion Fluid: [**2159-8-9**] 04:45PM OTHER BODY FLUID WBC-1175* Hct,Fl-8.5* Polys-35* Lymphs-39* Monos-16* Eos-1* Macro-9* [**2159-8-9**] 04:45PM OTHER BODY FLUID TotProt-5.3 Glucose-85 LD(LDH)-996 Amylase-23 Albumin-3.4 CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes, red blood cells, hemosiderin-laden histiocytes, and rare mesothelial cells. . [**2159-8-11**] 06:15AM BLOOD WBC-11.4* RBC-3.65* Hgb-10.1* Hct-30.5* MCV-83 MCH-27.7 MCHC-33.2 RDW-18.4* Plt Ct-411 [**2159-8-11**] 06:15AM BLOOD Glucose-144* UreaN-19 Creat-1.0 Na-138 K-4.9 Cl-103 HCO3-25 AnGap-15 Brief Hospital Course: PRIMARY REASON FOR ADMISSION: 69 y/o woman with renal cell carcinoma and non-small cell lung cancer diagnosed early [**2159**], undergoing chemotherapy and radiation, who presents with DOE and worsening pericardial effusion with evidence of early tamponade by echocardiogram. Admitted to CCU for monitoring s/p pericardial drain placement. ACTIVE ISSUES: . # PERICARDIAL EFFUSION: Pericardiocentesis was performed with immediate drainage of 400cc sanguinous fluid. Overnight, another ~450cc sanguinous fluid drained, and samples were sent for gram stain, protein content, culture, electroyltes and cytology. Post-procedure echo showed a small loculated residual effusion with no evidence of tamponade physiology. Cytology was negative for malignacy, but suspicion remains high for a malignant etiology. Pulsus was followed throughout her hospital course, and at the time of post-procedure echo pulses was 12 by doppler. Pt was asymptomatic at the time of discahrge and specifically denied CP/SOB/DOE, palpitations or lightheadedness. If pericardial effusion reaccumulates, would consider CT surgery consult for pericardial window. . # RENAL CELL CARCINOMA, NON-SMALL CELL LUNG CANCER: No treatments were undertaken during this hosptial course. Pt was discahrged with Heme/Onc follow-up with Dr. [**Last Name (STitle) **]. . # TACHYCARDIA - Pt remained tachycardic to the 100-120s throughout her course. Initially it was felt this may have been [**2-28**] tamponade physiology, but tachycardia persisted s/p pericardiocentesis. She was then transfused 2U pRBCs at the request of Dr. [**Last Name (STitle) **] and bolused 1L NS due to concern for anemia/hypovolemia, but tachycardia persisted. Review of clinic visits revealed that she has been persistently tachycardic for several months, which may be related to the small loculated effusion that was not accessed by the tap. The patient denied pain throughout her course and refused any pain medicaitons. Orthostatics were checked at discahrge and were normal. . # ANEMIA: Her Hct has trended down over the past 6 months. This is likely related to chonric disease, and pt was transfused 2U pRBCs during this admission. She is taking Fe supplementation, which was continued during her hospitalization. . # LEUKOCYTOSIS: She had a low grade leukocytosis throughout her admission, which is consistent with her baseline. Suspect this is related to her malignancies. She remained afebrile and normotensive throughout her course, pericardial and urine cultures were negative and CXR showed no evidence of pulmonary process. . CHRONIC ISSUES: . # HYPERTENSION: Generally normotensive. Continued home meds (amlodipine 10 mg PO daily, HCTZ 25 mg PO daily) with holding parameters. . # HYPERLIPIDEMIA: Continued rosuvastatin 10 mg PO QHS. . # DEPRESSION/ANXIETY: Denies current depression. States she takes Xanax once daily in the mornings. Continued Effexor XR 150 mg PO daily. Continued Xanax 0.5 mg PO daily (in AM). . # OSTEOPOROSIS: Continued alendronate 70 mg PO Q week (Mondays). . TRANSITION OF CARE: Pt was discharged home with Heme/Onc follow up. She was also scheduled for an outpatient echo that should be followed up by her PCP/Oncologist. She was instructed to return to the ER if she experiecned worsening SOB/CP, as this may represet reaccumulation of pericardial fluid. Medications on Admission: - Alendronate 70 mg PO Q week on Mondays - Alprazolam 0.5 mg PO PRN (takes once daily in AM) - Amlodipine 10 mg PO daily - Hydrochlorothiazide 25 mg PO daily - Maalox:Benadryl:2%Lidocaine Mixture 1:1:1 15 minutes before meals and at bedtime PRN (no recent use) - Olmesartan 40 mg PO daily - Odansetron 8 mg PO Q8H PRN nausea (no recent use) - Prochlorperazine 10 mg PO Q8H PRN nausea (no recent use) - Rosuvastatin 10 mg PO QHS - Venlafaxine ER-24 hr 150 mg PO daily - Acetaminophen 325-650 mg PO 30 minutes before meals PRN odynophagia (no recent use) - Ferrous sulfate 325 mg PO daily - Fish oil DHA EPA 1,200 mg-144 mg PO daily - Magnesium oxide 400 mg PO daily Discharge Medications: 1. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 3. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. halobetasol propionate 0.05 % Cream Sig: One (1) Topical QID (4 times a day) as needed for Dry skin. 7. Maalox:Benadryl:2%Lidocaine Mixture Sig: One (1) 15 minutes before meals and at bedtime. 8. Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO once a day. 9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 10. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 13. olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 15. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Cardiac Tamponade SECONDARY DIAGNOSIS Lung Cancer Renal Cancer Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 90050**], It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a condition called pericardial tamponade. This is caused by fluid surrounding the heart, and it can cause the heart to not beat effectively. For this you underwent pericardiocentesis, a procedure where a doctor drains the fluid with a needle to restore the normal functioning of the heart. After this procedure we performed another Echocardiogram to confirm that the fluid had not reaccumulated and felt you were safe to return home. During this hospitalization, we made NO CHANGES to your medicatios. It will be important for you to follow up the results of the cytology from your pericardial fluid analysis with you oncologist. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2159-8-16**] at 12:00 PM With: [**Name6 (MD) 8111**] [**Name8 (MD) 8112**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]

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icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

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4434

Discharge summary

report

Admission Date: [**2188-10-8**] Discharge Date: [**2188-10-10**] Date of Birth: [**2123-6-24**] Sex: M Service: MEDICINE Allergies: Clotrimazole / Augmentin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: mental status changes, poor po Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname **] is a 65 year old male with chronic pancreatitis and a long history of multiple intra-abdominal abscesses, s/p multiple drainage procedures with perihepatic collection who presents today with changes in mental status. Wife notes symptoms have been going on since Monday. S he also notes that he has been increasingly pa.le. Legs have been more swollen. He has had poor appetite. He was seen today in [**Hospital **] clinic, mildly confused and hypotensive to 80s/50s (baseline 90s). Hct was noted to be 23 from baseline of 29 five days ago. He was referred to the ED. . Pt has a complicated medical history with multiple intraabdominal abscesses with fistulas draing to the skin and bowel. Most recently he has had several admissions with details as below: . - [**2188-8-25**]: R flank pain and sepsis. IR drainage of perihepatic fluid collection with polymicrobial infection (MRSA and vanco-sensitive enterococcus). ERCP/biliary stent placed for biliary leak (empirically) - perihepatic drain continued to drain bilious fluid. No positive [**Year (4 digits) **] cultuers on discharge. Discharged on Daptomycin, moxifloxacin, and fluconazole. PICC placed [**9-18**]. . - [**2188-9-24**]: Admitted for GPCs on BCx from [**9-24**]. Thought to be due to obstruction of the biliary drain. Drain was repaired, fluid culture grew Klebsiella and MRSA. PICC line was also changed. [**Month/Year (2) **] cultures from NE [**Hospital1 **] grew Staph epi in [**12-9**] bottles from the PICC and MRSA from peripheral site. Subsequent Bcx at [**Hospital1 18**] were all negative. He was discharged on [**10-1**] on same antibiotics to NE [**Hospital1 **] where he has continued to have intermittently poor drain function. . . He reports poor appetite. Abdomen is generally swollen and tender. R flank hurts constantly. Feet are swollen. He denies fevers or chills. . In the ED inital vitals were, 97.8 75 91/61 12 100% RA. In the ED, BP in upper 70s. Received 2L IVF, 3rd hanging, with improvement of pressures. WBC 11.3. Received Vanco and Zosyn. Surgical consult placed for diffuse abdominal tenderness. CT scan showed pigtail catheter coiled in a perihepatic fluid collection, smaller than previous, severe anasarca and diffuse bowel wall thickening, and extensive pneumonbilia. Surgery found no acute surgical process. Recommended IR guided drainage if needed. He also received 4mg IV morphine X 2. Vital signs on transfer: afebrile, HR 80s, BP 104/62. . On the floor, he denies any symptoms. He reports that he does not want aggressive care. . Review of systems: (+) Per HPI (-) Per pt (who is confused) Denies fever, chills. 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, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Multiple polymicrobial fluid collections, status post multiple drain procedures over the past several years. Most recently MRSA in new L flank abscess in [**2188-6-6**], past h/o psoas abscess, retroperitoneal abscess, enterocutaneous fistula. 2. Ventral hernia repair complicated by severe pancreatitis, leading to a nearly yearlong hospitalization starting [**2185-4-7**] at [**Hospital6 10353**] and at the [**Hospital1 2177**] to rehabilitation ending [**2186-1-8**]. 3. Pancreatic mass per GI notes. Endoscopic ultrasound performed twice, most recently [**2187-1-8**] showing 2 x 3 cm ill-defined mass to the pancreas. FNA was performed. No malignancy was found. 4. CAD status post MI [**2185**] 5. Diverticulosis. 6. Anxiety. 7. Hypothyroidism. 8. Hypertension. 9. Lower extremity DVT status post IVC filter ([**2185**] or [**2186**]) 10. Portal vein thrombosis. 11. Status post fundoplication 16 plus years ago complicated by splenic injury requiring splenectomy. 12. BPH. 13. Vitamin D deficiency. 14. Abnormal LFTs intermittently, most recently thought due to Augmentin. 15. Gynecomastia. 16. Cirrhosis - dx in [**2186**] Social History: Lives in [**Location (un) 7913**] with [**Doctor First Name 1258**] his wife. [**Name (NI) **] is unemployed. - Tobacco: smoked <1 PPD for 1 year in the past - Alcohol: denies - Illicits: denies Family History: Denies any known family history. Physical Exam: ADMISSION EXAM: General: Alert, oriented to person, place year, no acute distress, emaciated body habitus with wasting of his face, neck and muscles of his chest. Anasarca. HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally. reduced breath sounds at bases, poor inspiratory effort. otherwise clear CV: distant heart sounds. Regular rate and rhythm. Abdomen: soft, diffusely tender. non distended. ABS. R abdominal tube in place with drainage fo dark brown liquid. Has what appears to be an old drain site with puckering and erythemetous scale consistent with fungal infection. GU: + foley, unable to visualize penis which is retracted within scrotum. Ext: warm, well perfused. Significant dorsal edema. Left leg twice as large as right with pitting edema. DISCHARGE EXAM: General: AAOx3, no acute distress, emaciated body habitus with wasting of his face, neck and muscles of his chest. Anasarca. HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally. reduced breath sounds at bases, poor inspiratory effort. otherwise clear CV: distant heart sounds. Regular rate and rhythm. Abdomen: soft, diffusely tender. non distended. ABS. R abdominal tube in place with drainage fo dark brown liquid. GU: + foley, unable to visualize penis which is retracted within scrotum. Ext: warm, well perfused. Significant dorsal edema. Left leg twice as large as right with pitting edema. Pertinent Results: ADMISSION LABS: [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] WBC-11.3* RBC-2.83* Hgb-8.7* Hct-27.1* MCV-96 MCH-30.6 MCHC-32.0 RDW-18.5* Plt Ct-432 [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] Neuts-86* Bands-1 Lymphs-8* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2188-10-8**] 05:27PM [**Month/Day/Year 3143**] PT-14.0* PTT-26.8 INR(PT)-1.2* [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] Glucose-79 UreaN-21* Creat-1.1 Na-139 K-4.8 Cl-112* HCO3-20* AnGap-12 [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] ALT-16 AST-47* AlkPhos-357* TotBili-0.7 [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] Lipase-30 [**2188-10-8**] 12:30PM [**Month/Day/Year 3143**] Albumin-1.9* DISCHARGE LABS: [**2188-10-9**] 03:45AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-3.4 Mg-1.8 [**2188-10-10**] 04:33AM [**Month/Day/Year 3143**] WBC-7.9 RBC-2.47* Hgb-7.5* Hct-23.2* MCV-94 MCH-30.3 MCHC-32.2 RDW-18.6* Plt Ct-492* [**2188-10-10**] 04:33AM [**Month/Day/Year 3143**] Glucose-88 UreaN-17 Creat-1.0 Na-139 K-3.8 Cl-116* HCO3-15* AnGap-12 [**2188-10-10**] 04:33AM [**Month/Day/Year 3143**] ALT-15 AST-40 LD(LDH)-130 AlkPhos-297* Amylase-35 TotBili-0.7 [**2188-10-10**] 04:33AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-3.3 Mg-1.8 Iron-PND IMAGING: CXR: Stable tiny left effusion and basilar atelectasis. Interval retraction of PICC line with tip residing at the expected location of the left brachiocephalic vein. CT A/P: Examination limited by lack of IV contrast and diffuse anasarca/third spacing. 1. Stable position of right abdominal drain with tip in perihepatic fluid collection which is slightly smaller in size. Pocket of air inferior to the right lobe of the liver is similar in size. When viewed in conjunction with the tube check of [**2188-9-29**], this fluid collection and air pocket was confirmed to be in communication with the biliary system. Extensive pneumobilia is stable. 2. Bowel wall stable thickening, likely secondary to 3rd spacing. However, infection cannot be completely excluded. 3. Mild fullness of the right renal collecting system, unchanged. 4. Stable small pleural effusions. MICRO: [**2188-10-8**] 4:00 pm [**Month/Day/Year 3143**] CULTURE PICC #1. [**Month/Day/Year **] Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2188-10-10**]): Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6463**] @ 11:12A [**2188-10-10**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. [**2188-10-8**] 4:10 pm [**Month/Day/Year 3143**] CULTURE PICC #2. [**Month/Day/Year **] Culture, Routine (Pending): (NGTD) URINE CULTURE (Final [**2188-10-10**]): 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2188-10-8**] 11:09 pm ABSCESS Source: abdomen. GRAM STAIN (Final [**2188-10-9**]): Reported to and read back by [**First Name8 (NamePattern2) 251**] [**Last Name (un) **] @ 00:15A [**2188-10-9**]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): YEAST(S). FLUID CULTURE (Preliminary): RESULTS PENDING. ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): YEAST. Brief Hospital Course: 65 year old male with chronic pancreatitis and a long history of multiple intra-abdominal abscesses, s/p multiple drainage procedures with perihepatic collection who presents with hypotension and altered mental status in the setting of intraabdominal or urinary tract infection. # Hypotension/rule out sepsis: Initially thought pt was septic because of hypotension and elevated WBC count. Pt was hypotensive to SBP of upper 70s and has had a baseline SBP in the 90s at home. Was initially placed on pressors and antibiotics broadened to linezolid/cefepime/flagyl/fluconazole from home regimen of daptomycin/moxifloxacin/flagyl/fluconazole. Responded well to fluids, so was quickly weaned off pressors and SBP remained stable ranging 110s-140s off pressors. WBC count came down and pt was never febrile. Pt reported poor po intake prior to admission as had very low albumin with new onset LE edema. Hypotension thought to be secondary to intravascular volume depletion, likely secondary to poor intake plus third spacing. CXR neg for PNA. CT showed improvement in abdominal fluid collection and bowel wall edema consistent with third spacing. One of two [**Month/Day/Year **] cultures (2 out of 4 bottles) drawn off same PICC were positive for GPCs and this was thought to be [**1-9**] contamination because it was not universally positive (as one would expect in the case of bacteremia), plus patient was already on excellent gram positive coverage with daptomycin/moxifloxacin. Urine taken from foley grew out a resistant strain of Klebsiella pneumoniae which was similar in sensitivities to past cultures. Abscess fluid was polymicrobial. Since pt recovered so quickly and [**Month/Day (2) **] cultures were not positive for GNRs, urine was thought to be colonization in the setting of a chronic foley, and the abscess is currently being treated with a drain. Switched patient back to his home antibiotics (daptomycin/moxifloxacin/flagyl/fluconazole) with plan to broaden should he show signs of decompensation. Pt refusing painful or invasive procedures - treatment of UTI would require removal of foley, which would likely be painful in the setting of severe scrotal edema (could not visualize penis). Pt will follow up with his primary care and ID doctor as an outpatient. # LE edema: pt admitted with new onset LE edema bilaterally but worse on left. Per PCP this is new over the past 2 months. Obtained LE dopplers which showed occlusive DVT on left from common femoral vein down to calf veins. On right there was impaired compressibility that could indicate partially occlusive clot but no definite thrombus. Recommend discussion with PCP as to risks and benefits of anticoagulation for palliation of LE edema. Currently has an IVC filter for pulmonary embolus prophylaxis. # altered mental status: per wife pt was confused at the time of hypotension. Pt ruled out for sepsis as above. Thought to be [**1-9**] volume depletion vs medication effect. Pt improved with IV fluids. PCP adjusted pt's medication regimen, stopping all benzos and recommending a max of 15mg po oxycodone and 6mg po dilaudid per day. Palliative care recommends spacing out those medications as follows: 5mg oxycodone po q8h standing with 2mg dilaudid po q8h in between; hold if patient is confused or sedated. # Pneumobilia: Chronic, since ERCP. Surgery has elected not to perform CCY given patient's high risk abdomen. Has been stable with this finding over the last month. Surgery has reevaluated in the ED with no indication for acute surgery. # Goals of care: Pt and wife have discussed his current state and multiple episodes of acute on chronic infection. Would prefer to avoid aggressive care in respect to measures that would cause him additional pain and prolong his suffering. Reviewed ICU consent with wife who does not want large needles or tubes in body, no IVs in neck including EJ. Had family meeting with PCP and ID doc in which he re-affirmed his DNR/DNI status but was not ready for CMO or hospice yet and asked to continue to treat infection and send to long term care facility. # Elevated LFTs/Cirrhosis: Pt has cirrhosis with some element of obstruction that is chronic, but LFTs are reduced compared to previous hospitalizations. No action taken. # Anemia: likely secondary to chronic disease; appears to have been dropping steadily since end of [**Month (only) **]. checked iron studies which were pending at the time of discharge. # Hypoalbuminemia: Pt has very severe malnutrition which is contributing to his anasarca. Likely contributing to gut wall edema. Requested recommendations from nutrition. # Pancreatitis: stable. continued creon # CKD: At baseline. held sevelemer and neutraphos and rechecked electrolytes, which were stable, so restarted on discharge. # Hypothyroidism: continued levothyroxine # Skin rash: continued miconazole powder, desenex # CAD: continuedASA # Chronic pain: continued lido patch, standing tylenol max 2gm daily, prn zofran. Held narcotics while in house and can restart as above as outpatient # Anxiety: stopped ativan. TRANSITIONAL ISSUES: - follow up cultures - monitor for hemodynamic decompensation - may need to broaden antibiotics if so - follow up iron studies - discuss anticoagulation with patient for palliation of LE edema in the setting of DVT - pain control Medications on Admission: levothyroxine 25mg qday lipase-protease-amylase 5,000-17,000-27,000 2caps tid w/meals miconazole powder tid ASA 81mg daily lidocaine patch 5% daily tylenol 1000 prn sevelamer 1600 tid w/meals colace senna dulcolax daptomycin 400mg IV q48hrs omeprazole 40mg daily moxifloxacin 400mg daily fluconazole 200mg daily zofran prn Nephrocaps daily MVI Zinc 220mg daily Ativan 0.5 mg qhs prn ProSource No Carb 30mL daily Roxicodone 5mg q6h Desenex 2 % tid Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off. 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for fever or pain. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 10. daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg Intravenous Q48H (every 48 hours). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day. 13. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. 14. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 15. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 16. multivitamin Capsule Sig: One (1) Capsule PO once a day. 17. Zinc-220 220 (50) mg Capsule Sig: One (1) Capsule PO once a day. 18. terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 21. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: between doses of oxycodone. hold for confusion or sedation. 22. sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day: with meals. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: dehydration medication side effect Secondary Diagnosis: abdominal abscess chronic foley 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: Thank you for letting us take part in your care at [**Hospital1 771**]. You were brought to the hospital because you were confused and your [**Hospital1 **] pressure was low. You were given IVF and your [**Hospital1 **] pressure and mental status improved. You were also given additional antibiotics to protect you from infection. Your [**Hospital1 **] cultures did not indicate that there was an infection in your [**Last Name (LF) **], [**First Name3 (LF) **] you were placed back on your home antibiotics. You improved so you were sent home. You should drink plenty of fluids and avoid certain medications (below) which can lead to confusion. The following changes were made to your medications: 1. You should avoid benzodiazepines. 2. You should not take more than 15mg oxycodone (short-acting) per day 3. You should not take more than 6mg dilaudid per day Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2189-2-2**] at 1:45 PM With: [**Name6 (MD) 15991**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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Discharge summary

report

Admission Date: [**2166-4-1**] Discharge Date: [**2166-4-7**] Date of Birth: [**2092-12-30**] Sex: M Service: CARDIOTHORACIC Allergies: Iodine; Iodine Containing / Metoprolol / Diltiazem Er Attending:[**First Name3 (LF) 922**] Chief Complaint: chronic Type A dissection Major Surgical or Invasive Procedure: [**2166-4-3**] Redo Sternotomy, Replacement of Ascending Aorta(32mm Gelweave Dacron Graft), Re-implantation of saphenous vein grafts History of Present Illness: Mr. [**Known lastname **] is a 73 year old male who underwent coronary artery bypass grafting and Maze procedure on [**2166-2-21**]. he has done well since, maintaining sinus rhythm. During a routine followup cardiac MRI, he was noted to have an aortic dissection involving the ascending aorta. Given the findings, he was admitted for further evaluation and treatment. He was relatively asymptomatic but was complaining of some right sided chest discomfort which appeared more musculoskeletal in nature. On admission, he denied back pain, syncope, lightheadedness and dizziness. Past Medical History: s/p coronary artery grafting & Maze procedures coronary artery disease h/o Atrial fibrillation Prostate CA hypertension Dyslipidemia Hx of transient ischemic attack Hx of Splenic Infarcts Hypertriglyceridemia Anaphylactoid reaction to Iodinated contrast Social History: He has three children, all in good health. He lives in Peace village community setting. He is a retired Professor Emeritus in accounting and management at [**University/College 5201**]. He stopped smoking in [**2127**], does not drink alcohol or use recreational drugs. Family History: Family history is remarkable for parents who died very late in life. His father did have some heart disease. A brother is deceased at 65 of prostate cancer. Two other brothers are in poor health in their 80s. A sister is deceased at 62. Physical Exam: Admission: VS - 97.3, 185/78, 60, 16, 95%RA Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple without lymphadenopathy. CV: regular rate and rhythm, normal S1, S2. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. CTA bilaterally, 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. Skin: Brown skin changes around left lower leg. No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ DP 1+ Left: Carotid 2+ Femoral 2+ DP 1+ Pertinent Results: [**2166-4-1**] Cardiac MRI: Aortic dissection involving the ascending aorta; dissection does not appear to involve the valve plane on the provided images but probably approaches within 1-2 cm. Origin of a coronary bypass graft on the anterolateral aspect of the ascending aorta is located immediately adjacent to the dissection flap. [**2166-4-2**] Transthoracic ECHO: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. 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. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [**2166-4-2**] Coronary CTA: 1. Short segment dissection (43 mm) in the ascending aorta, extending just below the origin of the graft in the right lateral border of the aorta to the level of the sinotubular junction, without involving the origins of the grafts or native coronary arteries. 2. Patent all three bypass grafts: left anterior mammary artery to left anterior descending, graft from aorta to obtuse marginal one, and graft from aorta to right coronary artery. 3. Mild cardiomegaly. 4. Small amount of fluid surrounding the ascending aorta and a small amount of pericardial effusion, probably related to recent surgery. [**2166-4-5**] 07:00AM BLOOD WBC-11.5* RBC-3.18* Hgb-9.8* Hct-27.9* MCV-88 MCH-30.7 MCHC-34.9 RDW-15.1 Plt Ct-189 [**2166-4-7**] 05:30AM BLOOD UreaN-19 Creat-1.4* K-4.0 [**2166-4-5**] 07:00AM BLOOD Glucose-93 UreaN-18 Creat-1.3* Na-134 K-4.4 Cl-106 HCO3-23 AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was directly admitted to the Cardiovascular Intensive Care Unit for strict blood pressure control. He was hypertensive on admission and started on Nipride which was titrated for goal systolic blood pressure less than 120 mmHg. In anticipation for surgical intervention, he was given Vitamin K for Warfarin reversal. Further evaluation included an echocardiogram and coronary CT angiogram - see result section for details. Given his Iodine allergy, he was pre-treated with Prednisone and Benadryl without complication. On [**4-3**], he underwent redo sternotomy with repair of his chronic type A aortic dissection. For surgical details, please see operative note. Given inpatient stay was greater than 24 hours, Vancomycin was given for perioperative antibiotics. Following the operation, he was brought to the CVICU for invasive monitoring. He weaned from bypass easily. Within 24 hours, he awoke neurologically intact and was extubated without incident. His hypertension was treated with beta blockers and ACE inhibition. Anticoagulation was not resumed as he has been in sinus rhythm. Diuresis was begun towards his preoperative weight. Physical therapy worked with him for strengthening an d mobilization. A short stay in a rehabilitatiuon facility was necessary before return to independent living. Discharge instructions and medications were detailed in the summary and discharge plans as were followup directions. Medications on Admission: Amiodarone 200 mg QD Docusate Sodium 100 [**Hospital1 **] Aspirin 81 QD Warfarin 4 QD or as directed Hydromorphone as needed for pain. Atorvastatin 10 QD Atenolol 25 QD Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**5-5**] hours as needed for 2 weeks. 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: decrease to 40mg daily after 7 days ([**4-15**]). 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days: Decrease to daily after 7 days ([**4-15**]). 14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Chronic Type A Aortic Dissection s/p Repair ascending dissection & reanastamosis of grafts [**2166-4-3**] Coronary Artery Disease Atrial Fibrillation s/p Coronary Artery Bypass Grafting and Maze Procedure on [**2166-2-21**], Hypertension Dyslipidemia h/o of transient ischemic attack Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**5-4**] weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-4**] weeks ([**Telephone/Fax (1) 3393**]) Dr. [**Last Name (STitle) 5210**] in [**3-4**] weeks Dr. [**Last Name (STitle) **] in [**4-2**] weeks please call for appointments Completed by:[**2166-4-7**]

[ "519.3", "441.01", "272.4", "V58.61", "V12.54", "996.03", "E878.2", "V45.81", "401.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.45", "39.61" ]

icd9pcs

[ [ [] ] ]

7858, 7948

4734, 6186

344, 479

8276, 8283

2728, 4711

9081, 9444

1671, 1910

6406, 7835

7969, 8255

6212, 6383

8307, 9058

1925, 2709

279, 306

507, 1089

1111, 1367

1383, 1655

25,009

102,545

22801+22802+57323

Discharge summary

report+report+addendum

Admission Date: [**2130-4-28**] Discharge Date: [**2130-5-8**] Date of Birth: [**2075-3-5**] Sex: F Service: CSU ADMISSION DIAGNOSES: 1. Sternal wound infection. 2. Coronary artery disease status post coronary artery bypass grafting x2 ([**2130-4-12**]). 3. Insulin dependent diabetes mellitus, hypertension and hypercholesterolemia. DISCHARGE DIAGNOSES: 1. Sternal wound infection - status post sharp debridement, VAC placement. 2. Right thyroid nodule. 3. Right lower lobe lung nodule. 4. Left adrenal nodule. 5. Coronary artery disease - status post CABG. 6. Insulin dependent diabetes mellitus. 7. Hypertension. 8. Hypercholesterolemia. ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname 17025**] is a 55 year old female with a history of coronary artery disease who underwent coronary artery bypass grafting on [**2130-4-12**]. She was subsequently discharged to Rehab in good condition, but several days prior to her presentation on [**2130-4-28**], she noticed a slight amount of drainage from the inferior aspect of her wound. This became progressively foul-smelling and she presented for a wound check and was found clinically to have about a 3 cm x 10 cm lower sternal wound infection. She had otherwise denied any sense of fever or chills. She had not noticed any sort of crepitus or cracking in her chest. On her initial examination, her temperature was 101.0, her pulse was in the low 100s and her pressures were in the 110s. She was otherwise oxygenating well. Her exam was essentially remarkable for a 4 x 15 cm area of erythema with tenderness at the inferior aspect of her sternal wound with necrotic debris emanating from the incision. There was otherwise no evidence of sternal instability. Her white count was 11.7. Her BUN and creatinine were 23 and 0.7. She had a chest x-ray which showed that her sternal wires were still intact, but CT scan to further evaluate the wound showed a defect in the anterior soft tissue with inflammatory changes with gas in the region of the mediastinum. There was no evidence of defect in the osseous structures. Incidentally, on CT scan, a 22 x 17 mm right thyroid nodule was noted as was a 4 mm lung nodule at the right lung base and a 26 x 28 mm adrenal nodule, all of which require follow-up imaging in the future for further characterization. HOSPITAL COURSE: The patient was admitted and started on broad spectrum antibiotics which included vancomycin and levofloxacin. Blood cultures were obtained as were wound cultures. The wound was sharply debrided down to healthy tissue with a significant amount of necrotic tissue removed and was treated initially with saline wet-to-dry dressing changes. Plastic Surgery was consulted who recommended further debridement with dressing changes with future placement of VAC. We changed over to acetic acid dressing changes for a short course with subsequent placement of a VAC on hospital day 4 as the wound looked good. The patient remained afebrile throughout the remainder of her hospitalization with a normal white blood cell count. Her VAC dressing was changed every 3 days in consultation with Plastic Surgery with development of good early granulation tissue by the time she was ready for discharge. She never evidenced any sort of sternal instability and follow-up chest x-rays did not show any change in location of her sternal wires or development of any new pleural effusions. We consulted the [**Last Name (un) **] Diabetes Service for aid and management of her diabetes with improved control with change in her morning and evening insulin regimen. It was felt on hospital day 11 that the patient had been afebrile and was otherwise showing no infection of infection and had a nicely healing wound with the VAC that she be discharged to Rehab in fair condition. On the day of her discharge, her T-max was 100.0. She was otherwise hemodynamically normal. Her white blood cell count was 6.7. Her wound had grown out coag-negative staphylococcus. One of four blood culture bottles did also grow out coag-negative staphylococcus, but this was felt to be a contaminant and follow-up surveillance blood cultures were negative. She was sent to Rehab on the following medications - Tylenol #3 with codeine 1-2 tabs every 4-6 hours as needed for pain, Zantac 150 mg p.o. b.i.d., aspirin 81 mg p.o. once daily, pravastatin 80 mg p.o. once daily, Colace 100 mg p.o. b.i.d., metformin 500 mg p.o. b.i.d., ibuprofen 400 mg p.o. q.8h. as needed for pain, furosemide 60 mg p.o. b.i.d., lisinopril 5 mg p.o. once daily, carvedilol 6.25 mg p.o. b.i.d., vancomycin 1 g IV q.12h. to finish a 6-week course, insulin NPH 26 units at breakfast, 20 units at bedtime with a Regular insulin sliding scale. She was to have her VAC changed at Rehab. She will have her VAC changed every 3 days with follow- up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Plastic Surgery in 1 week at his office. The patient will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**8-6**] days for further outpatient workup of the incidental thyroid, lung and adrenal nodules found during workup of the wound infection. She will follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in the clinic as per her previously scheduled postoperative appointment in [**1-28**]/2 weeks. She will be discharged to Rehab on a cardiac, diabetic, heart healthy diet and strict sternal precautions. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2130-5-8**] 08:42:01 T: [**2130-5-8**] 09:19:46 Job#: [**Job Number 58965**] Admission Date: [**2130-4-28**] Discharge Date: [**2130-5-17**] Date of Birth: [**2075-3-5**] Sex: F Service: CSU ADDENDUM: Please see previous discharge summary from [**2130-5-8**] for hospital course up until that time. We had previously planned to discharge the patient on [**2130-5-8**], but upon final inspection of her wound at that time, we noted that there was some necrotic tissue at the margins, and there was concern that there may be additional necrotic tissue deeper to this wound. It was therefore decided to perform a partial bedside operative debridement, which in fact did reveal the presence of necrotic tissue more deeply. We therefore took her to the operating room on [**2130-5-10**] for full operative debridement. At that time, there was significant necrotic tissue at the base of the wound and at the margins. We debrided this sharply and widely with good bleeding and viable tissue at the margins at the end of the procedure. The patient, notably, had an intact sternum. She was taken to the cardiac surgery intensive care unit postoperatively, and remained on paralytics up until [**2130-5-12**], at which time Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the plastic surgery service were able to take her for bilateral pectoralis myocutaneous flap closure of an open chest wound. Ms. [**Known lastname 17025**] [**Last Name (Titles) 8337**] this procedure well. There were no intraoperative complications. Postoperatively, she was brought to the cardiac surgery intensive care unit and extubated. She did quite well. She remained afebrile and otherwise hemodynamically normal. She was extubated by postoperative day 1, and the remainder of her hospital course was essentially unremarkable. Notably, her wound grew out Prevotella species. Therefore, she was treated with vancomycin and Zosyn. Given the fact that this infection extended likely down to the bone, we felt that she needed a full 6 week course of antibiotics, which she was started on. A few medication adjustments were also made prior to her discharge. The following is an updated list of her discharge medications: Tylenol with codeine #3 1-2 tablets every 4 hours as needed for pain. Zantac 150 mg p.o. b.i.d. Aspirin 81 mg p.o. once daily. Pravastatin 80 mg p.o. once daily. Colace 100 mg p.o. b.i.d. p.r.n. Metformin 500 mg p.o. b.i.d. Ibuprofen 1 tab every 8 hours as needed. Vancomycin 1 gram every 12 hours for 5 weeks. Zosyn 4.5 grams IV every 8 hours for 5 weeks. Lopressor 12.5 mg p.o. b.i.d. Her followup appointments were to be as noted with Dr. [**Last Name (STitle) 70**] in the [**Hospital **] medical office building, Dr. [**Last Name (STitle) 58966**] from the congestive heart failure service, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], and her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At the time of her discharge, her white blood cell count was 7.2, hematocrit 32. Her BUN and creatinine were 12 and 0.4. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2130-5-17**] 15:18:36 T: [**2130-5-17**] 15:52:04 Job#: [**Job Number 58967**] Name: [**Known lastname **],[**Known firstname 356**] Unit No: [**Numeric Identifier 10861**] Admission Date: [**2130-4-28**] Discharge Date: [**2130-6-8**] Date of Birth: [**2075-3-5**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 674**] Addendum: Please see previously written discharge summaries from [**5-8**] and [**5-17**]. She was not discharged on either of these dates. Instead she has remained in-house. [**5-17**] was POD [**8-1**]. Over the next several she continued to receive care on the floor with IV antibiotics -- vancomycin and Zosyn -- and her JP drains were removed. On PODs [**12-6**] she developed diarrhea and C. diff was ruled out. Discharge to rehabilitation was considered but the plastic surgery team decided to hold off and watch her wound for [**1-29**] more days because the distal portion of her wound comtinued to be necrotic/non-healing. A CT scan on PODs 13/11 showed fluid collection posterior to the sternum and it was decided that pt would return to the OR for debridement with plastics. On [**5-25**] (PODs 15/13) Ms. [**Known lastname 2031**] had an I&D if her sternal wound with placement of a vac dressing with plans for reconstruction to follow. On [**5-29**] (19/17) she proceeded to the OR again for rectus flap and split-thichness skin graft to sternal wound. A new vac dressing was also placed in the OR. (Please see OP note for full details.) Over the next several days she remained in-house with careful monitoring but the plastic surgery team. Her vac dressing was ultimately discontinued. She had three JP drains with only one removed on [**6-6**]. She was also followed closely by the [**Last Name (un) 616**] team with adjustment of her insulin needs as she healed. She had fevers for several days for which the ID team was consulted; the underlying cause of the fevers was not found with multiple pan cultures negative. She ultimately became afebrile and on [**6-8**] had been afebrile and without an elevated whote blood cell count for two days. Her IV antibiotics were discontinued per the ID team and she was continued on PO flagyl and linezolid. On PODs 57/29/27/10 it was decided that she was safe for discharge home with PO antibiotics and two JP drains with visiting nurses to follow and appointment with Dr. [**Last Name (STitle) 5111**] (plastic surgery) in one week. Major Surgical or Invasive Procedure: Sternal wound debridement (bedside) [**2130-5-10**]. Operative Wound Debridement [**2130-5-12**]. Bilateral pectoralis myocutaneous flap closure of open chest wound [**2130-5-25**]. Right-sided rectus muscle flap with split thickness skin graft from left thigh to chest [**2130-5-29**]. Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*0* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*0* 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 18 days. Disp:*54 Tablet(s)* Refills:*0* 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 18 days. Disp:*36 Tablet(s)* Refills:*0* 10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: [**Location (un) **] Manor - [**Location (un) **] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2130-6-8**]

[ "V45.81", "998.31", "V58.67", "552.21", "998.32", "250.00", "276.1", "519.2", "998.59", "401.9" ]

icd9cm

[ [ [] ] ]

[ "77.61", "86.74", "53.51", "83.82", "86.69", "93.59", "38.93", "00.14", "99.04", "86.22", "83.45" ]

icd9pcs

[ [ [] ] ]

13389, 13604

11678, 11967

384, 2341

11990, 13366

2359, 11640

155, 363

44,430

183,554

48676

Discharge summary

report

Admission Date: [**2189-2-6**] Discharge Date: [**2189-2-8**] Date of Birth: [**2137-10-18**] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 7333**] Chief Complaint: VT ablation Major Surgical or Invasive Procedure: EPS Intubation History of Present Illness: (largely from records as patient is intubated): This patient is a 51 y/o M with history of hyperlipidemia, hypertension and CAD s/p IMI complicated by VT s/p ICD placement. He has had intermittent episodes of VT over the past 1.5 years. He underwent a noninvasive EP study and ICD testing on [**2-1**], that demonstrated monomorphic VT at 145 bpm, originating from the inferior septum. Antitachycardia pacing was successful in terminating the arrhythmia. In late [**2187**], he had several episodes of VT that were terminated by ICD shock. He was started on IV amiodarone and transitioned to an oral dose which was effective in suppressing the arrhythmia. He had been doing well since that time and presented to [**Hospital1 18**] on [**2-6**] for elective VT ablation. During the procedure, multiple areas around his MI scar were ablated, although VT inducibility remained. In the PACU, the patient was extubated. However, his O2 sats dropped, resulting in reintubation. Initial ABG was 7.26/49/66. Repeat gas showed 7.31/47/113. CXR and bronch at bedside were unremarkable. He was transferred to the CCU for further care. On arrival to the CCU, patient was intubated and sedated. Therefore, ROS was unable to be obtained. Past Medical History: IMI in [**2177**] s/p RCA stent, s/p LAD stent in [**2182**] Ventricular tachycardia s/p ICD for primary prevention of cardiac death HTN Hyperlipidemia H/O ankle fracture, s/p surgical repair Anxiety Arthritis Tobacco abuse- 1 ppd x 35 years CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: RCA stent [**2177**], LAD stent [**2182**] -PACING/ICD: ICD placed [**2182**] Social History: He is divorced with one grown child. He smokes 1 ppd x 35 years. He drinks 2-3 drinks weekly. He is a licensed general contractor. Family History: Grandfather who died suddenly at age 43 as well as a father who died at age 49, believed associated with a myocardial infarction but categorized as sudden death. Physical Exam: VS: T 97.6, HR 67, BP 130/78, RR 16, 97% on AC 650/16, PEEP 10, FiO2 100% GENERAL: WDWN male, intubated and sedated. HEENT: NCAT. Sclera anicteric. PERRL. ETT in place. NECK: Supple with no appreciable JVD. CARDIAC: Distant heart sounds. RRR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Slightly coarse BS bilat, no crackles or wheezes. ABDOMEN: Obese. Quiet BS. Soft, NTND. EXTREMITIES: Trace ankle edema. 2+ femoral, DP, radial pulses bilat. No femoral bruits or hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission labs [**2189-2-6**] 04:01PM BLOOD Glucose-158* Na-138 K-5.0 Cl-102 [**2189-2-6**] 07:35PM BLOOD Lactate-1.5 [**2189-2-6**] 04:01PM BLOOD Type-ART Rates-14/1 Tidal V-750 PEEP-10 FiO2-88 pO2-66* pCO2-49* pH-7.26* calTCO2-23 Base XS--5 AADO2-540 REQ O2-86 Intubat-INTUBATED Vent-IMV [**2189-2-6**] 07:00AM BLOOD Glucose-105 UreaN-16 Creat-1.0 Na-141 K-4.5 Cl-105 HCO3-24 AnGap-17 [**2189-2-6**] 07:00AM BLOOD PT-13.4 PTT-26.4 INR(PT)-1.1 [**2189-2-6**] 07:00AM BLOOD WBC-10.2 RBC-5.26 Hgb-16.1 Hct-46.7 MCV-89 MCH-30.5 MCHC-34.4 RDW-13.1 Plt Ct-252 Discharge Labs [**2189-2-7**] 03:11AM BLOOD WBC-16.3*# RBC-4.65 Hgb-14.2 Hct-42.1 MCV-90 MCH-30.6 MCHC-33.8 RDW-13.3 Plt Ct-209 [**2189-2-8**] 08:00AM BLOOD WBC-14.5* RBC-4.47* Hgb-13.7* Hct-40.7 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-199 [**2189-2-8**] 08:00AM BLOOD Glucose-93 UreaN-18 Creat-0.8 Na-144 K-3.9 Cl-108 HCO3-29 AnGap-11 [**2189-2-8**] 08:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.4 [**2189-2-7**] 12:41PM BLOOD Type-ART Temp-36.6 FiO2-60 pO2-78* pCO2-27* pH-7.45 calTCO2-19* Base XS--2 Intubat-NOT INTUBATED Reports/Imaging CTA Chest [**2189-2-6**] IMPRESSION: 1. No pulmonary embolism. No pneumothorax. 2. Moderate dependent bibasilar atelectasis. TTE [**2189-2-6**] Urgent study performed by on-call cardiology fellow to exclude tamponade physiology. Limited views obtained. Suboptimal image quality due to body habitus, poor positioning, and ventilator.The right ventricular cavity is dilated with depressed free wall contractility. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. No pericardial effusion. Dilated RV with depressed free wall contractility. CT Head IMPRESSION: No acute intracranial process. CHEST (PORTABLE AP) Study Date of [**2189-2-6**] 5:40 PM Two supine views. Comparison with [**2189-2-6**]. Volumes are low as before. There is streaky density at the lung bases consistent with subsegmental atelectasis as demonstrated previously. There is no new focal infiltrate. The heart and mediastinal structures are unchanged. An endotracheal tube and ICD remain in place. IMPRESSION: No significant change. Brief Hospital Course: 1) Hypoxic Respiratory failure: Most likely related to sedative medications received for his EP study, and underlying sleep apnea. However, his marked A-a gradient suggested a contributor other than hypoventilation. CT head was negative. CT chest showed no heart failure, PE, pneumothorax or pneumonia. There was some atelectasis, which may have been contributory. He was weaned down on the ventilator over the first night and was extubated without difficulty the following day. His respiratory function subsequently remained stable. 2) VT: Status post ablation procedure, although continued to have inducible VT at the end of the procedure. He was continued on amiodarone and had no events with telemetry monitoring. Medications on Admission: Amiodarone 200mg daily Amlodipine 2.5mg daily Clonazepam 0.5mg twice daily Toprol XL 200mg daily Lyrica 150mg daily Crestor 20mg daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ventricular Tachycardia 2. Respiratory Failure 3. Obstructive Sleep Apnea Discharge Condition: Stable. Patient is tolerating oral intake, ambulating, and has returned to his baseline condition. Discharge Instructions: You were admitted to the hospital for treatment of your abnormal heart rhythm. You underwent a procedure and your heart rhythm has improved considerably. After your procedure, you had difficulty breathing and were placed on a breathing tube. This was thought most likely related to medications and your sleep apnea. Within 24 hours, your breathing had improved considerably and the breathing tube was removed. . We made no changes to your medications. . Please seek immediate medical attention if you develop any episodes of passing out, palpitations, shortness of breath, chest pain, light-headedness, dizziness, fevers, shaking chills, night sweats, abdominal pain, nausea, vomiting, numbness or tingling in your legs. Followup Instructions: Please follow-up with your cardiologist Dr. [**Last Name (STitle) 1911**] within the next 4-6 weeks. You can call his nurse practitioner to set up this appointment. Please ask them to help schedule an echocardiogram for you prior to this visit. . Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 1-2 weeks of your discharge. Please call his office at [**Telephone/Fax (1) 82239**] to schedule this appointment. Completed by:[**2189-2-10**]

[ "272.4", "412", "518.0", "401.9", "E937.8", "300.00", "327.23", "V45.82", "997.39", "518.5", "716.90", "414.01", "V45.02", "427.1", "305.1" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.27", "37.34", "96.71", "93.90", "96.04", "33.23" ]

icd9pcs

[ [ [] ] ]

6698, 6704

5229, 5949

282, 299

6844, 6945

2965, 5206

7714, 8262

2197, 2360

6134, 6675

6725, 6725

5975, 6111

6969, 7691

2375, 2946

231, 244

327, 1554

6744, 6823

1576, 2032

2048, 2181

73,409

125,375

54151

Discharge summary

report

Admission Date: [**2117-5-4**] Discharge Date: [**2117-5-13**] Service: MEDICINE Allergies: Trazodone Attending:[**First Name3 (LF) 398**] Chief Complaint: Altered Mental Status, tachypnea, anemia Major Surgical or Invasive Procedure: RIJ Central Line Placement History of Present Illness: Mr. [**Known lastname 75404**] is an 88 yo M with CAD s/p CABG, MVR, CHF, COPD, afib, with recent admission for chronic L pleural effusion/hemothorax, s/p VATS with decortication complicated by HAP, who presents from rehab with altered mental status. . He was admitted to [**Hospital1 18**] from [**Date range (1) 110979**] for evaluation and management of L pleural effusion/hemothorax. He underwent partial decortication and parietal pleurectomy on [**4-16**]. His course was complicated by repeat mucous plugging requiring bronchosocopy. He was also treated for CAP with levofloxacin and HAP with vanco/zosyn through [**4-30**]. Furthermore, he failed multiple swallow evaluations, undergoing a G tube for tube feeds. Hematology evaluated the patient for persistent thrombocytopenia, which was felt to be due to MDS. His INR was also persistently high, despite having his coumadin held for his procedures. After a prolonged hospitalization, he was discharged to rehab. . At rehab, his mental status had been below baseline but was slowly improving. However, Over the last 24 hr his mental status became worse, with more somnolence. At baseline he is awake and conversant according to his son. The staff also noted an increasing fluid collection in his LLE. Blood work was sent which showed a Hct of 22 and new leukocytosis. ALso there was a question of bloody stool. He was therefore sent to [**Hospital1 18**] ED for evaluation. . In the ED, T96, BP 97/41, HR 68, RR 16, 96% 2L. LLE fluid collection aspirated. Given 1g vanco, zosyn for ? infection. Appeared to calm slightly during the course of the ED stay. CXR, CT head, LLE LENIs performed. He was noted to be tachypneic but with stable 02 sats. . On arrival to the floor, he is moaning and tachypneic. He is able to nod yes-no to simple questions, but is non-conversant. . ROS: As per above, otherwise unable to obtain Past Medical History: CAD, s/p two vessel CABG in [**2103**] -MVR at the time of CABG in [**2103**] -HTN -cervical laminectomy in [**2103**] or '[**04**]- pt noted that it was done in attempt to treat leg weakness -gout -s/p removal of RLE hematoma and skin grafting -s/p THR in [**2101**] Social History: Lived with his wife on [**Location (un) **] prior to last hospitalization but admitted from rehab. Has hired live-in help. They also have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Location (un) 86**]. He is a semi-retired owner of a manufacturing plant in aerospace materials and offshore oil. He is a former cigar smoker, but quit two-three years ago. He drinks 2 alcoholic beverages (mostly mixed drinks) per day. Denies illicit drug use. Family History: Notable for father with cardiac disease. No known history of neurologic disease. Physical Exam: VS: T 96.5, HR 100, BP 142/71, RR 38, 94% 4L NC Gen: awake, moaning, not answering questions, moderate work of breathing HEENT: anicteric sclera, MM dry, PERRL Neck: supple, RIJ intact Heart: tachy, irregular, no obvious murmurs Lung: Coarse BS diffusely with decreased BS at L base. Wet upper airway sounds Abd: soft, NT + BS Ext: 2+ edema on L, brown discoloration bilat. large firm LLE fluid collection behind popliteal fossa with mild skin break down and erythema Skin: multiple ecchymoses Neuro: awake but moaning, not answering questions. PERRL, corneal reflexes intact, moving upper ext with good strength Pertinent Results: Na 139 / Cl 107 / BUN 72 / BG 103 K 5.4 / CO2 28 / Cr 2.4 . WBC 13.5 / Hct 24.5 / Hb 8.0 / Plt 205 N:58.0 L:35.0 M:3.8 E:2.6 Bas:0.6 . PT: 15.1 PTT: 38.2 INR: 1.3 . ABG: 7.37/48/116, Lact 0.9 . [**2117-5-4**] Portable CXR - Continued left mid and lower lung opacification, unchanged. Resolving right lower lobe opacities. No new consolidations seen. . [**2117-5-4**] CT Head - No evidence of acute intracranial hemorrhage or large masses. . [**2117-5-4**] Left LENI - 1. No DVT seen though evaluation incompletee due to patient discomfort. 2. Large heterogeneous mass in the popliteal/ calf region, most compatible with large hematoma. . [**2117-5-5**] Echo The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. At least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**5-6**] CT Torso w/o contrast: CHEST: There is consolidation within the right lower lobe. There is consolidation/collapse of the left lower lobe, with a small amount of pleural effusion on the left. There is no axillary, mediastinal, or hilar lymphadenopathy by size criteria. Coronary calcifications are noted. Post-CABG changes are noted. ABDOMEN: A nasogastric tube is in place. The evaluation of the solid organs is limited by non-contrast technique. Allowing for this limitation, there is no gross contour abnormality associated with the liver, spleen, pancreas, or adrenals. The kidneys are atrophic bilaterally, and contain punctate non- obstructing calculi. There are bilateral exophytic renal lesions which cannot be characterized as simple cysts. There is no hydronephrosis. Abdominal aortic aneurysm is again identified, unchanged, measuring approximately 3.9 cm in maximal diameter. There is no retroperitoneal hematoma. There is no abdominal lymphadenopathy. PELVIS: Evaluation of the pelvis is limited due to extensive streak artifact from patient's bilateral hip arthroplasties. Allowing for this limitation, there is no gross fluid collection or abnormality within the pelvis. LOWER EXTREMITIES: There is a large hematoma within the left calf, starting at the level of the popliteal fossa, extending for approximately 20 cm craniocaudad. There is extensive soft tissue edema and thickening of the facial planes superior to the hematoma. Extensive arterial calcifications are noted in the lower extremities bilaterally. OSSEOUS STRUCTURES: There is diffuse osteopenia. There is extensive degenerative change. Bilateral hip arthroplasties are noted. There are no destructive osseous lesions. IMPRESSION: 1. Large left calf hematoma. No retroperitoneal bleed. 2. Bilateral lower lobe consolidation/atelectasis as described above. . [**5-9**] CT Chest FINDINGS: Compared to the recent study, there is interval increase in the secretions within the trachea as well as within the left main bronchus, and left upper and left lower lobe bronchi with subsequent development of an atelectasis which involves almost entire left lower lobe with and a significant part of left upper lobe with sparing of the apex. These findings may contribute to the fluid-like appearance of the chest radiograph but actually no interval worsening of pleural effusion has been demonstrated. The right pleural effusion has increased in the interim but still small. At the right base, there is interval development of consolidation that is disproportional to the amount of pleural fluid and might represent an area of infection/aspiration. The rest of the right lower lobe and the right upper lobe is grossly unremarkable but note is made that the quality of the study is not optimal due to the presence of motion artifact. In the superior portion of the left upper lobe, there are areas of consolidation as well as pleural thickening that have progressed since [**2117-5-6**] and most likely are sequelae of the atelectasis rather than interval development of lymphangitic spread of the tumor. The extensive mediastinal lymphadenopathy is unchanged with lymph nodes in the aortopulmonic window, right upper and lower paratracheal area and prevascular location ranging up to 13 mm and the paraortic lymph node, 4:112, is 17 x 12 mm, all of them unchanged since the prior study. The heart size is significantly enlarged, unchanged including all [**Doctor Last Name 1754**]. There is a focal dilatation of the aorta at the level of the aortic arch, 4:62, which appears to be accompanied by medial displacement of the mural calcification that can be followed toward the descending aorta and might represent area of dissection. Correlation with contrast-enhanced studies is recommended. Enlargement of pulmonary arteries is present with the main pulmonary artery ranging up to 4 cm, right main 3.3 cm and left 2.7 cm consistent with pulmonary hypertension. The patient is after median sternotomy and CABG with appearance has not been changed since the recent prior study. Degenerative changes of the thoracic spine are present, unchanged. IMPRESSION: 1. The original dictation has been lost and the study that was done on [**5-9**], [**2116**] has been redictated today on [**2117-5-11**]. 2. There is interval development of atelectasis of almost entire left lower lobe that may also be accompanied by consolidation and the presence of extensive secretions in the left main, left upper and lower lobe that might be consistent with the increase in consolidation on the chest radiograph. The shift of the mediastinum to the left is consistent with volume loss and atelectasis. 3. Increasing right lower lobe consolidation accompanied by new pleural effusion that might represent infection and parapneumonic effusion or aspiration. 4. Suspected aortic arch and descending aorta dissection, chronicity undetermined and should be evaluated with contrast-enhanced study. 5. Extensive mediastinal lymph nodes that appears to be unchanged since [**2117-5-6**] but in the absence of more remote comparison, the chronicity and nature is difficult to assess and they may be either reactive or malignant and should be followed closely in not more than three months. 6. Hyperdense (25 Hounsfield units) right renal cyst. It should be correlated with ultrasound. . [**5-10**] CT head FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, shift of normally midline structures or hydrocephalus. The ventricles and sulci remain prominent, likely due age-related parenchymal atrophy. Calcifications are noted of vertebral and cavernous carotid arteries. Again noted is mild mucosal thickening involving the left maxillary sinus, unchanged. The remainder of the imaged paranasal sinuses and mastoid air cells is unremarkable. Osseous structures and soft tissues are stable in appearance. IMPRESSION: No evidence of acute intracranial process, including no hemorrhage, edema or mass. Stable appearance of lacunar infarction. . [**5-13**] IMPRESSION: AP chest 2:39 a.m. [**5-13**] submitted for review on [**5-17**] compared to [**5-12**]: Left pleural effusion and left lower lobe consolidation improving since [**5-11**], consolidation at the right lung base and small right pleural effusion unchanged. The heart enlarged but partially obscured by pleural and parenchymal abnormality. No pneumothorax. . [**2117-5-10**] 03:54AM BLOOD WBC-9.5 RBC-2.81* Hgb-8.7* Hct-26.3* MCV-94 MCH-31.1 MCHC-33.2 RDW-18.5* Plt Ct-112* [**2117-5-8**] 02:28AM BLOOD PT-15.7* PTT-28.8 INR(PT)-1.4* [**2117-5-5**] 02:47PM BLOOD ESR-132* [**2117-5-10**] 03:54AM BLOOD Glucose-116* UreaN-77* Creat-2.5* Na-147* K-4.2 Cl-118* HCO3-19* AnGap-14 [**2117-5-6**] 03:03AM BLOOD ALT-13 AST-27 LD(LDH)-223 TotBili-1.4 [**2117-5-5**] 03:45AM BLOOD CK(CPK)-8* [**2117-5-10**] 03:54AM BLOOD Calcium-9.6 Phos-2.8 Mg-2.2 [**2117-5-6**] 03:03AM BLOOD Hapto-71 [**2117-5-5**] 02:47PM BLOOD CRP-141.8* [**2117-5-6**] 03:03AM BLOOD Vanco-22.1* [**2117-5-8**] 09:03PM BLOOD Vanco-15.7 Brief Hospital Course: 88 yo M with CAD s/p CABG, MVR, afib, COPD, s/p recent admission for VATS/decortication/pleurectomy for L hemothorax, who presents with altered mental status and LLE hematoma. LMWH was stopped and although he required several units of blood as the result of the LLE hematoma, he remained HD stable and the bleeding stopped. His primary residual problems during his hospital course were delirium and aspiration pneumonias. Ultimately, as his pneumonias were not improving with antibiotics (he was not able to cough up his secretions and had persistent mucus plugging) he expired from recurrent pneumonia. His family decided that a trach was not consistent with his living will and he was eventually made CMO. . Hospital course complicated by the following problems: . 1. Altered Mental Status DDx included multiple medical illnesses and aspiration, underlying infection, ARF, metabolic derangement, medications, seizure, chronic hospitalization, LLE infection. No evidence of bleed on CT. Picture more consistent with delirium over stroke. Head CT was negative x2 for acute bleed or stroke. There were no signs of meningitis. LFTs wnl. Patient was treated for possible PNA/aspiration with 8 days of vanc/cefepime. Patient also had left lower extremity drained upon arrival and mental status improved, however it continued to wax and wane throughout the hospitalization which was consistent with delirium in the setting of infection. . 2. LLE Hematoma: Patient had an ultrasound on admission that was suggestive of [**Hospital Ward Name **] cyst with hemorrhage and clot. He underwent aspiration with serosanguinous fluid drained. Patient's hematocrit has remained relatively stable after 4 U PRBC and 2 units of FFP and discontinuation of the LMWH. . 4. CAD s/p CABG: He remained asymptomatic. He was continued on beta blockade. No symptoms of ischemia. - Cont Metoprolol - ? not on ASA, statin . Afib: Afib on EKG. - Cont metoprolol - hold coumadin/LMWH given bleeding . CHF: Per OSH Echo in [**2115**], EF 40%. Likely ischemic in origin given CAD. Currently no signs of gross fluid overload - Cont BB . COPD: Unclear degree of COPD. No PFTs available - Albuterol, ipratropium prn - 02 as needed . Acute on chronic renal failure: Baseline Cr 2. Was slightly above during hospital course. [**Month (only) 116**] be related to pre-renal physiology given underlying infection. . Anemia/Thrombocytopenia: Recent baseline Hct 28. Prior Plt count 50-70s. Per recent hematology eval, anemia likely multifactorial to include MDS, inflammation (Ferritin >800), CKD. Thrombocytopenia likely related to MDS. Well above baseline currently. Guaiac neg and no signs of active bleeding. . HTN: Cont metoprolol . FEN: TF per G-tube were continued until he was made CMO . Medications on Admission: MVI daily Mucomyst inhaled q12 Albuterol nebulizer q12 Colace 100mg [**Hospital1 **] Dorzolamide 1 drop R eye [**Hospital1 **] Ipratropium 4 puff q6 Metoprolol 12.5mg [**Hospital1 **] Miconazole topical q8 Calcium + D TID Lovenox 80mg SQ [**Hospital1 **] Tylenol 650mg q6 prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Pneumonia LLE hematoma L-sided pleural effusion CAD CHF Atrial fibrillation Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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Discharge summary

report

Admission Date: [**2125-4-19**] Discharge Date: [**2125-4-23**] Date of Birth: [**2068-6-5**] Sex: M Service: MICU and general medicine. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10036**] is a 56-year-old male with coronary artery disease and long history of alcohol consumption who presents with melena on two bowel movements. The patient reported increased fatigue times two weeks which had become progressively more severe during the past 2 days prior to admission. He then had one black bowel movement the night before admission and one on the morning of admission. On presentation to the Emergency Room his hematocrit was noted to be 25 with positive NG lavage, PTT was noted to be 64 (there were no old PTT's for comparison). PAST MEDICAL HISTORY: Coronary artery disease, status post non Q wave MI in [**2119-4-10**]. The patient has had CABG with LIMA to LAD, SVG to ramus, ETT mibi in [**2125-4-10**] showed 7 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol with 93% of maximal heart rate. There were no EKG changes and no perfusion defects at rest or at stress. EF was noted to be about 60%. Hypertension, hypercholesterolemia, alcohol abuse for many years. Please see social history. MEDICATIONS: On admission Adalat CC 30 mg q day, Lipitor 20 mg q day, Aspirin, Tenormin 25 mg q day, Vitamin E. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has been married for 30 years, stating that he has had one extramarital partner. [**Name (NI) **] has not had HIV testing. He has abused alcohol for 15-20 years. There have been multiple times when he has had several cases of beer at one time. He has lost multiple jobs secondary to his alcohol consumption and has participated in many detox programs. The patient has been abstinent from alcohol for 7 months at the longest interval. He denies any drug use. He has been unemployed for three years and states that he was previously active with the Mic Mac tribe. PHYSICAL EXAMINATION: On admission blood pressure 101/60, pulse 95, respiratory rate 14, satting 97% on room air. This is a pleasant male lying in bed in no acute distress. HEENT: Reveals head was atraumatic, normocephalic with pupils that were equal, round and reactive to light. Extraocular movements intact and sclera were anicteric. Neck has a flat JVP with a supple neck. Chest exam reveals a well healed midline surgical scar secondary to CABG. Lungs were clear to auscultation bilaterally. Heart sounds were regular rate and rhythm with a normal S1 and S2, there were no murmurs, rubs or gallops. Abdomen was obese and soft, nontender. There was no hepatosplenomegaly appreciated. The patient was guaiac positive. Extremities showed no edema and no palmar erythema. He had no petechiae or telangiectasias. On neurologic exam the patient was alert and oriented times three, cranial nerves were intact, language was fluent, reflexes were decreased throughout. There was no tremor at baseline. LABORATORY DATA: On admission white count 6.7, hematocrit 25.5, with MCV of 86 and platelet count of 17, INR 1 with PTT 63.8. Chem 7 was unremarkable with the exception of BUN of 39, creatinine 1.1, ALT 22, AST 20, alkaline phosphatase 74, total bilirubin 0.4, amylase 26, cholesterol panel on record showed total cholesterol 174 with an HDL of 49, LDL 92, triglycerides 167. EKG showed normal sinus rhythm at 90/minute with a normal axis, normal intervals, there was T wave flattening in 1 and AVF and no other acute ST-T wave changes. There was no change when compared with EKG from [**5-/2120**]. HOSPITAL COURSE: The patient had endoscopy by gastroenterology team in the Intensive Care Unit. This revealed non bleeding gastric erosion at multiple sites with one oozing ulcer at the lesser curvature. BICAP was applied with good hemostasis. The patient received 6 units of packed red blood cells with a minimal increase in his hematocrit to 28. Platelets were also noted to be dropping and the this was believed to be secondary to ITP. A [**Month/Year (2) 1978**] consultation was obtained and the patient was started on IVIG times two doses. He was also given DDAVP and one bag of platelets with a minimal response. PTT was also noted to be elevated on admission. Hemolysis labs were sent and found to be unremarkable. The patient had an evaluation of his liver and spleen via ultrasound and there was no thrombosis noted. He was also started on an Octreotide drip and treated with high dose Prilosec [**Hospital1 **] times 7 days, then to be lowered to once daily dosing. H. pylori serology was sent. For further work-up of his thrombocytopenia the patient consented to HIV testing. A hepatitis panel was sent with a negative hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody, and hepatitis B viral antibody. With his history of heavy alcohol abuse, the most likely etiology of the thrombocytopenia was most likely primary bone marrow suppression secondary to alcohol. Octreotide drip and IVIG was not continued on transfer to the medical team on the floor. Hematocrit rose to the low 30's on serial examination and was 33 at the time of discharge. White count was 3.7 and platelets had increased to 63. The patient will have follow with [**Hospital1 1978**] and his primary care doctor with plans for possible bone marrow biopsy in the future if his platelet count does not improve over time. During the [**Hospital 228**] hospital course there were no signs of delirium tremens. I was able to have a long discussion with the patient regarding the need for alcohol rehab. The patient appeared positive and hopeful that this recent bleed might be enough to keep him abstinent given his insurance. The patient was knowledgeable for inpatient detoxification program but was referred to outpatient program that he could contact through his insurance company. All hypertensive medications were held given his low blood pressure. DISCHARGE DIAGNOSIS: 1. Upper GI bleed. 2. Thrombocytopenia either secondary to ITP or alcohol induced. DISCHARGE MEDICATIONS: Lipitor 20 mg q day, Prilosec 40 mg [**Hospital1 **] to be changed to 40 mg q day, Folate 1 mg po q day. STATUS: To home. CONDITION: Satisfactory. FOLLOW-UP: The patient will have follow-up with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 1978**] over the next two weeks. He should have his hematocrit and platelet count checked. HIV antibody and H. pylori serologies were still pending at the time of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10037**], M.D. [**MD Number(1) 10038**] Dictated By:[**Name8 (MD) 10039**] MEDQUIST36 D: [**2125-5-25**] 13:39 T: [**2125-5-25**] 15:29 JOB#: [**Job Number 10040**]

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Discharge summary

report

Admission Date: [**2127-12-11**] Discharge Date: [**2127-12-30**] Date of Birth: [**2069-10-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p [**9-19**] ft Fall Major Surgical or Invasive Procedure: Triple Lumen Subclavian Line Placement [**2127-12-17**] History of Present Illness: 58 yo male s/p ~[**9-19**] ft fall from ladder onto his head. Comabative at scene; bleeding from left ear; transferred to [**Hospital1 18**] for trauma care. Past Medical History: Sleep Apnea on BIPAP at home Hypercholestrolemia Knee Surgery Social History: Married Employed as a landscaper Family History: Noncontributory Physical Exam: VS upon arrival to truam bay: 145/61 98 20 99.6 pr O2 sat 99% GCS 12 Gen-Alert & oriented to name HEENT-right periorbital ecchymosis with swelling; blood left ear Neck-c-collar in place Chest-CTA bilat Cor-RRR no m/r/g Abd-FAST exam negative Rectum-guaiac negative Extr-MAE x4 Pertinent Results: [**2127-12-11**] 07:28PM GLUCOSE-122* UREA N-19 CREAT-1.1 SODIUM-141 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-23 ANION GAP-12 [**2127-12-11**] 07:28PM CK-MB-6 cTropnT-<0.01 [**2127-12-11**] 07:28PM MAGNESIUM-1.9 [**2127-12-11**] 07:28PM WBC-15.2* RBC-4.14* HGB-11.5* HCT-33.5* MCV-81* MCH-27.8 MCHC-34.4 RDW-13.6 [**2127-12-11**] 07:28PM PLT COUNT-186 [**2127-12-11**] 07:28PM PT-13.2 PTT-20.5* INR(PT)-1.2 [**2127-12-11**] 12:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CHEST (PORTABLE AP) [**2127-12-24**] 9:09 AM CHEST (PORTABLE AP) Reason: eval infiltrate [**Hospital 93**] MEDICAL CONDITION: 58 year old man s/p fall, extubated [**12-18**], febrile REASON FOR THIS EXAMINATION: eval infiltrate INDICATION: Status post fall. Portable AP chest. The lung fields are clear. No pneumothorax. The heart size is normal. Mediastinal contours are normal. No pleural effusions. No evidence of rib fracture. IMPRESSION: No acute cardiopulmonary process. BILAT LOWER EXT VEINS PORT [**2127-12-24**] 1:23 PM BILAT LOWER EXT VEINS PORT Reason: S/P TRAUMA; EVAL FOR THROMBUS INDICATION: Trauma. Evaluate for thrombus. FINDINGS: [**Doctor Last Name **] scale and color Doppler son[**Name (NI) 493**] examination of both lower extremity venous systems was performed. Normal compressibility, color flow, waveform, and augmentation was seen in both common femoral veins, superficial femoral veins, and popliteal veins. No intraluminal thrombus was identified. IMPRESSION: No evidence of DVT in either lower extremity. CT ORBITS, SELLA & IAC W/ & W/O CONTRAST [**2127-12-16**] 9:05 AM CT 100CC NON IONIC CONTRAST; CT ORBITS, SELLA & IAC W/ & W/ Reason: Progression of right orbital derangement. [**Hospital 93**] MEDICAL CONDITION: 58 year old man with multiple orbital fractures and small SAH/SDH s/p fall REASON FOR THIS EXAMINATION: Progression of right orbital derangement. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Multiple orbital fractures and intracranial bleeds status post fall, question progression of right orbital derangement. COMPARISON: Head CT, [**2127-12-15**] at 16:30. TECHNIQUE: Axial CT images of the sinuses without and after the administration of contrast were reviewed. FINDINGS: The post-septal extraconal right hematoma is not significantly changed from the 17-hour interval but enlarged since [**2126-12-14**]. The hematoma measures approximately 2 cm in greatest diameter and is located superomedially beneath a displaced right orbital roof fracture and also exhibits displacement of the superior rectus, oblique, and medial rectus muscles. There is continued elongated deformity of the right globe from hematoma-induced mass effect. The optic nerve itself is not significantly displaced. Post- contrast imaging does not demonstrate rim enhancement of the extraconal collection to indicate organized abscess formation, but superimposed infection cannot be excluded by imaging. Otherwise, the examination is unchanged, with multiple orbital fractures and sinus fractures as previously described. Fluid is present throughout the paranasal sinuses. IMPRESSION: No significant change in post-septal extraconal right superomedial hematoma with right globe distortion from mass effect. The urgency of these findings was discussed with the ophthalmology resident caring for the patient, [**12-16**] at 1 p.m. CT HEAD W/O CONTRAST [**2127-12-16**] 9:13 AM CT HEAD W/O CONTRAST Reason: re-eval of intraparenchymal brain lesions [**Hospital 93**] MEDICAL CONDITION: 58 year old man s/p fall REASON FOR THIS EXAMINATION: re-eval of intraparenchymal brain lesions CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL INFORMATION: Re-evaluation of intraparenchymal brain lesions. NON-CONTRAST HEAD CT. FINDINGS: There has been no change from yesterday's examination in the appearance of the brain or the multiple intraparenchymal hemorrhages with the exception that the left parietal extra-axial collection appears to perhaps be slightly more prominent. The extraconal hematoma in the right orbit is likewise unchanged. IMPRESSION: Slight increase in left parietal extra-axial blood collection. Otherwise, stable appearance of brain and orbits compared to the previous exam. MR L SPINE SCAN [**2127-12-12**] 2:26 PM MR L SPINE SCAN Reason: evluate L1 burst fracture [**Hospital 93**] MEDICAL CONDITION: 55 year old man s/p fall with multiple skull fx, ICH, L1 burst fx, intubated REASON FOR THIS EXAMINATION: evluate L1 burst fracture MRI OF THE LUMBAR SPINE CLINICAL INFORMATION: Patient is status post fall with multiple skull fractures and L1 burst fracture, for further evaluation of the fracture. TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images of the lumbar spine were acquired. FINDINGS: The T12 and L1 vertebral bodies demonstrate increased signal on inversion-recovery images and low signal on T1-weighted images in the mid portion, indicative of fractures and marrow edema. There is minimal decrease in height of the L1 vertebral body seen. There is no retropulsion noted. There is no evidence of destruction of the ligamentous structures identified. There is no evidence of abnormal increased signal seen within the intraspinous ligaments. From T11-12 to L4-5, no significant disc bulge or herniation is seen. At L5- S1 level, there is mild disc bulging seen. Bilateral spondylolysis of L5 is noted without marrow edema indicating chronic spondylolysis. Note is made of fluid-fluid level within the distal thecal sac in the sacral spinal canal indicative of small amount of intrathecal blood which could be secondary to subarachnoid blood seen on the head CT. The distal spinal cord shows normal signal intensities. IMPRESSION: Signal changes indicative of fractures of T12 and L1 without significant retropulsion or high-grade thecal sac compression. No evidence of epidural or subdural hematoma in the spine. Fluid-fluid level indicating intrathecal blood within the distal thecal sac, which could be related to subarachnoid hemorrhage seen on the head CT. Bilateral spondylolysis of L5 which appear chronic due to absence of signal changes on inversion-recovery images with mild disc bulging at L5-S1 level. CT C-SPINE W/O CONTRAST [**2127-12-11**] 1:27 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: FALL INDICATION: Status post 12 foot fall TECHNIQUE: Non-contrast axial images of the cervical spine with coronal and sagittal reformations were reviewed. COMPARISON: None. FINDINGS: No fractures of the cervical spine are identified. There is anatomic vertebral body alignment. There is no prevertebral soft tissue swelling. The patient is intubated with the tip of the endotracheal tube in standard position. A nasogastric tube is also present within the esophagus. There is no facet joint or vertebral disc widening. C1 through T2 are well visualized. Although CT is not optimal for evaluation of the intrathecal contents, the visualized intrathecal contents are unremarkable. IMPRESSION: No evidence of fracture or dislocation. Brief Hospital Course: Patient admitted to the trauma service. Plastic Surgery, Ophthalmology, Otolaryngology, Neurosurgery and Orthopedics were all consulted because of patient's multiple injuries. His orbital fractures were non operative and he will need to follow up with Plastic surgery in 2 weeks. On [**12-15**] he underwent right lateral decanthotomy by Ophthalmology, he is on several eye drops and will require follow up in [**Hospital 8183**] Clinic in 1 week after discharge. Orthopedic consulted for his lumbar spine injuries, L1 vertebral body fracture; he was fitted for a TLSO brace which will need to be worn at all times when patient is out of bed. He will need to follow up with Orthopedic Spine in 2 weeks after discharge. Neurosurgery will follow up with patient in [**3-11**] weeks for his head bleed; he will be booked for a repeat head CT scan at that time. Physical therapy, Speech and Swallow were consulted as well. Patient must wear his TLSO brace while out of bed. He will require 1:1 supervision for meals as per recommendation of Speech and Swallow. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours) 7. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. Dexamethasone 0.1 % Drops, Suspension Sig: Four (4) Drop Ophthalmic Q12H (every 12 hours). 11. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Gentamicin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 14. Vancomycin 500 mg Recon Soln Sig: One (1) Drop Intravenous Q6H (every 6 hours). 15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital6 1970**] - [**Hospital1 1559**] Discharge Diagnosis: s/p [**9-19**] ft fall Right displaced orbital roof fracture Ethmoid fracture Left orbital roof fracture, non-displaced Right Subarachnoid hemorrhage Bilateral Frontal and Temporal Contusions Discharge Condition: Stable Discharge Instructions: *Follow up in Trauma And Plastic Surgery Clinic in [**2-7**] weeks *Follow up in [**Hospital 8095**] Clinic in 1 week. *Follow up with Neurosurgery in 4 weeks *Follow up with ENT in 2 weeks. *Follow up with your primary doctor after your discharge from rehab Followup Instructions: 1.Call [**Telephone/Fax (1) 6439**] for an ppointment in Trauma Clinic in [**2-7**] weeks 2.Call [**Telephone/Fax (1) 4652**] for an appointment in Plastic Surgery Clinic 3.Call [**Telephone/Fax (1) 253**] for an appointment in [**Hospital 8095**] Clinic in 1 week you will need to be seen. 4.Call [**Telephone/Fax (1) 2349**] for an appointment with Dr. [**First Name (STitle) **], ENT in 2 weeks 5.Call [**Telephone/Fax (1) 1669**] for an appointment with Dr. [**Last Name (STitle) 63264**] in 4 weeks. Inform the office that you will need a repeat head CT scan performed prior to this appointment. 6.Call [**Telephone/Fax (1) 1228**] for an appointment with Dr. [**Last Name (STitle) **] in 2 weeks. 7.Call your PCP after your discharge from rehab for an appointment Completed by:[**2127-12-30**]

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icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "96.6", "96.72", "08.51", "38.93", "93.90" ]

icd9pcs

[ [ [] ] ]

10665, 10735

8184, 9242

339, 397

10971, 10980

1070, 1681

11291, 12093

736, 753

9265, 10642

5465, 5542

10756, 10950

11004, 11268

768, 1051

277, 301

5571, 8161

425, 584

606, 670

686, 720

7,801

139,115

26114

Discharge summary

report

Admission Date: [**2144-4-4**] Discharge Date: [**2144-5-15**] Date of Birth: [**2084-4-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**4-12**] Exploratory laparotomy, small bowel resection [**4-23**] Bedside debridement with opening of abdominal wound, placement of VAC History of Present Illness: History based on night float admission note obtained w/ aid of an interpreter and electronic medical records. In brief, 59 yoF s/p colectomy w/ ileostomy for recurrent colorectal cancer [**4-2**] who represented [**2144-4-4**] AM to [**Hospital1 18**] ED for lower abdominal pain and found to have UTI. Pt was started on Cipro and went back to rehab with foley in place. However, then decided she did not want to stay at rehab and returned to [**Hospital1 18**] ED. At that time c/o SSCP radiating to back. In the ED, CTA negative for PE or aortic dissection. ECG w/ no ischemic changes and unchanged from old EKG [**2144-3-26**]. Biomarkers negative x 1 in ED. She described the pain as sharp, burning quality, radiating to back, w/ no associated SOB, diaphoresis. + Nausea but no vomiting. Worse laying down. Improved sitting up. Not related to exertion but she does not exert herself much at baseline. Pain lasted ~24 hours. She has never had this pain before. Overnight, her chest pain was treated with protonix and maalox. The following morning on this admission, she continued to complain of mild chest pain. No other localizing complaints currently. She was intially admitted to the medicine service and later transfered to the colorectal surgical service for furthur care. Past Medical History: # rectal CA s/p [**Month (only) **] age 29 # recurrent adenocarcinoma of transverse colon s/p colectomy/ileostomy [**2144-4-2**] # urinary retention s/p Foley placement prior admission [**Date range (1) 8762**] Social History: Chinese speaking only. Immigrated 2 years ago with help of mother and brother. Does not speak to either at this time. Married with husband and son in [**Name (NI) 651**]. Shares a rented room with a friend. [**Name (NI) 1403**] full-time as a home health aide. Non-smoker, no alcohol use. Does have a friend and two cousins in town who are willing to provide health but patient does not want her medical condition shared with them. Family History: No family history of colon cancer. Physical Exam: PE: 99.5, 110/58, 75, 20, 100% 2LNC Gen: NAD Heent: NC/AT. EOMI. PEERL. MMM Neck: low JVP Heart: RRR no mrg Lungs: CTAB Abd: Soft, nt, nd. Ileostomy stoma c/d/i w/ brown stool. Ext: WWP. No CCE. Pertinent Results: CXR: New free intraperitoneal air consistent with patient's history of recent colectomy. Similar appearance of scarring and calcifications in the right upper lobe. Otherwise, no cause for patient's symptoms identified. . CTA: 1. No evidence of pulmonary embolism or aortic dissection. 2. Prominent lymph nodes in the right axilla, unchanged since [**2144-2-26**]. 3. Granulomatous changes in the right upper lobe. 4. Free air and other post-surgical changes seen in the abdomen. [**2144-4-4**] 02:50PM BLOOD WBC-5.5 RBC-3.42* Hgb-10.2* Hct-29.8* MCV-87 MCH-29.7 MCHC-34.1 RDW-12.7 Plt Ct-240# [**2144-4-5**] 06:07AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.4* Hct-28.2* MCV-88 MCH-29.3 MCHC-33.3 RDW-13.0 Plt Ct-208 [**2144-4-4**] 02:50PM BLOOD Glucose-128* UreaN-14 Creat-0.5 Na-137 K-3.3 Cl-104 HCO3-24 AnGap-12 [**2144-4-5**] 06:07AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-140 K-4.0 Cl-109* HCO3-24 AnGap-11 [**2144-4-4**] 09:30PM BLOOD CK(CPK)-51 [**2144-4-5**] 06:07AM BLOOD CK(CPK)-45 [**2144-4-4**] 09:30PM BLOOD cTropnT-<0.01 [**2144-4-5**] 06:07AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2144-4-5**] 06:07AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 Iron-PND Gallbladder ultraound [**4-9**]: IMPRESSION: 1. Normal liver with no focal lesion. 2. Gallbladder sludge with no evidence of cholecystitis. 3. Small amount of free fluid is noted within the abdomen. . Abdominal and Pelvic CT scan [**4-6**]: IMPRESSION: Extensive small bowel obstruction, which has progressed since prior study performed eight hours before associated with edema of the right ileostomy. Anterior wall air fluid collection where the colostomy was located. Pneumoperitoneum. . Cardiology Report ECG Study Date of [**2144-4-5**] 9:02:08 AM Sinus rhythm Normal ECG Since previous tracing of the same date, no significant change . CT scan [**4-25**]: IMPRESSION: 1. Interval increase in small bowel dilatation seen previously, with resolution of bowel wall thickening seen previously. This could reflect obstruction at the ileostomy, vs. ileus - clinical correlation is required. There is no evidence of ischemia. 2. Continued third spacing of fluid, with bilateral pleural effusions, slightly decreased ascites, and soft tissue anasarca. . Angiogram [**5-4**]: IMPRESSION: Selective SMA and ileocolic angiograms demonstrate mild peristomal hypervascularity, however, no active extravasation. No embolization performed. If the patient rebleeds, a tagged RBC scan may help to localize the bleeding prior to any repeat angiogram. . Abdominal X-ray [**5-13**]: IMPRESSION: Distended loops of gas filled small bowel extending to ileostomy with multiple scattered air-fluid levels. This may represent ileus, however obstruction at the ileostomy as mentioned on prior CT cannot be entirely excluded. Recommend clinical correlation. . Discharge labs: [**2144-5-11**] 01:41PM BLOOD Hct-26.9* [**2144-5-9**] 04:17AM BLOOD Plt Ct-324 [**2144-5-13**] 06:00AM BLOOD Glucose-99 UreaN-12 Creat-0.3* Na-135 K-4.1 Cl-105 HCO3-26 AnGap-8 [**2144-5-13**] 06:00AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 [**2144-5-9**] 04:17AM BLOOD calTIBC-182* Ferritn-973* TRF-140* [**2144-5-9**] 04:17AM BLOOD Triglyc-134 [**2144-5-7**] 01:05AM BLOOD Triglyc-171* HDL-13 CHOL/HD-6.4 LDLcalc-36 . [**2144-4-21**] 8:36 am SWAB Source: abdominal midline wound. GRAM STAIN (Final [**2144-4-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2144-4-26**]): ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITITITIES PER DR [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Numeric Identifier 62524**]) [**2144-4-24**]. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _____________________________________________________ ENTEROCOCCUS SP. | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN--------- <=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LINEZOLID------------- 2 S MEROPENEM------------- <=0.25 S PENICILLIN------------ =>64 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ =>32 R . [**2144-4-27**] 3:31 am URINE Source: Catheter. URINE CULTURE (Final [**2144-4-29**]): YEAST. ~6OOO/ML. PROBABLE ENTEROCOCCUS. ~6OOO/ML. . [**2144-5-4**] 9:48 pm URINE Source: Catheter. URINE CULTURE (Final [**2144-5-6**]): NO GROWTH. . [**2144-5-4**] 8:39 am MRSA SCREEN Source: Rectal swab. . MRSA SCREEN (Final [**2144-5-6**]): No MRSA isolated. Brief Hospital Course: 59 year oold female with history of recurrent colorectal cancer s/p colectomy and ileostomy approx 10 days prior to this admission, and recently diagnosed UTI, presents with complaints of substernal chest pain. The patient was initially admitted to the medicine service and then transfered to the surgical service for furthur care. During this patient's admission, her issues have been as follows: . Chest pain/Cardiac: On admission, the patient presented with atypical CP. This was thought to be most likely costochondritis given reproducibility with palpation of chest wall. GERD also considered. Chest pain resolved with proton pump inhibitor. No evidence of ischemia on EKG or cardiac enzymes. There was no evidence of PE or dissection on CTA on imaging. Post-operatively, the patient's chest pain had resolved but she remained tachycardic at baseline. She "triggered" for tachycardia to the 140-150's. On discharge, her HR ranged from the 90-110's. She denied chest pain on discharge. . Neuro: Alert and oriented to time, place, and person throughout entire hospitalization. Cantonese speaking only, daily plan of care communicated via interpreter. . GI: On hospital day #2, patient developed severe diffuse abdominal pain. Abdominal labs revealed only mild elevation in AST/ALT. KUB showed some dilated loops of bowel but was otherwise unremarkable. A CT scan of the abdomen showed a small bowel obstruction. An NG tube was placed, patient was made NPO with intravenous hydration. The patient was then transferred to the surgical service. On HD 5, NGT removed, ostomy with air and stool, liver function tests without elevation, gallbladder ultrasound without evidence of cholecystitis. On Diet advanced HD 6, tolerating a regular soft diet, ostomy functioning well. On POD 12/HD 8, she had an episode of tachycardia and increased abdominal pain, she was made NPO with intravenous hydration, nasogastric tube was placed, CT scan demonstrated a worsening small bowel obstruction, her stoma was necrotic appearing, she was transferred to the ICU for close monitoring, placement of a central line, intravenous antibiotics and aggressive fluid resuscitation; she was then taken back to the OR and underwent an a lysis of adhesions, resection of her terminal ileum, and revision of her ileostomy without complication. POD 15/HD 11, TPN was started, ostomy had +flatus, diuresis with Lasix was initiated, she remained hemodynamically stable. HD 13/POD 4, she was extubated without difficulty, ostomy with loose output, volume replaced with intravenous fluid and Imodium started. POD 20/HD 16, she was transferred to an in-patient nursing unit, central line was removed, TPN was stopped, and her diet was advanced however poor oral intake with significant malnutrition, Dobbhoff placed and trophic tube feeds started along with replacement of central line and TPN. Repeat CT scan [**4-25**] without evidence of ischemia and resolution or small bowel thickening. . Chest: Oxygenating well on room air. Encouraged IS use on a regular basis. . Colorectal cancer: s/p recent colectomy [**2144-3-30**]. . UTI: Urine culture from [**4-4**] grew Klebsiella sensitive to Cipro. She completed seven day course of Cipro. Repeat urinalysis and culture without bacteria. . Urinary retention: Post-op urinary retention during recent admission [**Date range (1) 8762**]. Her Foley was removed but then replaced in the setting of SBO, failed four voiding trial with successful removal of foley and ability to void without difficulty on POD 40/27 with the addition of Ditropan. . FEN: Inability to maintain optimal caloric intake with po diet and evidence of malnutrition demonstrated by nutrition labs, Dobbhoff feeding tube placed with trophic tube feeds and TPN, intermittent episodes of NPO during episodes of GI bleeding, once hematocrit stabilized and no further bleeding demonstrated, diet was slowly advanced. Tolerating minimal amounts of regular diet at time of discharge with goal rate of trophic tube feeds and half strength TPN. Nutrition requirements to be followed closely at rehabilitation facility with goal of weaning both tube feeds and TPN once caloric oral intake increased. . PPx: PPI. SQH. Bowel regimen. Pneumatic boots. . ID: +VRE, MRSA negative, repeat urine culture negative, HD 19, incision with erythema, opened at bedside with copious amounts of purulent drainage, cultures sent,+VRE, Klebsiella, and trace yeast, Linezolid started along with Zosyn and Caspofungin. Wound VAC placed. Leukocytosis to 16k with improvement to 10k after initiation of antibiotics. Antibiotics stopped on POD 37/24, remained afebrile without leukocytosis. Wound VAC continued with every [**1-25**] day dressing change with overall improvement in abdominal wound; pink granulation tissue present without erythema or induration. Left subclavian central line in place at time of discharge for TPN, to be removed once TPN discontinued. No antibiotics necessary at time of discharge. White count normal. . Heme: POD 34/21 ostomy with frank bleeding, hematocrit dropped to 16, transfused PRBC's to maintain hematocrit > 24 and transferred to SICU for close monitoring, remained normotensive with baseline tachycardia 100's; angiogram without source of bleeding identified, GI consulted; EGD done without evidence of bleeding, erosion in the distal small bowel seen and area close to ileostomy with edema. Treated with Octreotide drip during acute blood loss episodes and PRBC transfusions; hematocrit stabilized POD 37/24, she remained hemodynamically stable, bowel prep of Mag citrate given without bleeding and stool guaiac negative. Remained hemodynamically stable with a hematocrit of 26.9 at time of discharge. . Pain: Pain was initially well controlled with intravenous Dilaudid, once she started taking po's was transitioned to oral Dilaudid; narcotic tolerance had increased over course of prolonged hospitalization, Oxycontin started with oral Dilaudid for breakthrough pain along with intravenous Dilaudid during dressing changes at time of discharge. She will require continued narcotics at rehab and weaning as tolerated. . MSK: Followed by physical therapy throughout hospitalization with gradual improvement in ambulation. Recommend transfer to [**Hospital 19586**] rehab for continued therapy to increase gait, strength, and functional mobility. At time of discharge, the patient was ambulating with assistance but will require furthur physical therapy. Medications on Admission: Percocet Protonix Colace Discharge Medications: 1. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain: Hold for sedation, confusion, or RR < 12. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mL Injection every six (6) hours as needed for breakthrough pain: Dose should equal 1 mg To be used for severe pain only after oral medication has been given . 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: To eachl lumen of CVL. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day): Until ambulating independently, then d/c. 10. Remove CVL Sig: Remove left subclavian line once: Remove CVL on [**5-17**] when TPN has finished. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Small bowel obstruction Necrotic bowel Wound infection Malnutrition Secondary: 1. colorectal cancer 2. urinary retention 3. UTI Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency department if you experience, increased or persistent pain not relieved by pain medication, Fever > 101.5, nausea, vomiting, or abdominal distention, increased or decreased ostomy outputs over 24 hours, change in color or appearance of stoma, inability to urinate after foley removed, if abdominal wound develops redness or drainage, shortness of breath or chest pain, any other symptoms concerning to you. . Continue a regular diet. Continue tube feeds. Engage in physical exercise. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1120**] in [**12-24**] weeks, [**Location (un) 470**] [**Hospital Ward Name 23**] building . Call [**Telephone/Fax (1) 160**] for an appointment. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] upon discharge from rehabilitation facility, call [**Telephone/Fax (1) 8236**] for an appointment. Completed by:[**2144-5-15**]

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icd9cm

[ [ [] ] ]

[ "45.13", "54.59", "86.28", "99.04", "45.62", "93.59", "46.41", "38.93", "00.14", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

15819, 15885

8046, 14511

324, 464

16067, 16076

2762, 5554

16659, 17062

2491, 2528

14586, 15796

15906, 16046

14537, 14563

16100, 16636

5570, 8023

2543, 2743

274, 286

492, 1788

1810, 2022

2038, 2475

28,720

113,567

31511

Discharge summary

report

Admission Date: [**2157-7-29**] Discharge Date: [**2157-8-4**] Date of Birth: [**2106-10-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Self hanging Major Surgical or Invasive Procedure: None History of Present Illness: 50 you male s/p self hanging attempt, ?5-10 minutes. GCS 8. He was taken to a referring hospital where he was later transfered to [**Hospital1 18**] with a C1 C2 subluxation. Past Medical History: HTN GERD Seasonal allergies EtOH abuse Depression Social History: +EtOH Family History: Noncontributory Physical Exam: GENERAL: The patient is sedated, in chemical coma. HEENT: Normocephalic, atraumatic. NECK: Has a hard cervical collar. CARDIOVASCULAR: Tachycardic. PULMONARY: Clear to auscultation. ABDOMEN: Soft and nontender. DERMATOLOGIC: Shows no rashes or lesions. NEUROLOGICAL: He is in coma, chemically induced. Pertinent Results: [**2157-7-29**] 03:10AM GLUCOSE-119* UREA N-6 CREAT-0.5 SODIUM-136 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-13 [**2157-7-29**] 03:10AM WBC-6.3 RBC-3.52* HGB-13.0* HCT-37.5* MCV-107* MCH-37.0* MCHC-34.7 RDW-15.3 [**2157-7-29**] 03:10AM PLT COUNT-112* [**2157-7-29**] 03:10AM PT-16.0* PTT-30.8 INR(PT)-1.5* [**2157-7-28**] 11:59PM ASA-NEG ETHANOL-121* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT C-SPINE W/O CONTRAST Reason: please eval for fx or malalignment [**Hospital 93**] MEDICAL CONDITION: 50 year old man s/p hanging REASON FOR THIS EXAMINATION: please eval for fx or malalignment CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 50-year-old man status post hanging. Evaluate for fracture or malalignment. No prior comparison exams are available. CT THE CERVICAL SPINE TECHNIQUE: MDCT acquired axial images were obtained via cervical spine without intravenous contrast. Coronal and sagittal reformations were evaluated. FINDINGS: Vertebral body height and alignment appear preserved. Well corticated fragments noted anterior to the C4 through C6 vertebral bodies are likely small regions of anterior longitudinal ligament ossificiation as no prevertebral soft tissues identified, however in the setting of trauma, ligamentous injury cannot be completely excluded. The coronal view demonstrates mild asymmetry to the lateral masses of C1 on C2 on the left side due to slght head rotation. Visualized contents of the intrathecal sac appear unremarkable, however MRI examination will be more sensitive for evaluation of spinal cord injury. Retained oral secretions are noted within the nasal and oropharynx. IMPRESSION: 1. Maintained vertebral body height and alignment. Small well corticated osseous fragments adjacent to the C4 through C6 vertebral bodies appear degenerative in nature as no prevertebral soft tissue swelling is identified, however in setting of hanging injury, ligamentous injury cannot be entirely excluded. 2. Mild asymmetry to the lateral masses of C1 on C2 due to rotation. These findings may be better evaluated with dedicated MRI examination, if clinically indicated. CHEST (PORTABLE AP) Reason: please evaluate for ARDS/contusion s/p hanging [**Hospital 93**] MEDICAL CONDITION: 50 year old man with recent hanging REASON FOR THIS EXAMINATION: please evaluate for ARDS/contusion s/p hanging UPRIGHT PORTABLE CHEST X-RAY PERFORMED ON [**2157-7-29**] AT 8:10 A.M. COMPARISONS: None. TECHNIQUE: Single portable chest x-ray, upright. CLINICAL HISTORY: 50-year-old man with recent hanging, evaluate for ARDS, contusion. FINDINGS: An endotracheal tube is in place, with its tip approximately 7 cm above the carina. The NG tube is seen extending into the left upper quadrant. Lungs are clear bilaterally. Cardiomediastinal silhouette is unremarkable. There is no pneumothorax. No fractures are identified. IMPRESSION: ET tube and NG tube in good position. No acute intrathoracic abnormality. Brief Hospital Course: He was admitted to the Trauma Service. Neurosurgery was consulted given his cervical spine injury; no operative intervention, he was placed in a hard cervical collar which will need to remain in place for a total of 12 weeks. Cardiology was consulted because of persistent tachycardia; he was given beta blockers and placed on telemetry. His tachycardia has resolved. Behavioral Neurology was also consulted because of concerns over anoxic brain injury related to the hanging attempt. It was recommended to minimize sedation and to perform EEG to evaluate for seizures if slow to awaken. He did wake up and has been alert and oriented, cooperative with his care. He will require outpatient follow up in [**Hospital **] clinic after discharge. Psychiatry was also consulted given that this was a suicide attempt and have recommended inpatient psychiatric admission. He is being treated with a 7 day course Keflex for a right arm cellulitis from an infiltrated IV site. Medications on Admission: pt denies Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for HR <60; SBP <110. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for agitation. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) ML Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing: via nebulizer. 9. Sodium Chloride-Aloe [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37062**], Non-Aerosol Sig: [**1-25**] Sprays Nasal TID (3 times a day) as needed for nasal dryness. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: s/p Self hanging C1 C2 subluxation Discharge Condition: Stable Discharge Instructions: You must continue to wear your cervical (neck) collar for a total of 12 weeks. Return to the Emergency room if you develop any numbness, weakness, loss of function in any of your extremities, shortness of breath, chest pain and/or any other symptomsthat are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 23813**], Neurosurgery, in 4 weeks. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat CT scan of your cervical spine for this appointment. Completed by:[**2157-8-4**]

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icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

6018, 6063

4008, 4981

330, 336

6142, 6151

1015, 1508

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652, 669

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13987+56499

Discharge summary

report+addendum

Admission Date: [**2138-7-29**] Discharge Date: [**2138-8-4**] Date of Birth: [**2077-6-2**] Sex: F Service: GYNECOLOGY/ONCOLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 61-year-old female with a past medical history significant for recurrent uterine leiomyosarcoma status post debulking surgery times two and radiation who presented to the Emergency Department at [**Hospital 1474**] Hospital on [**2138-7-28**] with 24 hour history of nausea and vomiting. The patient also noted increasing abdominal distention over the past few days and diarrhea. The patient notes that the diarrhea began at the onset of radiation therapy in late [**Month (only) 958**] and has persisted. She denied fever and chills. She has been passing flatus and stool regularly. She has had p.o. intake as early as the a.m. prior to presentation. PAST MEDICAL HISTORY: 1. Recurrent uterine leiomyosarcoma with extension into retroperitoneum. Status post initial total abdominal hysterectomy and bilateral salpingo-oophorectomy in [**5-2**], status post debulking procedure for recurrence in [**3-3**]. 2. Hypertension. 3. Panic attacks. ADMISSION MEDICATIONS: Atenolol 12.5 mg p.o. q.d. ALLERGIES: Penicillin, sulfa. FAMILY HISTORY: Bladder cancer. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile with vital signs stable. Her blood pressure was slightly decreased at 98/42. Her examination was significant for very pale appearing and toxic in moderate distress. The neck was supple with no lymphadenopathy. She had a regular rate and rhythm without murmur. The abdomen was distended and tympanitic, diffusely tender, especially in the right lower quadrant with some voluntary guarding in the right lower quadrant. There was no rebound or guarding. The extremities were cool. She had mild edema. LABORATORY/RADIOLOGIC DATA: The patient had a chest x-ray which revealed free air under the bilateral hemidiaphragms at the outside hospital. The white blood count was elevated at 27.2. Hematocrit was 20.7. The electrolytes were within normal limits. KUB was repeated and revealed free air and dilated small bowel loops. HOSPITAL COURSE: The patient was taken to the Operating Room from the Emergency Department for exploratory laparotomy by the General Surgery Service. Findings on the operation included a perforated intestine. The patient underwent a transverse colostomy. Gynecology/Oncology was also present for the procedure. Please see the operative note for details. Following her operation, the patient was admitted to the Surgical Intensive Care Unit in critical condition. She was intubated and required pressors. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**] Dictated By:[**Last Name (NamePattern1) 6458**] MEDQUIST36 D: [**2138-8-4**] 02:19 T: [**2138-8-10**] 13:35 JOB#: [**Job Number 41788**] Name: [**Known lastname 2534**], [**Known firstname 1940**] E Unit No: [**Numeric Identifier 7561**] Admission Date: [**2138-7-29**] Discharge Date: [**2138-8-4**] Date of Birth: [**2077-6-2**] Sex: F Service: HOSPITAL COURSE: (Continued) Surgical Intensive Care Unit: As noted above, the patient was admitted to the Surgical Intensive Care Unit on [**2138-7-29**] following surgery on [**2138-7-28**]. She was intubated and required pressors to maintain blood pressure. She was in critical condition. A family discussion on postoperative day one concluded that the patient be DNR/DNI. The patient was extubated, and all lines were removed. Following extubation, the patient continued to have adequate oxygen saturation on nasal cannula. She became alert transiently. The patient requested a full code. The patient was transferred to the Gynecological Oncology Service on postoperative day three. Over the subsequent 24 hours, her respiratory status declined. The patient again requested DNR/DNI status. Antibiotics were continued as well as intravenous fluids and infrequent vital monitoring. The patient's status continued to decline. With a family meeting, the patient and family decided to again become comfort measures only on postoperative day five. Given the family's wishes as described above, the patient was started on a morphine drip. The patient was able to respond in the affirmative that she was comfortable. On postoperative day six, the patient's respiratory status gradually declined throughout the day. At approximately 1:00 a.m. on postoperative day seven, the patient passed away. DIAGNOSIS: 1. Recurrent leiomyosarcoma. 2. Death secondary to bowel perforation and respiratory depression. 3. Hypertension. 4. Panic attacks. The patient's family was notified at the time of her death. Their wishes were to defer a voluntary autopsy. The funeral home was notified per the family wishes. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4784**] Dictated By:[**Last Name (NamePattern1) 7562**] MEDQUIST36 D: [**2138-8-4**] 02:30 T: [**2138-8-10**] 13:31 JOB#: [**Job Number 7563**]

[ "197.6", "569.83", "197.4", "197.5", "568.0", "198.89", "V10.42" ]

icd9cm

[ [ [] ] ]

[ "54.11", "46.03", "54.59" ]

icd9pcs

[ [ [] ] ]

1249, 1287

3251, 5248

1171, 1231

1302, 2175

874, 1147

28,092

167,679

25469

Discharge summary

report

Admission Date: [**2142-5-18**] Discharge Date: [**2142-6-14**] Date of Birth: [**2080-8-27**] Sex: F Service: NEUROLOGY Allergies: Codeine Attending:[**First Name3 (LF) 8850**] Chief Complaint: Mental Status Changes. Major Surgical or Invasive Procedure: None. History of Present Illness: [**Known firstname **] [**Known lastname 63651**] is a 61-year-old right-handed woman with a past medical history including recurrent glioblastoma who presented to the ED with increasing somnolence and lower extrmity weakness and was found to have right frontal hemorrhage in a prior resection site. According to the patient's husband, Ms. [**Known lastname 63651**] presented to Dr. [**Name (NI) 19006**] clinic on [**2142-5-15**] to receive an infusion of Avastin. The procedure went smoothly. The patient was even able to walk up the three steps to their front door with assistance on the way home. He indicates she was "fine" on [**2142-5-16**]. However, she seemed to become more somnolent on [**2142-5-18**]; her husband explains she "kept wanting to close her eyes" and would only offer verbal responses to "every fourth sentence." When he tried to help her stand, she slipped through his arms and was unable to support her own weight. The symptoms occurred in the setting of cough. As she has previously developed similar symptoms in the setting of infection, Mr. [**Known lastname 63651**] thought she might be ill. He called Dr. [**Name (NI) 19006**] office and was referred to the [**Hospital1 18**] ED for further evaluation. Upon arrival to the ED, a non-contrast CT of the head was done. The imaging revealed hemorrhage in a prior right frontal resection site, intraventricular extension, and mild hydrocephalus. At baseline, Ms. [**Known lastname 63651**] is able to walk with assistance. However, her husband reports residual left-sided (particularly arm) weakness. She also tends to "look to the right." Past Medical History: Oncological History: (1) a stereotaxic brain biopsy and placement of a Rickham ventricular access device by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2140-4-15**], (2) involved-field cranial irradiation with daily temozolomide from [**2140-5-4**] to [**2140-6-15**], (3) s/p 2 cycles of adjuvant temozolomide at 200 mg/m2/day x 5 days, (4) started ANG1005 on [**2140-9-22**] and received 1 cycle but discontinued due to elevated ALT and AST, (5) s/p second surgical resection of right frontal glioblastoma by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D., Ph.D. on [**2140-10-30**], (6) received NovoTTF-[**Age over 90 **]F study on [**2140-11-29**] to [**2141-3-17**], (7) s/p 2 cycles of CT-322 at 2 mg/kg from [**2141-4-18**] to [**2141-6-13**], (8) started bevacizumab, lomustine, and procarbazine on [**2141-6-22**] and finished 3 cycles, and (9) s/p OMED Admission from [**2141-10-24**] to [**2141-10-27**] for encephalopathy. Past Medical History: Hypothyroidism, glioblastoma, mitral regurgitation, and syncope. Past Surgical History: Brain surgery, unknown abdominal surgery (infraumbilical scar). Social History: Currently disabled, but worked as a hairdresser. She was from [**Location (un) 4708**]. She lives with husband who works for UPS. She has no alcohol or tobacco history. Family History: There is no family history of intracranial malignancy. Her parents are deceased but she does not know their medical illnesses. She has a brother but she does not have children. Physical Exam: VITAL SIGNS: Temperature 98.0 F, pulse 79, respiration 12, blood pressure 156/98, and oxygen saturation 98% on 2 liters of air. GENERAL: Arouses to loud voice. Abulic. Alopecia. SKIN: No rashes or concerning lesions noted. HEENT: Normocepahlic, no scleral icterus noted. NECK: Supple. CARDIOVASCULAR: Regular rate, normal S1 and S2. PULMONARY: Lungs are clear to auscultation bilaterally anteriorly. ABDOMEN: Obese. Normoactive bowel sounds. Soft. Non-tender, and non-distended. EXTREMITIES: Warm, well-perfused. NEUROLOGICAL EXAMINATION: Mental Status: * Degree of Alertness: Arouses easily to voice * Language: Paucity of speech. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. * Frontal Release signs: right grasp Cranial Nerves: * I: Olfaction not evaluated. * II: PERRL 6 to 3 mm and brisk. * III, IV, VI: gaze conjugate to right; eyes do cross the midline but she does not bury the sclera with left lateral gaze; does not follow request/track in vertical direction * V: Facial sensation intact to light touch in the V1, V2, V3 distributions. * VII: slight facial asymmetry with apparent flattening of the left nasolabial fold. * VIII: Hearing intact to voice. Motor: * Bulk: No evidence of atrophy. * Tone: increased in left upper extremity Strength: * Left Upper Extremity: able to hold extremity up at least versus gravity * Right Upper Extremity: able to hold extremity up at least versus gravity (longer than left) * Left Lower Extremity: moves spontaneously * Right Lower Extremity: moves spontaneously (more than left) Reflexes: * Left: 2+ throughout Biceps, Triceps, difficult to obtain patella * Right: 2+ thoughout Biceps, Triceps, difficult to obtain Patella * Babinski: mute bilaterally Sensation: * Light Touch: intact bilaterally in lower extremities, upper extremities, trunk, face. Pertinent Results: ADMISSION LABS: [**2142-5-18**] 01:30PM WBC-10.1 RBC-4.84 HGB-14.7 HCT-45.0 MCV-93 MCH-30.3 MCHC-32.7 RDW-16.4* [**2142-5-18**] 01:30PM PT-11.4 PTT-21.0* INR(PT)-0.9 [**2142-5-18**] 01:30PM GLUCOSE-248* UREA N-21* CREAT-0.9 SODIUM-143 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-19 [**2142-5-18**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG DISCHARGE LABS: IMAGING: CT Head [**2142-5-18**]: right frontal hemorrhage in the cavity of prior resection site with extension into the right lateral ventricle. Bleeding is noted in the third and 4th ventricle. Mild hydrocephalus is noted. CT Head [**2142-5-19**]: IMPRESSION: Stable right frontal hemorrhage with intraventricular extension and dilation. Hyperdense material in the suprasellar cistern likely represent hemorrhage, stable. Close follow up if no intervention is contemplated. CT Head [**2142-5-20**]: IMPRESSION: Stable right frontal hemorrhage, with intraventricular extension. CT Head [**2142-5-21**]: IMPRESSION: Stable examination with right frontal hemorrhage and intraventricular extension. Brief Hospital Course: [**Known firstname **] [**Known lastname 63651**] is a 60-year-old woman with recurrent glioblastoma multiforme was admitted for neurological deficits from baseline and was found to have a right intracranial hemorrhage on CT scan. She was admitted to the ICU on the Neurosurgical Service, for Q1 [**Last Name (un) **] neuro checks, and was placed on Decadron and Keppra. A repeat of her CT Scan the following morning was performed, which did not reveal any change is the size of the bleed. The patient was transferred to the floor on to the Medical Oncology service once the ICH was stable. She expired after a second large episode of epistaxis. (1) Right ICH: Per Neurosurgery recommendations, seizure prophylaxis with Decadron and Keppra was continued. The initial plan was to repeat a CT scan at time of discharge, however, as further events resulted in change in goals of care, this plan was no longer appropriate. (2) Glioblastoma Multiforme: Per Dr. [**Last Name (STitle) 724**], the disease is at this time terminal and there are no plans for further treatments. She was continued on seizure prophylaxis as above. She was also given Ritalin twice a day, however as she started to deteriorated, Ritalin was no longer given. (3) Epistaxis: She had an episode of epistaxis on [**2142-5-29**]. It was of unclear etiology (platelets, coagulations were neg). Applied pressure and Afrin did not control the bleeding. She was aspirating the blood and was not able to protect her airway well. Suctioning to remove the blood from airway was attempted. She started to desaturation requiring nonrebreather. At that moment, a discussion took place with the husband to confirm her's code status. As a result of that discussion, she was made DNR/DNI and thus she was not intubated and taken to the ICU. ENT was consulted and controlled the bleeding with packing. She recovered from the acute respiratory distress though she continued to breath with accessory muscles. On [**2142-6-14**] she had a second large episode of epistaxis. She was given morphine to make her comfortable and she quickly passed. (4) Respiratory Distress: After the episode of epistaxis, her breathing deteriorated, with her using accessory muscles and RR decreasing over time. She was transitioned to inpatient hospice. Atropine drops sublingually and scopolamine patch were used for secretions. (5) UTI: She had low grade temperatures and was in sinus tachycardia which prompted an infectious work up. Proteus was seen in urine culture, thus pt was treated with a 7 day course of ceftriaxone for a complicated UTI (pt had a Foley). (6) Hypothyroidism: She was continued on [**Date Range 27672**] (was switched to IV because she was unable to take POs). After patient was made CMO and goals of care were discussed with her husband, the [**Name (NI) 27672**] was stopped. (7) She was initially full code, however, after discussion during the episode of epistaxis, her status was changed to DNR/DNI (confirmed with husband [**Name (NI) **] [**Name (NI) 63651**] [**0-0-**]). She was made CMO and was on inpatient hospice. After a second large episode of epistaxis the patient passed comfortably. Her husband consented to a full autopsy for further investigation of the cause of death. Medications on Admission: Decadron 4mg PO daily Ritalin 20mg PO BID Hydral 50mg PO TID [**Year (4 digits) 27672**] 50mg PO daily Keppra 1000mg PO bid Pantoprazole 40 mg PO daily MVI Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Death, intracranial hemorrhage, glioblastoma multiforme,UTI Secondary Diagnoses: Epistaxis, hypothyroidism, mitral regurgitation, syncope Discharge Condition: None. Discharge Instructions: None. Followup Instructions: None.

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icd9cm

[ [ [] ] ]

[ "21.02" ]

icd9pcs

[ [ [] ] ]

10133, 10142

6613, 9897

292, 299

10345, 10352

5443, 5443

10406, 10415

3351, 3531

10103, 10110

10163, 10243

9923, 10080

10376, 10383

5886, 6590

3081, 3146

3546, 4099

10265, 10324

230, 254

327, 1961

4341, 5424

5460, 5870

4114, 4325

2991, 3057

3162, 3335

77,904

194,031

8586

Discharge summary

report

Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-22**] Date of Birth: [**2114-3-17**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Doctor First Name 1402**] Chief Complaint: Bradycardia, nausea/vomiting, abdominal discomfort. Major Surgical or Invasive Procedure: None History of Present Illness: 44 year old patient with history of paroxysmal atrial fibrillation s/p multiple cardioversions, first pulmonary vein isolation in [**2157-12-20**] who presents today with 2 day history of bradycardia, nausea/vomiting and abdominal discomfort. The patient was recently discharged from the hospital after pulmonary vein isolation and a cavo-tricuspid isthmus line was done for typical right-sided flutter. The patient reports taht his symptoms started the evening after his discharge after dinner when he took his metoprolol. He felt somewhat dizzy and when he checked his pulse it was in the 30s. During the night, he also had some stomach discomfort with multiple soft stools overnight, culminating in an episode of vomiting this morning. He called the electrophysiology clinic and spoke with Dr. [**Last Name (STitle) **], who told him to come into the hospital to be evaluated. In the ED, the patient triggered for bradycardia with a heart rate of 36. Rates on telemetry were consistently in the 30s but did drop briefly to 29. EKG showed atrial flutter with 5:1 to 3:1 conduction. Pacer pads were placed but were not used. Atropine was placed at the bedside but was not used. He was given ibuprofen 600 mg PO for a headache and 1L NS. Chest x-ray was unremarkable. The EP service requested his beta-blocker be held. Vital signs on transfer to the floor were T 98.4, HR 40, BP 104/64, RR 14, 97% on RA . On the floor the patients admit vitals were: 102/65, HR 45, RR12, JVP was 7 cm. ECG: Atrial fibrillation with ventricular response of 35 bpm. ECG2: atrial bigeminy with blocked PACS, with a ventricular response of 35 bpm. PR 400 ms. [**Name13 (STitle) **] had a chest x-ray which showed no acute abnormality. On telemetry there were multiple pauses noted, the longest of which was 4.75 secs in duration from which the patient reported feeling somewhat lightheaded. Pacer pads were placed and then he was subsequently transferred to the CCU for closer monitoring. On review of systems, the patient stated that he felt somewhat sweaty, but has had no fevers or chills. He denied chest pain or shortness of breath. No recurrence of diarrhea, nausea or vomiting. The patient states that he has not been exposed to any fertilizers or other agents in the last several days. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (-) Hypertension 2. CARDIAC HISTORY: 1. Paroxysmal atrial fibrillation for approximately 10 years, s/p PVI in [**2157-12-20**]. Echo at that time showed LVEF > 55% with mild LA enlargement and mild to moderate mitral regurgitation. He had arrhythmia recurrence early after the precedure, treated with flecainide + metoprolol, and requiring DC in [**2158-7-20**]. He underwent a second PVI procedure 2 days ago, during wich [**3-23**] pulmonary veins were isolated and a cavo-tricuspid isthmus line was done for typical right-sided flutter. No acute complications were observed and the patient was discharged on Wednesday under the same previous treatment. -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -GERD -S/p right arm ORIF in [**2132**] -S/p resection of a benign throat polyp approximately 20 years -Possible sleep apnea (has never been studied) -L3-S1 herniated discs, s/p steroid injections/nerve blocks Social History: Married with four sons, aged 6/8/10/12. Private Entrepeneur. -Tobacco history: Neg. -ETOH: [**2-22**] drinks/week -Illicit drugs: Denies Family History: Long history of atrial fibrillation (father/aunts). Father had Diabetes. Both grandmothers suffered strokes. Physical Exam: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular, normal S1, S2. Bradycardic. 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. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2158-10-20**] 09:23PM GLUCOSE-152* UREA N-21* CREAT-1.0 SODIUM-138 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12 [**2158-10-20**] 09:23PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-1.9 [**2158-10-20**] 09:23PM WBC-6.8 RBC-4.66 HGB-13.5* HCT-39.4* MCV-84 MCH-29.0 MCHC-34.4 RDW-15.4 [**2158-10-20**] 09:23PM PLT COUNT-132* [**2158-10-20**] 09:23PM PT-31.7* INR(PT)-3.2* [**2158-10-20**] 12:25PM URINE HOURS-RANDOM [**2158-10-20**] 12:25PM URINE GR HOLD-HOLD [**2158-10-20**] 12:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028 [**2158-10-20**] 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2158-10-20**] 12:25PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2158-10-20**] 10:58AM GLUCOSE-176* NA+-138 K+-4.8 CL--102 TCO2-21 [**2158-10-20**] 10:50AM GLUCOSE-188* UREA N-32* CREAT-1.3* SODIUM-131* POTASSIUM-8.5* CHLORIDE-106 TOTAL CO2-20* ANION GAP-14 [**2158-10-20**] 10:50AM WBC-7.5 RBC-5.09 HGB-14.8 HCT-44.0 MCV-86 MCH-29.1 MCHC-33.7 RDW-15.5 [**2158-10-20**] 10:50AM NEUTS-79.3* LYMPHS-13.7* MONOS-5.2 EOS-1.1 BASOS-0.7 [**2158-10-20**] 10:50AM PLT COUNT-173 [**2158-10-19**] 06:45AM UREA N-17 CREAT-1.0 SODIUM-136 POTASSIUM-4.0 CHLORIDE-102 [**2158-10-19**] 06:45AM PT-29.4* INR(PT)-2.9* EKG on admission to CCU: Atrial flutter with slow ventricular response at rate of 66. Normal QRS axis. QRS not prolonged. Normal Q-T interval without evidence of St segment deviations. Imaging: CXR [**10-20**] IMPRESSION: No acute cardiopulmonary abnormality. Discharge Labs: [**2158-10-22**] 05:59AM BLOOD WBC-6.5 RBC-5.09 Hgb-14.8 Hct-42.7 MCV-84 MCH-29.0 MCHC-34.6 RDW-15.4 Plt Ct-137* [**2158-10-22**] 05:59AM BLOOD Plt Ct-137* [**2158-10-22**] 05:59AM BLOOD PT-33.9* PTT-34.0 INR(PT)-3.4* [**2158-10-22**] 05:59AM BLOOD Glucose-94 UreaN-15 Creat-1.1 Na-141 K-4.2 Cl-106 HCO3-27 AnGap-12 Brief Hospital Course: 44 y.o male with history of paroxysmal atrial fibrillation s/p pulmonary vein isolation and cavo-tricuspid isthmus ablation for right sided atrial flutter who presents to the hospital with nausea, vomiting and symptomatic bradycardia. #Bradycardia: Per EP, was thought to be due to nodal suppression with metoprolol and flecainide in conjunction with AV block attributed to cavo-tricuspid ablation edema. Metoprolol and flecainide were held and the patient's bradycardia resolved; a low dose isoproteranol drip was started and discontinued within 3h for an episode of bradycardia into the 30s bpm. Theophylline SR 200 mg PO BID was started and continued for 24h and tolerated well by the patient with exception to insomnia, which resolved with Ativan 0.5mg; after starting the Theophylline, the patient had no further episodes of bradycardia and remained hemodynamically stable. The patient was discharged in stable condition on half of the previous doses of Flecainide and Metoprolol, Flecainide 75 mg PO BID, Metoprolol SR 25 mg PO QD; Theophylline was stopped prior to discharge. #Atrial fibrillation: Atrial fibrillation continued through the course of the hospitalization wtih slow ventricular response. Warfarin was held in the setting of a supratherapeutic INR and the patient was discharged with plans to follow-up with the [**Hospital 18**] [**Hospital3 **] in [**Location (un) 620**] to recheck his INR and redose his Warfarin. #Nausea/vomiting: The etiology of this presenting problem remained unclear, but was thought to not be cardiac-related and more likely due to a recent flu shot given the chronicity of his symptoms. The patient was discharged in stable condition with no nausea or vomiting. The patient remained full code for the duration of the admission. Medications on Admission: MEDICATIONS (Home): Esomeprazol 40 mg PO daily Flecainide 150 mg PO BID Metoprolol SR 50 mg PO BID Warfarin 5 mg Tablet; [**1-21**] - 1 Tablet by mouth DAILY (Daily): Per INR. 5 mg on Monday thru Friday. 2.5 mg ([**1-21**] pill) on Saturday and Sunday. ASA 81 mg PO daily Ergocalciferol 1000 units daily Magnesium Oxide MEDICATIONS (Floor): Pantoprazole 40 mg PO Q24H Aspirin 81 mg PO/NG DAILY Fish Oil (Omega 3) 1000 mg PO BID Vitamin D 1000 UNIT PO/NG DAILY Ibuprofen 600 mg PO Q8H:PRN Pain Warfarin 5 mg PO/NG MON, TUES, WED, THURS, FRI Magnesium Oxide 500 mg PO/NG [**Hospital1 **] Warfarin 2.5 mg PO/NG SAT, SUN Discharge Medications: 1. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 4. Magnesium Oxide 400 mg Tablet Sig: 1.25 Tablets PO BID (2 times a day). 5. Outpatient Lab Work Please have your INR checked at the [**Hospital 18**] [**Hospital3 **] next week to redose your coumadin. 6. Flecainide 150 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Bradycardia likely due to medications and recent ablation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It has been a privilege to have taken care of you in the hospital. . You were hospitalized for bradycardia and nausea and vomiting. Your bradycardia was likely caused by a number of factors, including your metoprolol and flecainide as well as your recent cavo-tricuspid isthmus line procedure. Your bradycardia resolved after stopping these medications and starting you on medications to stimulate your heart to beat faster. Your nausea and vomiting resolved without further intervention; we suspect it was unrelated to your bradycardia and that it may have been related to your recent flu shot. . No changes were made to your medications other than following: STOPPED: Flecainide 150 mg twice daily CHANGED TO: Flecainide 75 mg twice daily STOPPED: Toprol XL 50 mg once daily CHANGED TO: Toprol XL 25 mg once daily STARTED: Fish oil, once daily STOPPED TEMPORARILY: Coumadin as prescribed Your coumadin was held because your INR was too high when you were admitted; please follow-up with the [**Hospital 18**] [**Hospital **] on [**2158-10-23**] to recheck your INR and redose your coumadin. Followup Instructions: Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], [**Hospital1 30120**] [**Hospital3 **]; please have your INR checked [**2158-10-23**]. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-11-16**] 10:00

[ "530.81", "427.31", "E942.6", "780.52", "784.0", "E942.0", "722.10", "787.01", "427.89", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10107, 10113

6761, 8542

327, 333

10215, 10215

4794, 4794

11484, 11801

3877, 3989

9210, 10084

10134, 10194

8568, 9187

10366, 11461

6421, 6738

4004, 4775

2769, 3462

236, 289

361, 2652

4811, 6405

10230, 10342

3493, 3704

2674, 2749

3720, 3861

1,932

123,386

17781

Discharge summary

report

Admission Date: [**2127-4-15**] Discharge Date: [**2127-4-25**] Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman with a history of hypertension, hypercholesterolemia, and coronary artery disease. She had rotablation at [**Hospital6 8866**] four years ago. She was in her usual state of health until two days prior to admission when she experienced [**7-3**] chest pressure while doing light housework. Her symptoms were accompanied by mild diaphoresis and shortness of breath, and she presented to the [**Hospital3 **] Emergency Department where she was pain free with aspirin, Lopressor, and nitroglycerin. She was started on Lovenox and Plavix and ruled in for a myocardial infarction with a troponin of 1.48 and a peak creatine kinase of 125. An electrocardiogram revealed T wave inversions in V2 to V6, and she has been pain free since admission to the hospital. She was transferred to [**Hospital1 69**] for cardiac catheterization. She also reports dyspnea on exertion over the past several weeks and was able to walk approximately 30 yards before becoming short of breath. She denies paroxysmal nocturnal dyspnea or shortness of breath at rest. PAST MEDICAL HISTORY: (Her past medical history is significant for) 1. History of hypertension. 2. History of hypercholesterolemia. 3. History of coronary artery disease; status post non-Q-wave myocardial infarction on [**4-14**]. 4. Status post percutaneous coronary intervention four years ago. 5. History of Raynaud's. 6. Status post colon cancer in [**2115**]; treated with chemotherapy. 7. Status post total abdominal hysterectomy/bilateral salpingo-oophorectomy. 8. Question of a history of mild dementia. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Plavix 75 mg p.o. once per day. 2. Lopressor 25 mg p.o. twice per day. 3. Lipitor 20 mg p.o. once per day. 4. Cardizem-CD 180 mg p.o. once per day. 5. Aspirin 325 mg p.o. once per day. 6. Lovenox (started at the outside hospital). 7. Nitroglycerin drip. 8. Exelon 1.5 mg p.o. once per day. 9. Daypro 1200 mg p.o. once per day. 10. Cytotec 100 mg p.o. twice per day. 11. Prilosec 20 mg p.o. once per day. 12. Accupril 20 mg p.o. once per day. 13. Lasix 20 mg p.o. as needed. FAMILY HISTORY: Her family history is significant for coronary artery disease. SOCIAL HISTORY: She never smoked cigarettes. She drinks alcohol rarely. REVIEW OF SYSTEMS: Her review of systems was unremarkable. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination she was a well-developed and well-nourished elderly female in no apparent distress. Vital signs were stable, afebrile. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Extraocular movements were intact. The oropharynx was benign. The neck was supple with full range of motion. No lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. The lungs were clear to auscultation and percussion. Cardiovascular examination revealed a regular rate and rhythm. A 2/6 systolic ejection murmur. The abdomen was soft and nontender, with positive bowel sounds. No masses or hepatosplenomegaly. Extremity examination revealed no clubbing, cyanosis, or edema. Dorsalis pedis pulses were 2+ bilaterally. Posterior tibialis pulses were 1+ bilaterally. Neurologic examination was nonfocal. She was alert and oriented times three. PERTINENT RADIOLOGY/IMAGING: She underwent cardiac catheterization which revealed an ejection fraction of 70%. No mitral regurgitation. A 70% to 80% left main stenosis. A proximal 99% left anterior descending artery stenosis. A 90% right coronary artery stenosis. HOSPITAL COURSE: She was admitted, and Dr. [**Last Name (STitle) 1537**] was consulted. She also had vein mapping preoperatively and was in the Coronary Care Unit. In the past, she also had some left saphenous vein stripping and right lower leg saphenous ligation. ? She did have a saphenous vein in her right thigh. On [**4-18**], she underwent a coronary artery bypass graft times three with a reversed saphenous vein graft to the left anterior descending artery, ramus, and right coronary artery. (she had bilateral [**Last Name (un) 24082**] saphenous used). She was transferred to the Cardiothoracic Surgery Recovery Unit in stable condition on propofol and Neo-Synephrine. She was extubated. On postoperative day one, her chest tubes were discontinued. She was also given aggressive respiratory therapy. As well, she was found to have some pneumonia preoperatively and required aggressive pulmonary therapy. She was transferred to the floor on postoperative day three. She had her wires discontinued, and she continued to require oxygen and aggressive pulmonary toilet. DISCHARGE DISPOSITION: On postoperative day seven, the patient was discharged to rehabilitation in stable condition. PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories on discharge revealed hematocrit was 34.4, white blood cell count was 11.5, and platelets were 486. Sodium was 137, potassium was 4.3, chloride was 98, bicarbonate was 29, blood urea nitrogen was 23, creatinine was 1, and blood glucose was 101. MEDICATIONS ON DISCHARGE: 1. Lasix 40 mg p.o. twice per day (times seven days). 2. Potassium chloride 20 mEq p.o. twice per day (times seven days). 3. Colace 100 mg p.o. twice per day. 4. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). 5. Rivastigmine 1.5 mg p.o. once per day. 6. Lipitor 20 mg p.o. once per day. 7. Nystatin oral 5 cc swish-and-swallow four times per day (times seven days). 8. Quinapril 10 mg p.o. once per day. 9. Lopressor 75 mg p.o. twice per day. 10. Prilosec 20 mg p.o. once per day. 11. Ecotrin 325 mg p.o. once per day. 12. Daypro 1200 mg p.o. every day. 13. Cytotec 100 mg p.o. twice per day. DISCHARGE STATUS: The patient was discharged to rehabilitation. CONDITION AT DISCHARGE: Condition on discharge was stable. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2127-4-25**] 08:54 T: [**2127-4-25**] 09:07 JOB#: [**Job Number 49388**]

[ "272.0", "V45.82", "401.9", "410.71", "414.01", "V10.05", "294.8" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "37.22", "36.13", "89.68", "39.61" ]

icd9pcs

[ [ [] ] ]

4901, 5024

2358, 2422

5330, 6037

1801, 2341

3808, 4877

6052, 6372

5039, 5303

2518, 3789

130, 1206

1229, 1774

2439, 2497

71,645

122,755

32501

Discharge summary

report

Admission Date: [**2168-6-2**] Discharge Date: [**2168-6-12**] Date of Birth: [**2109-12-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Hep C patient w cirrhosis and MELD 31 Major Surgical or Invasive Procedure: [**2168-6-2**]: Orthotopic liver transplant History of Present Illness: 58yo M with a history of hepatitis C cirrhosis, hepatocellular carcinoma, s/p RF ablation [**3-20**]. He has a lab MELD of 27 and a MELD of 31 with exception points and is admitted for liver transplant today. He has no significant cardiac history and his most recent ([**4-21**]) Echo showed normal [**Hospital1 **]-ventricular activity with LVEF >55%. The donor is a 19yo DCD and patient is aware and had no questions or concerns when informed. He has a history of medically refractory ascites and is on Lasix and Aldactone daily. In addition, he is requiring paracentesis approximately every 1-2 weeks. He had a hernia repair that was complicated by MRSA SBP in [**2167-3-14**] and finished a 4 week course of vancomycin. He was also recently admitted ([**Date range (1) 75820**]) for cellulitis at the prior umbilical hernia site and was also empirically treated for MRSA SBP due to elevated WBC of 1000 on paracentesis. Fortunately, the ascitic fluid has since proved no bacteria growth. Swab cultures from the umbilicus grew VRE and E. coli resistant to Cipro and the patient was sent to rehab on a 11 day course of daptomycin and Bactrim for SBP. He finished his daptomycin course and remains on Bactrim for SBP prophylaxis. His most recent paracenteses performed on [**5-23**] and [**5-30**] where 4L was removed each time, were negative for SBP and had no growth on cultures. The patient has been afebrile and his cellulitis has resolved. He has been doing relatively well at [**Name (NI) **] rehab and has been on continuous tube feeds due to history of failure to thrive. Tube feeds were turned off and the patient made NPO in anticipation of transplant. Past Medical History: - Hepatitis C x 30 years (presumed to have been contracted through intranasal cocaine use); c/b portal hypertension, varices, refractory ascites, SBP - DM (diet and exercise-controlled before, though requiring insulin in setting of infection and therafter) - HCC s/p RFA in [**3-20**]. Social History: Patient denies a history of IVDU, but has a remote history of intranasal cocaine use. He denies tobacco or alcohol use. Has been at [**Hospital1 **] since his previous discharge prior to that, lived in [**Hospital3 **] w/ wife and 2 daughters. Reports to be independent in ADLs. Family History: NC Physical Exam: Gen: NAD, AOx3, Jaundiced Neuro: CN2-12 intact, sensations intact to light touch, strength 5/5 in all extremities Eyes: +Scleral icterus, EOMI, PERRL HEENT: NCAT, No LAD, No palpable masses CV: RRR, no M/R/G, no carotid bruit, no JVD, 2+ distal pulses, Lung: slight crackles at bases L>R, no wheezing Abd: distended, non-tender, small 2mm superficial with small amount of serous discharge, no erythema, no spider angioma Ext: UE: no asterixis LE: pitting edema to upper thighs b/l, discoloration b/l, sensations grossly intact Pertinent Results: [**2168-6-2**] 09:44PM PT-19.3* PTT-45.2* INR(PT)-1.8* [**2168-6-2**] 09:44PM WBC-4.5 RBC-3.51* HGB-10.8*# HCT-29.2* MCV-83 MCH-30.6 MCHC-36.9* RDW-15.4 [**2168-6-2**] 09:44PM ALT(SGPT)-345* AST(SGOT)-746* ALK PHOS-42 AMYLASE-29 TOT BILI-8.8* DIR BILI-5.4* INDIR BIL-3.4 Brief Hospital Course: [**6-2**] patient s/p liver transplant, admitted to SICU following the procedure. [**6-3**] liver U/S obtained that showed patent vasculature all and liver within normal limits. On this day his trauma line and cordis were removed and changed to a TLC. Patient was extubated and began to receive all his immunosuppressive meds. The following day the patient did well and trophic tube feeds were started. The patient was OOB without difficulty. [**6-5**] he was transferred to the floor in good condition. His tube feeds were advanced to goal. His blood sugars were elevated for which he initially required and insulin drip. His lateral JP was removed after minimal output. Two days later his medial JP was removed as well. This insulin drip was weaned and he was eventually seen by [**Last Name (un) **] who placed him on NPH and tightened his slidding scale. At this time he was tolerating a regular diet and tube feeds were weaned off. Patients pain was controlled and he was instructed on how to take his immunosuppressive medications. He was discharged home in good/stable condition. Medications on Admission: Oscal 1250mg", clotrimazole 10mg""', Ergocalciferol [**Numeric Identifier 1871**] units qFri, furosemide 20mg', Lantus 40units qPM, Lispro SS, Lactulose 40gm"", MVI', omeprazole 40mg', rifaximin 400mg"', Bactrim DS 1tab', spironolactone 50mg', Zofran 4mg q8PRN Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:*120 Capsule(s)* Refills:*2* 2. CellCept [**Pager number **] mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*2* 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*2* 6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*2* 7. 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* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Insulin Lispro 100 unit/mL Solution Sig: 2-14 units Subcutaneous four times a day: per sliding scale given to patient at time of discharge. Disp:*1 bottle* Refills:*2* 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous with lunch: please take at lunchtime. Disp:*1 bottle* Refills:*2* 16. GlucoLeader Enhance System Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*0* 17. GlucoLeader Lancing Device Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:*60 lancets* Refills:*2* Discharge Disposition: Home With Service Facility: bayada nurses inc Discharge Diagnosis: hepatitis C cirrhosis, hepatocellular carcinoma, s/p RF ablation [**3-20**] now s/p liver transplant [**2168-6-2**]. Discharge Condition: Stable/Good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding. No heavy lifting No driving if taking narcotic pain medication [**Month (only) 116**] shower, allow water to run over incision and pat dry. Leave incision open to room air. Staples come out at 3 weeks post transplant Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-6-16**] 8:30 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-6-23**] 8:30 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-6-30**] 9:00

[ "456.21", "V58.67", "262", "155.1", "571.5", "511.9", "707.03", "707.25", "572.3", "070.54", "250.00", "789.59" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59", "00.18" ]

icd9pcs

[ [ [] ] ]

7089, 7137

3595, 4694

352, 398

7298, 7312

3294, 3572

7825, 8257

2725, 2729

5005, 7066

7158, 7277

4720, 4982

7336, 7802

2744, 3275

275, 314

426, 2103

2125, 2412

2428, 2709

6,427

150,890

10069

Discharge summary

report

Admission Date: [**2102-3-1**] Discharge Date: [**2102-3-10**] Service: MEDICINE Allergies: Pletal Attending:[**First Name3 (LF) 5552**] Chief Complaint: Anemia, GI bleed. Major Surgical or Invasive Procedure: EGD ([**2102-3-2**]) History of Present Illness: 87 female with advanced rectal poorly differentiated squamous cell CA s/p 20 sessions XRT and xeloda, PVD s/p SFA PCI, htn, who p/w black tarry stools X 3 days. Felt dizzy this AM. No belly pain or nausea/vomiting/fevers. HCT 25 from 32 baseline. She is currently undergoing XRT for rectal CA. In ED, BP 110/50, w/ normal SBP ~150, also tachy to 110. Recieved protonix 40mg IV X 1, and NGL revealed few specks of BRB Past Medical History: 1. Rectal cancer; currently recieving XRT and xeloda 2. Hypertension 3. Peripheral vascular disease Social History: Lives alone, w/ daughter [**Name (NI) 33643**]. Occasional wine. Family History: NC Physical Exam: AF 140/89 80 15 98%RA Gen: NAD, A&O X 3, nontoxic Heent: EOMI, PERRL, MM dry Neck: flat Heart: RRR soft sys murmur, no gallops Lungs: Clear Abd: Soft, nt/nd, increased BS Ext: Trace edema B, warm, 1+ dp on right, 2+ on left Pertinent Results: ADMIT LABS ([**2102-3-1**]) CBC: WBC-5.5 RBC-2.59* HGB-8.9* HCT-25.8* MCV-100* MCH-34.2* MCHC-34.3 RDW-22.5* PLT COUNT-203 ANISOCYT-3+ MACROCYT-3+ NEUTS-79.5* LYMPHS-15.3* MONOS-4.0 EOS-0.9 BASOS-0.3 [**2102-3-1**] 11:52AM HCT-26 [**2102-3-1**] 06:50PM HCT-28.0* [**2102-3-1**] 09:56PM HCT-28.8* CHEMSITRIES: GLUCOSE-118* UREA N-43* CREAT-0.7 SODIUM-131* POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-25 ANION GAP-12 OSMOLAL-282 CALCIUM-8.9 PHOSPHATE-2.0* MAGNESIUM-1.8 LFTS: ALT(SGPT)-24 AST(SGOT)-31 CK(CPK)-123 ALK PHOS-80 TOT BILI-0.3 COAGS: PT-12.8 PTT-24.2 INR(PT)-1.1 CARDIAC ENZYMES: [**2102-3-1**] 11:40AM CK-MB-6 cTropnT-0.01 [**2102-3-1**] 06:50PM CK-MB-5 cTropnT-<0.01 [**2102-3-1**] 06:50PM CK(CPK)-74 EGD ([**2102-3-2**]): Ulcers in the pre-pyloric region and antrum (thermal therapy). Erythema, granularity and friability in the antrum compatible with acute gastritis Otherwise normal EGD to second part of the duodenum CXR ([**2102-3-1**]): No acute cardiopulmonary process Brief Hospital Course: 1. GIB: The presentation was suggestive of an upper GI bleed. An EGD showed multiple cratered ulcers ranging in size from 11mm to 7mm. A clot suggested recent bleeding. [**Hospital1 **]-CAP electrocautery was applied for hemostasis successfully on two of the ulcers one had a clot on it. No active bleeding was seen. Biopsy was taken and returned positive for h.pylori. The patient was started on eradication therapy and a PPI. She was given a total of 3 units of pRBCs with stabilization of her hematocrit. At the time of discharge, she was feeling well, ambulating with a stable hematocrit. She requied an 9 additional days of antibiotics after discharge. 2. Rectal cancer: Presented with a known diagnosis of rectal cancer, followed by Dr. [**Last Name (STitle) **] as an outpatient. After stabilization of her GI bleed, she completed 4 of her last 5 XRT treatments with planned return for the final treatment. 3. Diarrhea: During the admission, the patient had multiple loose stools each day. She reported a long history of having loose stools in the setting of stress, but had never brought this to medical attention. C.diff was negative x2 and there were no other signs/symptoms suggesting infection. She was placed on a low residue diet and treated with imodium. IVF were used for a short time to ensure volume repletion. 4. Hypertension: Given the GIB the patient's outpatient anti-hypertensives were held. Her blood pressure remained controlled (110s-130s systolic) and therefore the anti-hypertensives were held at discharge as well. 5. Peripheral vascular disease. Given the GIB, the patient's plavix and ASA were held. Vascular surgery was asked to comment and they felt that the patient could remain off of these medications. Medications on Admission: 1. Aspirin 81mg daily 2. Plavix 75mg daily 3. Labetolol 200mg [**Hospital1 **] 4. Xeloda 5. Aranesp Discharge Medications: 1. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 9 days. Disp:*18 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: 1. Gastrointestinal bleed, secondary to peptic ulcer Secondary: 1. Rectal cancer 2. Peripheral vascular disease 3. Hypertension Discharge Condition: Hemodynamically stable, ambulating without orthostasis. Stool having loose stools, but controlled. Discharge Instructions: You were admitted because you were having bleeding from your upper GI tract. An EGD showed ulcers in your stomach and you have a bacteria in your stomach called h.pylori which could be causing some of the problems. [**Name (NI) **] will need to complete a 14 day course of antibiotics for this infection. You need to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 2455**] for continued management of your cancer. You have an appointment with them on [**3-15**]. Please note the following medication changes: 1. Clarithromycin and metronidazole: These have been added for treatment of your h.pylor infection. They should be taken for a total of 14 days (9 remaining). 2. Pantoprozole: This is used to help protect your stomach and to treat against the h.pylori infection. It should be taken twice daily. 3. The following medications have been stopped: - Labetolol: Given your occasional lightheadedness, this has been stopped. Your blood pressure has been well controlled off this medication, but you should be sure to have it rechecked as an outpatient - Plavix/ASA: Given your recent bleed, these blood thinning medications have been stopped. You should discuss when/if to restart these medications. Followup Instructions: You have the following appointments scheduled: 1. [**Last Name (LF) 1576**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**]-[**Doctor Last Name 1576**] APG (SB) Date/Time:[**2102-3-14**] 1:50 2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2102-3-15**] 2:30 [**First Name11 (Name Pattern1) 14497**] [**Last Name (NamePattern1) 25880**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2102-3-15**] 2:30 In addition, your final radiation treatment is on [**Last Name (LF) 766**], [**3-13**].

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Discharge summary

report

Admission Date: [**2168-11-18**] Discharge Date: [**2168-12-2**] Date of Birth: [**2087-11-22**] Sex: M Service: SURGERY Allergies: peanuts Attending:[**First Name3 (LF) 1390**] Chief Complaint: hematemesis s/p ERCP Major Surgical or Invasive Procedure: [**2168-11-18**]: ERCP with [**Hospital1 **]-CAP electrocautery and epinephrine injection to sphincterotomy site [**2168-11-21**]: PICC placement [**2168-11-22**]: PICC replacement [**2168-11-25**]: ERCP with removal of previously placed biliary stent, Occlusion Balloon cholangiogram, and stent placement x's 2 [**2168-11-29**]: ERCP with removal of previously placed stents, cannulation of biliary duct, cholangiogram, and placement of a fully covered metal stent History of Present Illness: 80 year old gentleman with DM2, mild dementia with recently diagnosed gangrenous gallbladder s/p JP drain who is transferred from OSH for ERCP. He is now s/p ERCP with sphinchteromety with post-operative course complicated by hematemesis. . In brief, he initially presented to an OSH with loss of appetite. Subsequent imaging demonstrated gangreouns gallbladder. He is now s/p open cholecystectomy on [**11-12**] with bile drainage through a JP. His course was complicated by both abdominal and chest pain. A follow-up HIDA scan confirmed bile leak. Cardiac enzymes were negative. Transfer was arranged to [**Hospital1 18**] for ERCP for further evaluation. VSS, he was afebrile and labs significant for normal LFTs. . At [**Hospital1 18**], ERCP demonstrated a leak from the cyst duct stump. A sphincterotomy was performed and a 10Fx7 cm stent was placed. Slight bleeding was noted from the sphincterotomy which was injected with epinephrine with good hemostasis. . Upon transfer to the general medical floor he was immediately noted to have a small cups worth of bright blood mixed with black clots come from his nose and mouth. He was transferred to his medical bed and systolic blood pressure was 63. The patient was nauseous, mildly diaphoretic and complained of [**7-7**] abdominal pain. A second peripheral IV was placed, 2 units of IV NS were. He was transferred to the [**Hospital Unit Name 153**], where his MAPs >65 with SBPs in the 90-100s. He was subsequently deemed hemodynamically stable and transferred back to the ERCP suite where old blood was noted in the stomach and there was no evidence of active bleed at the site of the sphincteromety/stent. Nevertheless, thermal therapy was applied and he was given 4 epi shots at the site. VSS throughout. . On arrival back to the ICU, initial vitals were: 89 [**9-/2137**] 25 93% RA. He complained of improved abdominal pain and dizziness. He denied chest pain, shortness of breath, nausea, emesis. Past Medical History: 1. Diabetes Type 2 2. Mild Dementia 3. Hypertension Social History: - Tobacco: none - Alcohol: none - Illicits: none Lives with daughter, husband, and [**Name2 (NI) 7337**]. Family History: did not obtain Physical Exam: Admission Physical Exam: Vitals: 89 [**9-/2137**] 25 93% RA. General: Alert, oriented, uncomfortable appearing and mildly diaphoretic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly distended, c/d/i RUQ dressing, mild tenderness to palpation of RLQ. GU: no foly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Vitals: 97.0 79 107/75 18 94% RA General: Alert, oriented, NAD Lungs: Clear to auscultation bilaterally with diminshed breath sounds at bases, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly distended, nontender. subcostal incision with steristrips in place, no drainage. JP drain with small amount bilious outuput Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2168-11-18**] 04:33PM WBC-18.0* RBC-3.30* HGB-10.3* HCT-31.5* MCV-96 MCH-31.3 MCHC-32.8 RDW-13.5 [**2168-11-18**] 04:33PM NEUTS-73.4* LYMPHS-23.1 MONOS-2.6 EOS-0.6 BASOS-0.3 [**2168-11-18**] 04:33PM PLT COUNT-558* [**2168-11-18**] 04:33PM PT-11.8 PTT-26.5 INR(PT)-1.1 [**2168-11-18**] 04:33PM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-2.0 [**2168-11-18**] 04:33PM CK-MB-1 cTropnT-<0.01 [**2168-11-18**] 04:33PM ALT(SGPT)-31 AST(SGOT)-69* CK(CPK)-80 ALK PHOS-115 TOT BILI-0.3 [**2168-11-18**] 04:33PM GLUCOSE-247* UREA N-7 CREAT-0.8 SODIUM-140 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-24 ANION GAP-13 Labs at Discharge: [**2168-12-1**] 05:57AM BLOOD WBC-10.9 RBC-2.77* Hgb-8.2* Hct-26.0* MCV-94 MCH-29.7 MCHC-31.7 RDW-16.0* Plt Ct-375 [**2168-12-1**] 05:57AM BLOOD ALT-14 AST-22 AlkPhos-79 TotBili-0.2 [**2168-12-1**] 05:57AM BLOOD Lipase-13 Microbiology: Blood culture [**2168-11-19**]- no growth Urine culture [**2168-11-19**]- no growth [**2168-11-26**] 9:39 am PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2168-11-26**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. FLUID CULTURE (Final [**2168-11-30**]): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2168-11-30**]): NO ANAEROBES ISOLATED. Imaging: ERCP [**2168-11-18**]: Impression: Small amount of blood clots noted in the stomach Small amount of fresh blood noted in D2 S/P sphincterotomy, no active bleeding noted. Biliary stent noted in place Due to recent bleeding, [**Hospital1 **]-CAP electrocautery and epinephrine injection was applied to sphincterotomy site successfully ERCP [**2168-11-25**]: Impression: S/P sphincterotomy. Previously placed biliary stent was noted. It was removed using a snare Cannulation of the biliary duct was successful and deep after a guidewire was placed Occlusion Balloon cholangiogram was performed, the intrahepatic ducts were examined [**Last Name (un) 27185**], it appeared normal. Extravasation was noted at the cystic duct stump. This was consistent with cystic duct stump leak Balloon sweep was performed, no sludge or stones noted. Two 7cm by 10FR Cotton [**Doctor Last Name **] biliary stents were placed successful EHCO [**2168-11-29**]: Impression: A large periampullary diverticulum Previous sphincterotomy and 2 previously placed stents were noted at the major papilla The previously placed stents were removed Biliary duct was successfully cannulated Cholangiogram revealed extravasation of contrast via the cystic duct stump. CBD measured 7-8 mm. Intrahepatic ducts were normal. A fully covered metal stent 10mm x 60 mm was placed successfully A balloon was inserted and contrast injected to determine if there was any bile leak and no extravastion of contrast via stump was noted. Otherwise normal ercp to third part of the duodenum CT abd/pelvis [**2168-11-19**]- 1. Nonorganized fluid collection within the surgical bed with a few air bubbles, most probably post-surgical changes. 2. A rounded structure is seen just superior to the insertion of the biliary stent, it contains air-fluid level and is compatible with the large periampullary diverticulum that was seen on ERCP examination. 3. Small bowel loop that herniates into the umbilical laparoscopic trocar entrance region is seen with mild proximal dilatation of a small bowel loop, follow-up examination with abdominal plain films is recommended in cases of suspicious developing small-bowel obstruction. [**2168-11-21**] TTE- The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is dilated with normal free wall contractility. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Preserved biventricular systolic function. Dialated right ventricle. Moderate aortic valve thickening. Very small pericardial effusion with no echocardiographic evidence of tamponade physiology. [**2168-11-21**] CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. No evidence of duodenal leak. 2. A collection containing contrast and air, adjacent to the insertion of the biliary stent, likely represents the previously described duodenal diverticulum. 3. 8.2 x 1.8 cm fluid collection inferior to the gastric body may represent an evolving phlegmon, but is not drainable at this time. 4. Stable position of biliary stent with mild associated pneumobilia. 5. Stable position of JP drain. 6. Unchanged peripancreatic edema and stranding, compatible with post-ERCP pancreatitis without necrosis or associated vascular complications. 7. Unchanged celiac axis origin stenosis. 8. Left lower pulmonary artery is not definitively seen on this CT scan not protocoled to evaluate the pulmonary arteries. [**2168-11-24**] GALLBLADDER SCAN: IMPRESSION: Active fluid collection in the gallbladder fossa; however, the fluid collection appears to be connected to the surgical drain, and is seen to flow through the drain. [**2168-11-25**]: Chest x-ray: Bilateral lung volumes are low. Lungs are now better aerated as compared to the prior radiograph from [**2168-11-23**]. Pulmonary edema has resolved. Bilateral increased lower lung opacities likely from lobar collapse and probable right middle lobe collapse is persisting. Associated bilateral mild-to-moderate pleural effusions are similar. Mild- to moderate-sized hiatal hernia is present. Aorta is remarkable for moderate atherosclerotic calcification and mild tortuosity. Heart size is normal. [**2168-11-30**]: CT ABD & PELVIS W/O CON: Impression: No significant fluid collection in comparison to CT scan from [**2168-11-21**]. Brief Hospital Course: 80 year old M with DM2, mild dementia s/p CCY [**11-12**] at OSH with gangrenous gallbladder c/b cystic duct stump leak, s/p ERCP with stent/sphincterotomy performed at [**Hospital1 18**] with persistent leakage. [**Hospital Unit Name 13533**]- HYPOTENSION: In setting of rising white count and tachycardia, concern was very high for sepsis. No signs of septic shock with normal mentation, urine output, and lactate normal. Patient started on cipro/flagyl, added Vancomycin in setting of rising white count. Not responsive to fluid boluses and UOP low. Lactate 1.4 yesterday and this morning, will trend for signs of organ hypoperfusion. Source identified as biliary leak causing peritonitis, also concern for formation of abscess. Acute Care Service following and recommend holding off on imaging for [**12-30**] days. In addition, in setting of hematocrit drop, concern for persistent bleed at sphincterotomy site. - continue cipro/flagyl/Vancomycin - trend lactate - trend white count - fluid bolus for UOP<50cc/h, MAP <60 - start neo drip if not responsive to fluid boluses - consider bladder pressure monitoring if concerned for compartment syndrome - f/u ACS recommendations ACUTE BLOOD LOSS ANEMIA: Patient presented with hematemesis, assumed to be due to bleeding from sphincterotomy site. Hematocrit dropped overnight from 29 to 25 and patient received 1UPRBC. During ERCP, site was cauterized and injected with epinephrine x 3. No upper GI source of blood loss. - hct q8hrs - transfuse for hct < 25 or evidence of active bleed - 2PIV (large bore) - t/s + crossmatch 2 units GANGRENOUS GALLBLADDER: S/p cholecystectomy with JP drain complicated by bile leak, now s/p stenting, epi injection and sphincterotomy with persistent drainage. - antibiotics as above - monitor drainage from JP site - serial abdominal exams - f/u ERCP team recs - f/u ACS recs - morphine prn pain - f/u final read of CT abdomen CHEST PAIN: Appears to be more epigastric vs cardiac in origin. Will trend cardiac enzymes which are negative thus far and repeat EKG once no longer tachycardic to see if mild ST changes in I/avL improve. - trend cardiac enzymes - repeat EKG - Maalox prn HYPOXIA: Most likely secondary to splinting due to pain. However, evidence of harsh murmur most consistent with aortic stenosis, concerning for volume overload. However, would avoid diuresis in setting of SIRS. - TTE to evaluate cardiac function - check BNP - wean O2 as tolerated - IS at bedside DIABETES: Non insulin dependent diabetes. - Insulin Sliding scale overnight HYPERLIPIDEMIA: Off simvastatin currently. On [**11-21**] surgical consult was obtained for evaluation of patient with persistent bile leak from percutaneous drain s/p lap CCY at OSH [**11-12**] c/b cystic duct stump leak/biloma. As above, underwent ERCP [**11-19**] with stent placement and sphincterotomy. This was complicated by hemetemesis prompting return for repeat ERCP with epinephrine injection to sphincterotomy site. CT scan obtained [**11-20**] showed fluid collection in RUQ thought to be post-surgical change vs biloma; collection not amenable to IR drainage. Patient was transferred to TSICU [**11-21**] under care of ACS service for further management of this issue. Remainder of hospital course by system as follows: Neuro: Patient arrived A&Ox2 with no neurologic deficits which is patient's baseline. Analgesia maintained with acetaminophen/morphine with good effect. Pt significantly agitated [**11-23**] on floor w RUE PICC self-d/c'd (replaced [**11-23**]). Agitation subsequently resolved with return to baseline mental status. Analgesics switched to po when tolerating po intake. CV: Patient borderline hypotensive with tachycardia at time of transfer. Abx broaded (see ID) for management of possible sepsis and resuscitation carried out w combination crystalloid, colloid and pRBC [**11-21**]. Hypotension/tachycardia improved with continued resuscitation. Bedside TTE [**11-22**] revealed LVEF 75% (hyperdynamic) with dilated RV and small pericardial effusion. Lasix was given for diuresis with good response. [**11-23**] triggered for tachycardia/bloody BM on floor and xfer SICU for resuscitation. Home CV medications resumed [**12-1**] as patient remained hemodynamically stable with no further issues. vital signs were routinely monitored. Pulmonary: Pulmonary toilet including incentive spirometry and early ambulation were encouraged. Pleural effusions noted on interval CXRs while in hospital managed in conjunction with patient's overall volume status. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Given bile leak and possible need for procedures, patient maintained NPO w IVF hydration at time of transfer. Goal directed resuscitation carried out and titrated to hemodynamic parameters. Diet advanced as tolerated [**2086-11-23**]. Made NPO [**11-25**] w NS bolus for increased JP drainage in setting increased po intake. Diet advanced to clears [**11-27**] following ERCP replacement of CBD stents x2 [**11-26**]. Fulls begun [**11-27**] which were tolerated well though with increased JP drainage. Advanced to regular diet [**11-30**]. Bowel regimen given throughout admission as needed for adequate GI function. No futher evidence of blood in stools was noted. At time of arrival to surgical service pt had percutaneous JP drain in RUQ draining bile and ERCP placed stent in CBD. As diet was advanced [**2086-11-23**] bilioius JP drainage increased. HIDA scan obtained [**11-25**] showing persistent bile leak though this was seen to be fully captured by JP drain. ERCP was repeated [**11-26**] showing leak at cystic duct remnant. CBD stent exchanged for 2 new biliary stents. Persistent high JP output 1/1-2 prompted initiation of Octreotide SQ [**11-28**]. Taken to repeat ERCP [**11-29**] for placement of covered metal stent given persistent JP output/bile leak. Following this JP output steeply declined. Patient will follow up with ERCP in several weeks for re-evaluation and likely stent removal. Foley was placed in [**Hospital Unit Name 153**] for urine output monitoring. This remained given hemodynamic issues and persistent need for active diuresis. Foley was d/c'd [**11-27**] and patient voided appropriately. Intake and output were closely monitored. ID: At time of transfer pt on cipro/flagyl which was changed to vancomycin/zosyn for persistent leukocytsosis [**11-21**]. RUE PICC was placed [**11-22**] for difficult IV access and continued need for IV abx. Vancomycin dosage titrated to appopriate trough level. Leukocytosis slowly resolved on broadened regimen. Bilious JP drainage sent for culture [**11-27**] which showed [**Female First Name (un) **] and GPCs. Vancomycin d/c'd [**11-27**] as no MRSA seen in any cultures sent. Fluconazole added to coverage [**11-27**]. UA and UCx sent [**11-28**] for cloudy urine and this was negative. ID offered recommendations to d/c Zosyn [**12-1**] and to d/c on diflucan to complete course [**12-3**]. At time of discharge leukocytosis and resolved and patient was afebrile. The patient's temperature was closely watched for signs of infection. ENDO: Patient was maintained on ISS while in hospital. [**Last Name (un) **] consulted for assistance in management of refractory hyperglycemia and labile blood glucose levels. Home anti-hyperglycemic regimen resumed [**12-1**]. HEME: Patient stably anemic on this admission with hct mid to high 20s. This was thought to be combination of baseline anemia with superimposed blood loss (hct 29->25) following initial ERCP/sphincterotomy. 1u pRBC given with appropriate response. anemia process. DISPO: Pt xfer from [**Hospital Unit Name 153**] to TSICU for further management under ACS service. Transferred to floor [**11-22**] following resuscitation for tachycardia/hypotension. [**11-23**] pt triggered for tachycardia w PAC's and bloody BM prompting return to SICU. Returned to floor hemodynamically stable [**11-24**]. Evaluated by PT with disposition to rehab recommended. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on [**2168-12-2**], the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: 1. Metformin 500 mg [**Hospital1 **] 2. Lisinopril 40mg daily 3. Omeprazole 20mg daily 4. Simvastatin 40mg qhS 5. Aspirin 81 mg daily 6. Glyburide 5 mg daily 7. Multivitamin 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 1 days: Total fluconazole course to be finished this evening at 8pm, last dose. 16. insulin lispro 100 unit/mL Solution Sig: One (1) inj Subcutaneous QAC: Please adminster according to attached sliding scale. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Primary: cystic duct stump leak Secondary: sepsis with tachycardia and hypotension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] from an outside hospital after having your gallbladder removed and suffering a complication called a cystic duct stump leak. You were transferred here for intervential management, and you underwent a procedure called an ERCP on 3 occasions. During the procedures you had stents placed to control this bile leak. You will follow up with the GI doctors in one month to have your stent removed. You were also being treated with antibiotics to control the infection caused by the leak. You are medically stable and are now being discharged to rehab to continue your recovery. Followup Instructions: Department: DIGESTIVE DISEASE CENTER When: FRIDAY [**2168-12-30**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] When: WEDNESDAY [**2168-12-14**] at 2:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2168-12-2**]

[ "112.89", "424.1", "285.1", "038.9", "567.81", "995.91", "294.20", "250.00", "514", "998.11", "576.8", "E878.8", "997.49", "427.31", "272.4", "799.02", "786.59" ]

icd9cm

[ [ [] ] ]

[ "97.05", "51.85", "38.97", "51.87", "51.10", "39.98" ]

icd9pcs

[ [ [] ] ]

20559, 20679

10397, 18837

290, 758

20806, 20806

4032, 4032

21598, 22433

2970, 2987

19061, 20536

20700, 20785

18863, 19038

20959, 21575

3027, 3532

230, 252

4679, 10374

786, 2751

4048, 4660

20821, 20935

2773, 2827

2843, 2954

3557, 4013

32,096

158,366

31369

Discharge summary

report

Admission Date: [**2100-6-22**] Discharge Date: [**2100-6-30**] Date of Birth: [**2070-12-13**] Sex: F Service: SURGERY Allergies: Erythromycin Base Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Motor vehicle crash Right hip pain, sternal pain, right rib pain Major Surgical or Invasive Procedure: [**2100-6-24**] Open reduction, internal fixation of right acetabular fracture History of Present Illness: 29 year old female who was the restrained driver in a high speed motor vehicle crash vs tree; prolonged extrication. She was taken to an area hospital where fond to have extensive orthopedic injuries and was then later transferred to [**Hospital1 18**] for further care. Past Medical History: Extensive psychiatric history including depression, anxiety. s/p gastric bypass s/p cholecystectomy Social History: Polysubstance abuse including IV heroin, associated with 3 motor vehicle collisions. H/o of heavy smoking. Lives with husband and two children. Family History: Non-contributory Physical Exam: On day of discharge: Gen: patient in NAD, resting comfortably in bed HEENT: PERRL, IOMs intact, trachea midline Chest: CTAB CV: RRR, s1,s2, no murmurs Abd: s/ND/NT, +bowel sounds Extremities: WWP, neurovascularly intact with 2+ pulses. tender to range of motion in right lower extremity. Surgerical incision c/d/i Neuro: alert and oriented, CNII-XII intact. Moves all extremities. Pertinent Results: [**2100-6-28**] 04:57AM BLOOD WBC-4.9 RBC-2.80* Hgb-7.8* Hct-23.5* MCV-84 MCH-27.7 MCHC-32.9 RDW-16.5* Plt Ct-297 [**2100-6-28**] 04:57AM BLOOD Plt Ct-297 [**2100-6-28**] 04:57AM BLOOD Glucose-108* UreaN-9 Creat-0.4 Na-141 K-3.5 Cl-102 HCO3-32 AnGap-11 [**2100-6-24**] 01:07PM BLOOD LD(LDH)-273* [**2100-6-28**] 04:57AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.3 CHEST (PA & LAT) Reason: pna? [**Hospital 93**] MEDICAL CONDITION: 29 year old woman with fever and tacchycardia REASON FOR THIS EXAMINATION: pna? INDICATION: Fever, tachycardia. Evaluate for pneumonia. Frontal and lateral views of the chest were obtained, compared with examination from one day previously. FINDINGS: Left-sided subclavian central venous catheter is seen, with the tip at the confluence of the L brachiocephalic and SVC. Lung volumes are low. Cardiac and mediastinal silhouettes are unremarkable. No significant pleural effusions are present. Basilar atelectasis is seen, particularly on the right. ECG Sinus tachycardia. Normal ECG. Compared to the previous tracing the rate is faster. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 134 90 334/395.28 55 59 26 Brief Hospital Course: She was admitted to the Trauma Service orthopedics was immediately consulted given her injuries. Her right hip was relocated by the orthopaedic surgery service in the trauma bay without complication. She underwent open reduction, internal fixation of her right acetabular fracture on [**6-24**] without any complication. She is to remain non weight bearing on her right leg until cleared by Orthopedics. Her non-displaced paramedian sternal fracture and minimally displaced rib fractures in right ribs 3,4,5 were managed with non-operative treatment. She remained in the Trauma ICU for several days for close monitoring and was later transferred to the regular nursing unit. She did have pain control issues and so the Acute Pain service was consulted. She did have an epidural (T5-6)catheter placed to infuse bupivacaine for control of her rib fracture pain. The catheter was removed on [**2100-6-25**] and she was switched to long acting narcotics with breakthrough medication prn. She was also started on Neurontin; this dose was increased from 300 tid to 400 tid prior to discharge; scheduled doses of Tylenol was also added. It is likely that she will require further adjustments of her pain medication once at rehab. She did require blood transfusion with 2 units PRBC's for falling hematocrit postoperatively. Her hematocrit has stabilized and is currently 23.1; it has remained stable for the past several days. Hemodynamically she has remained stable with no evidence of active bleeding. Because of her age it is expected that her hematocrit will rise on it's on. Physical and occupational therapy evaluated and treated her; she gradually made improvements in mobility. It is being recommended that she go to a rehab facility for further therapy. She developed a UTI during her stay and was treated with three days of ciprofloxacin with resolution of her infection. Medications on Admission: Cymbalta, trazadone, ambien, xanax Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 3 weeks. 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 11. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO every eight (8) hours. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours): Apply to affected leg as directed. 17. Oxycodone 5 mg/5 mL Solution Sig: [**4-1**] ML's PO Q4H (every 4 hours) as needed for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital3 12564**] Health Network Discharge Diagnosis: s/p Motor vehicle crash 1. Posterior dislocation of right femur 2. Transverse acetabular fracture involving the roof, anterior lip and medial aspect with extension into the posterior wall and right ischium 3. Paramedian sternal fracture 4. Rib fractures of ribs 3,4,5 on right 5. Urinary tract infection Discharge Condition: Good Discharge Instructions: DO NOT bear any weight on your right leg Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1005**], Orthopaedic Surgery clinic in 1 week. Please call to make an appointment [**Telephone/Fax (1) 1228**]. Please follow-up in Trauma surgery clinic with Dr. [**Last Name (STitle) **] in two weeks. Please call to make an appointment: [**Telephone/Fax (1) 6429**]. Completed by:[**2100-6-30**]

[ "807.04", "304.70", "305.1", "824.0", "861.21", "278.01", "599.0", "807.4", "E823.0", "808.0", "891.0", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.59", "03.90", "99.04", "79.09", "79.39", "79.06" ]

icd9pcs

[ [ [] ] ]

6359, 6422

2699, 4581

347, 428

6775, 6782

1468, 1856

6871, 7221

1031, 1049

4666, 6336

1893, 1939

6443, 6754

4607, 4643

6806, 6848

1064, 1449

239, 309

1968, 2676

456, 728

751, 854

870, 1015

13,505

151,986

51704

Discharge summary

report

Admission Date: [**2153-7-27**] Discharge Date: [**2153-8-8**] Service: NEUROLOGIC MEDICINE DISCHARGE DIAGNOSIS: Large left middle cerebral artery stroke along with posterior cerebral artery strokes bilaterally. HISTORY OF PRESENT ILLNESS: This is an 86 year old woman who has a history of atrial fibrillation, peripheral vascular disease, and a history of atrial emboli who was admitted on [**2153-7-27**], to the Neurologic Intensive Care Unit service after collapsing at home at 8:30 p.m. She was found to have right sided weakness and was noted by her husband to have vomited. She was found comatose at home by EMS and was brought to the Emergency Department. On arrival to the Emergency Department, she was noted to have a temperature of 98.2, blood pressure 164/110, respiratory rate 28, and heart rate of 74. She was found to be responsive only to painful stimuli at this time. She was intubated for airway protection and received multiple medications prior to her initial neurologic examination. She was also noted to have a cold distal left upper extremity which was operated on and she is now status post left brachial artery embolectomy. Throughout her course on the Intensive Care Unit service, she has remained unresponsive with imaging studies consistent with a large left middle cerebral artery and posterior cerebral artery distribution cerebral infarction with mass effect and midline shift. There is evidence of bilateral occipital and cerebellar infarctions as well. Discussion with the patient's family by the Intensive Care Unit service has resulted in focusing on her comfort care. This decision was made after an extensive discussion with her husband and family as the likelihood of significant meaningful recovery is extremely low. Based on this, she is transferred to the Neurology service for focus on comfort care. PAST MEDICAL HISTORY: 1. Breast cancer, status post lumpectomy. 2. Mitral commissurectomy. 3. Atrial fibrillation. 4. Peripheral vascular disease. 5. Arterial emboli, left femoral artery. 6. Congestive heart failure. MEDICATIONS ON TRANSFER: 1. Lopressor intravenous q6hours. 2. Morphine Sulfate 1 mg intravenous p.r.n. ALLERGIES: Penicillin, Sulfa and Quinidine. SOCIAL HISTORY: She lived with her husband caring for him. PHYSICAL EXAMINATION: On the date of transfer, temperature 98.5, heart rate 80 and irregular, blood pressure 140/60, oxygen saturation 100% in room air. in general, the patient is minimally responsive woman in no acute distress. Head and neck - normocephalic, supple, no lymphadenopathy. Cardiovascular - irregular rhythm, normal rate. Pulmonary - Good air movement, but occasional rhonchi. Abdomen reveals positive bowel sounds, soft, nontender, nondistended. Extremities - no edema. Neurologic - The patient is unresponsive to verbal stimuli, withdrawals the left extremities to noxious stimulation. The right side does not move. Tone is increased on the right. Toes are upgoing on the right. Cranial nerves - The pupils are equal and reactive to light and accommodation. There is a left gaze preference. The fundi [**Location (un) **] difficult to visualize but there is no evidence of papilledema. Reflexes are down on the right side. Normal reflexes on the left side. LABORATORY DATA: White blood cell count 11.5, hematocrit 31.0, platelet count 290,000. INR 3.0. Potassium was 3.0, glucose 131. MR studies revealed a large left middle cerebral artery infarction with multiple smaller posterior circulation infarctions. HOSPITAL COURSE: The patient's course up to the date of transfer to Neurology has been outlined above. Briefly, she is an 86 year old woman who has suffered multiple cardioembolic cerebral infarctions in multiple arterial territories. She has remained unresponsive throughout the hospitalization and currently only withdraws to pain. After extensive discussion with her family, her care was focused on comfort. A low dose Morphine drip was initiated after further serious discussion with her husband and nieces and nephews. The patient passed away peacefully on [**2153-8-8**]. The family did not want postmortem examination. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 42820**], M.D. [**MD Number(1) 7499**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2153-10-1**] 18:47 T: [**2153-10-1**] 19:46 JOB#: [**Job Number 107106**]

[ "444.89", "V10.3", "784.3", "427.31", "434.11", "342.90", "780.09", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.03", "96.04" ]

icd9pcs

[ [ [] ] ]

126, 226

3567, 4460

2327, 3549

255, 1867

2116, 2243

1889, 2091

2260, 2304

1,141

150,003

9001

Discharge summary

report

Admission Date: [**2192-6-29**] Discharge Date: [**2192-7-2**] Service: MEDICINE Allergies: Vancomycin Hcl/D5w Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: anuria Major Surgical or Invasive Procedure: none History of Present Illness: 84 vent-dependent M with COPD, CHF, CAD, AS, afib, recent prolonged hospitalization for CHF complicated by spontaneous retroperitoneal hematoma, referred from vent facility for fevers, altered mental status, and hypoxia/difficulty ventilating, as well as anuria. On the day prior to admission pt, was reportedly febrile, hypoxic on his vent, and alternately agitated and lethargic. Cultures were sent and pt received 2 units PRBCs on [**2192-6-28**] for Hct 26, also kayexalate for K 6.1. Has grown VRE (E faecalis) in blood cultures sent [**6-28**], for which he is on linezolid at [**Hospital1 **] Care; sputum cultures have grown Enterbacter cloacae (sensitive to imipenem, genta, tobra, and amikacin). He became anuric and was transferred to [**Hospital1 18**]. . In ED, initial VS 99.2, 140/80, 85, ABG 7.04/97/60 after bagging in ambulance. Labs remarkable for ARF with hyperkalemia, rx'd with calcium, insulin + glucose, bicarb. Foley placed, pt remained anuric; GU confirmed foley in decompressed bladder. CXR showed opacified L hemithorax--started levo/vanc. Abd also distended and tender. Surgery consulted and CT thorax obtained, which showed large L pleural effusion, large ascites; surgery did not think any acute surgical pathology. When returned from CT, pt in afib/RVR to 190s. Past Medical History: 1.Aortic Stenosis (Moderate aortic valve stenosis by [**2188**] echo; aortic valve area 1 cm squared. Maximal gradient of 42, with a mean gradient of 26) 2.PVD s/p R fem-[**Doctor Last Name **] bypass 3.Carotid Artery disease 4.COPD 5.HTN 6.Paraganglionoma diagnosed during ex-lap in [**2191**] 7.s/p tracheostomy, vent dependent 8.s/p PEG-J Social History: Past history of tobacco use, none in past 25 years, no alcohol, no drug use. Has been living at vent facility almost one month Family History: NC Physical Exam: 98.5 127/37 59 20 92% on AC 650x20, 40% FiO2, 8 PEEP GEN: grimaces to painful stimulus, does not follow simple command HEENT: NC/AT, PERRL but sluggish, will not track to allow assessment of EOM, poor dentition NECK: trach, jugular veins appear flat CHEST: rhonchorous on L, bronchial breath sounds on R CV: heart sounds obscured by breath sounds ABD: marked distension, healing midline surgical scar, PEG/J in epigastrium with bilious drainage around site. dull to percussion BACK/EXT: skin tear under L shoulder blade. coccygeal ulcer with eschar and surrounding erythema. #+ pitting edema to mid-thighs SKIN: thin, weeping skin on arms, with skin tear on L wrist Pertinent Results: [**2192-6-29**] 05:45PM WBC-14.7* RBC-4.00*# HGB-12.5*# HCT-38.1*# MCV-95 MCH-31.3 MCHC-32.9 RDW-16.7* [**2192-6-29**] 05:45PM NEUTS-91.4* BANDS-0 LYMPHS-7.2* MONOS-0.9* EOS-0.3 BASOS-0.1 [**2192-6-29**] 05:45PM PLT SMR-NORMAL PLT COUNT-155 [**2192-6-29**] 05:45PM PT-11.1 PTT-23.9 INR(PT)-0.9 [**2192-6-29**] 05:45PM GLUCOSE-112* UREA N-140* CREAT-3.7*# SODIUM-140 POTASSIUM-10.4* CHLORIDE-107 TOTAL CO2-21* ANION GAP-22* [**2192-6-29**] 05:45PM ALT(SGPT)-57* AST(SGOT)-110* ALK PHOS-107 AMYLASE-110* TOT BILI-1.4 [**2192-6-29**] 05:45PM LIPASE-81* [**2192-6-29**] 05:45PM ALBUMIN-2.4* CALCIUM-8.4 PHOSPHATE-9.8*# MAGNESIUM-3.6* [**2192-6-29**] 06:00PM LACTATE-2.1* [**2192-6-29**] 06:45PM TYPE-ART TIDAL VOL-650 PEEP-5 O2-100 PO2-68* PCO2-60* PH-7.22* TOTAL CO2-26 BASE XS--4 AADO2-599 REQ O2-96 -ASSIST/CON CXR: There has been interval near complete opacification of the left hemithorax when compared to the previous exam. There is apparent slight shift of the mediastinum to the left, indicating a component of volume loss/collapse, possibly secondary to a mucus plug. There is most likely an associated left-sided pleural effusion. The right costophrenic angle has been clipped from the film. The visualized right lung appears within normal limits. The pulmonary vasculature within the right lung is within normal limits. The tracheostomy tube and percutaneous gastrostomy tube appear in unchanged positions. CT Abd/Pelvis: 1. Resolving retroperitoneal hematoma extending along the left posterior pararenal space inferiorly to the left groin. 2. Large left-sided pleural effusion with associated atelectasis and collapse of the left lower lobe. Small right-sided pleural effusion. 3. Large amount of ascites and anasarca. 5. Mildly thickened loops of small bowel with evaluation limited by ascites and lack of intravenous contrast. The appearance is similiar to the prior examination. The findings are likely secondary to anasarca. Ischemia cannot be completely excluded, especially given the appearance of the heavily calcified SMA and close clinical correlation is advised. RUQ Ultrasound with doppler to assess portal vessels: 1. Significantly shrunken liver with nodular contour and increased echogenicity consistent with cirrhosis. Significant amount of ascites is also identified. The main portal vein and hepatic veins demonstrate normal flow pattern. 2. Cholelithiasis with no evidence of cholecystitis. Brief Hospital Course: 84M with AS, CAD, COPD, vent dependent, now with likely Acinetobacter VAP, also Enterecoccus bacteremia, and oliguric renal failure . # Respiratory: Trach/vent dependent; continued ventilation to keep Sats >90%. L >> R pleural effusion--L effusion was last drained one month ago (3.5L removed) and has reaccumulated, likely sympathetic from ascites. As long as able to oxygenate well, would not drain urgently. Maintained COPD on alb/atro, inhaled steroids, and continued methylprednisolone with plan to taper. . # Cardiovascular: chronic problems include: - [**Name (NI) 31196**] AS by last echo, so would avoid sudden volume shifts as patient is likely very pre-load dependent - afib--rate controlled with metoprolol . # Acute oliguric renal failure, oliguric: Cr bumped from 1.0 a month ago to 2.0 three days ago and now up to 3.7. Urine lytes showed FeNa 11%, most likely ATN according to renal consultant. Renal team offered dialysis to patient's family, but explained that with his other significant co-morbidities, dialysis would not be likely to change his overall prognosis, and healthcare proxy decided that dialysis would not be in keeping with patient's wishes. . # GI: Ascites: pt is not known cirrhotic, so cause of cirrhosis not clear, although his CHF and hypoalbuminemia. low albumin state vs portal HTN. should have diagnostic tap in am (has not had paracentesis before). Tense ascites have displaced his PEG, contributing to the leak of bilious fluid from the PEG site and most likely also contaminating the peritoneum. Not clear if this was the source of Enterococcus bacteremia, but covered with Abx as below. - elevated AST/ALT--could be drug effect, infection, shock liver as patient was reportedly hypotensive - chemical pancreatitis--CT did not reveal pancreatitis . # ID--Reportedly febrile yesterday; WBC 14 with 91% polys, cultures from OSH growing VRE in blood and Enterobacter in sputum. Resent blood, urine, sputum cultures. For now, continue ampicillin for Enterococcus; Enterobacter was sensitive to imipenem (although not tested for meropenem) and aminoglycosides but no others, will use meropenem since less seizure risk in renal failure. . # Skin--breakdown on coccyx as well as upper back, and thin skin on arms with tears and ecchymoses. [**Doctor First Name **]-Air bed, wound consult. . # Code--full, per daughter [**Name (NI) **] [**Name (NI) 31197**] ([**Telephone/Fax (1) 31198**] [[**State 2690**]]); pt has girlfriend who has been very involved in his care ([**First Name8 (NamePattern2) 14880**] [**Last Name (NamePattern1) 1924**] [**Telephone/Fax (1) 31199**]). After several discussions of the futility of additional interventions such as dialysis in the setting of his numerous comorbidities and the low likelihood that he would survive any surgery to address the dehisced PEG and peritonitis, his family agreed he would want to focus the goals of his care on comfort. He was made CMO and expired shortly thereafter. Medications on Admission: APAP 650 prn morphine 2mg IV Q3 prn albuterol inh 6 puffs Q4h ipratropium inh 6 puffs Q4h calmoseptine top Dakin's solution top xenaderm top colace 100mg [**Hospital1 **] + senna fluticasone 110mcg x2puffs [**Hospital1 **] imipenem cilastatin 500mg iv Q12 cefepime 1gm daily insulin NPH [**Hospital1 **] (dose not stated) + SSRI isordil 20mg tid lansoprazole 30mg daily linezolid 600mg [**Hospital1 **] methylprednisolone 40mg Q12 metoprolol 75mg tid simvastatin 20mg daily terazosin 2mg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: # Enterococcus bacteremia # Enterobacter ventilator acquired pneumonia # peritonitis # trach # PEG # paraganglionoma # Aortic Stenosis (Moderate aortic valve stenosis by [**2188**] echo; aortic valve area 1 cm squared. Maximal gradient of 42, with a mean gradient of 26) # PVD s/p R fem-[**Doctor Last Name **] bypass # Carotid Artery disease # COPD # HTN Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "276.7", "567.9", "V44.0", "041.04", "482.83", "V46.11", "496", "584.5", "518.84", "707.03", "V44.4", "401.9", "427.31", "424.1", "789.5", "428.0", "276.2", "443.9", "790.7", "511.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "57.32" ]

icd9pcs

[ [ [] ] ]

8810, 8819

5268, 8237

239, 245

9220, 9229

2803, 5245

9281, 9423

2096, 2100

8782, 8787

8840, 9199

8263, 8759

9253, 9258

2115, 2784

193, 201

273, 1569

1591, 1935

1951, 2080

60,667

191,557

53114+59499

Discharge summary

report+addendum

Admission Date: [**2146-12-28**] Discharge Date: [**2147-1-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: altered mental status and poor urine output Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: This is an 85 y.o. with atrial fibrillation on coumadin, peripheral vascular disease, and stage IV CKD who presented to the hospital this morning with altered mental status and poor urine output since yesterday. Over the last three weeks the patient has been suffering from right hip and ischial pain after having sustained a mechanical fall. After this fall, he has had CT's of the head and pelvis that failed to show any acute pathology. Due to persistent pain he has been started on tramadol during the day and oxycodone-APAP at night with some relief of his symptoms. Over the last few days he has been feeling overall weak and more tired than usual. He also has had multiple episodes of altered mental status over the past two days with occasional confusion and auditory and visual and auditory illusions versus hallucinations (the patient cannot perfectly describe these episodes but most sound as if they were misinterpretations of existing stimuli). He has had two episodes of dizziness but no syncope. The patient has also been having intermittent involuntary jerking movements one of which caused him to knock a lamp off of his bedside table last night. Yesterday and this morning the patient's friend who helps care for him noted that he seemed to be urinating less (only twice yesterday) and given this cumulation of concerning symptoms he presented to the ED this morning. Overall, he denied any other specific complaints except feeling tired and generally unwell and those noted. He particularly denied any chest pain, shortness of breath, or frank syncope. In triage he appeared unwell with a HR of 28 and SBP's in the 70's. He was given 1 mg atropine with improvement of rates to the 40's and pressures to the mid teens but then rates dropped back to the 20's with ECG showing complete heart block. He received another amp of atropine with improvement of rates back to the 50's with SBP's greater than 100. Patient was evaluated by the elecrophysiology service who planned for pacemaker placement this afternoon. Labs also notable for acute kidney injury on his chronic kidney disease and potassium of 5.4. He received kayexalate and was admitted to the floor. On arrival to the floor the patient received insulin and glucose as well as calcium gluconate. He complained of feeling generally unwell but denied any localizing symptoms and was initially alert and oriented *3. A bit later he had some altered mental status and confusion and was found to have a blood glucose of 35. He received one amp of dextrose with improvement back toward baseline. Shortly after resolution (and repeat blood glucose>102). The patient was taken for permanent placemaker placement. He tolerated the procedure well and is now denying any complaints and reporting feeling much better. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He has exertional buttock pain that is stable. All of the other review of systems were negative. Cardiac review of systems is notable for chronic stable orthopnea and some mild lower extremity edema. It is notably negative for chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, palpitations or syncope. Past Medical History: -Rheumatoid arthritis (primarily shoulders, fingers) - atrial fibrillation - benign prostatic hypertrophy - Chronic renal insufficiency (baseline of 3.1 [**1-/2146**]) - Congestive Heart Failure (EF 55 % ECHO of [**5-6**]) - Hypertension - Peripheral vascular disease - s/p tonsillectomy - s/p appendectomy - s/p hernia operation - s/p bilateral TKA - s/p l peroneal vascular stent placement Social History: Pt is retired from job as secretary for Knights of Pytheus. Prior to that worked as a salesman, selling costume jewlery. Former smoker, 30 pack years, quit 30 years ago. Drinks one [**Doctor Last Name 6654**] each night. No illicit drug use. Lives in [**Location 701**] with female [**Last Name (LF) 15560**], [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Enjoys [**Location (un) 1131**], watching baseball. Has two children, two grandchildren. Wife died of CHF 4.5 years ago. Family History: Father died of prostate cancer Mother died from [**Name (NI) **] Daughter died of [**Name (NI) **] at age 33 Physical Exam: VS: 95.8, 58, 128/57, 17, 100% 2 liters by nasal cannula HEENT - NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - mild bibasilary crackles, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. bar-like systolic ejection murmur in apex radiating towards axila [**3-4**]. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. SKIN - no rashes or lesions. No stasis dermatitis, ulcers, scars, or xanthomas. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-3**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: Admission labs: [**2146-12-28**] 10:55AM BLOOD WBC-10.2# RBC-3.29* Hgb-9.3* Hct-30.6* MCV-93 MCH-28.4 MCHC-30.6* RDW-15.6* Plt Ct-112* [**2146-12-28**] 10:55AM BLOOD Neuts-81.5* Lymphs-10.2* Monos-4.9 Eos-2.8 Baso-0.7 [**2146-12-28**] 10:55AM BLOOD PT-20.5* PTT-30.0 INR(PT)-1.9* [**2146-12-28**] 10:55AM BLOOD Glucose-116* UreaN-84* Creat-6.4*# Na-139 K-5.4* Cl-106 HCO3-21* AnGap-17 [**2146-12-28**] 10:55AM BLOOD CK(CPK)-68 [**2146-12-28**] 10:55AM BLOOD cTropnT-0.03* [**2146-12-28**] 10:55AM BLOOD Calcium-8.5 Phos-5.7*# Mg-3.6* [**2146-12-28**] 11:03AM BLOOD Lactate-1.3 K-5.2 [**2146-12-28**] 12:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2146-12-28**] 12:15PM URINE Blood-NEG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2146-12-28**] 12:15PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2146-12-28**] 12:15PM URINE CastHy-0-2 Discharge Labs: [**2147-1-4**] 05:50AM BLOOD WBC-9.6 RBC-2.83* Hgb-8.2* Hct-25.7* MCV-91 MCH-29.2 MCHC-32.1 RDW-15.4 Plt Ct-104* [**2147-1-4**] 05:50AM BLOOD Plt Ct-104* [**2147-1-4**] 05:50AM BLOOD Glucose-96 UreaN-83* Creat-4.2* Na-145 K-3.5 Cl-114* HCO3-20* AnGap-15 [**2147-1-4**] 12:20PM BLOOD Iron-21* [**2147-1-4**] 12:20PM BLOOD calTIBC-138* Hapto-135 Ferritn-425* TRF-106* [**2147-1-4**] 12:20PM BLOOD TSH-1.7 STUDIES: [**12-28**] CXR: Aside from minor linear atelectasis in the left lung base which is stable since the previous study in [**2146-9-29**], there is no consolidation, pneumothorax, or pleural effusion. Heart size is top normal, unchanged. No obvious rib fractures. [**12-28**] CT Head: 1. No acute intracranial process. Specifically, there is no evidence of intracranial hemorrhage. 2. Chronic small vessel ischemic change. 3. Age-associated involutional changes. U/S, non-vascular, Left Upper Extremity: The soft tissues in the left upper arm again demonstrate some edematous changes, but no discrete fluid collection is identified. IMPRESSION: Edematous left arm tissues, but no discrete fluid collection. U/S, vascular, LUE: No evidence of left upper extremity DVT. CXR: Uncomplicated placement of dual-electrode pacer. No pneumothorax or any other complication. Brief Hospital Course: MED REC -AMIODARONE 200 mg by mouth daily --> continued -CARVEDILOL 25 mg by mouth twice a day --> continued -FUROSEMIDE 40 mg by mouth daily --> STOPPED -HYDROXYCHLOROQUINE 200 mg by mouth daily --> continued -LISINOPRIL 5 mg by mouth daily --> STOPPED -PRAVASTATIN 10 mg by mouth daily --> continued -TAMSULOSIN 0.4 mg by mouth at bedtime --> continued -APAP PRN --> continued -ASA 81 mg PO daily --> continued -DOCUSATE SODIUM 100 mg by mouth daily --> continued -FERROUS SULFATE 650 mg daily --> continued -MVI --> stopped, replaced with nephrocaps (B, C + folate) -DOXERCALCIFEROL 1 mcg daily --> stopped STARTED: -amlodipine 10mg daily -sevelamer 800 mg TID -thiamine _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ 85 year old male with past medical history of CKD, PAD, and AF but no known CAD presenting with hypotension and bradycardia and found to be in complete heart block with acute on chronic renal insufficiency. # [**Last Name (un) **]/CKI: Stage IV CKD. Creatinine up to 6.4 from baseline ~3.5, resolved to 3.8 on day of discharge. Believed to be perfusion-related kidney injury, in the setting of hypoperfusion from bradycardia. ACEi and diuretics held. Started sevelamer, multivitamin replaced with nephrocaps. Has follow up with Dr. [**Last Name (STitle) 118**] in clinic on [**1-11**]. # Anemia, Acute on Chronic: Acute component most likely [**1-31**] left arm hematoma in setting of supratherapeutic INR. Guiaic negative, no evidence of RP or other bleed, labs without evidence of DIC or other hemolysis. Chronic component likely [**1-31**] CKD. Not currently on erythropoeitin. Transfused 2 units PRBCs with 4 point rise in hematocrit. Please check hematocrit evening of transfer as per below. # Altered Mental Status w/Hallucinations: Patient presenting with confusion and possible hallucinations which resolved across the hospitalization. Most likely [**1-31**] uremia. Head CT negative. Started on thiamine and folate given h/o moderate alcohol use. # Hypertension: Hypertensive off of home lasix and lisinopril. Started on amlodipine 10mg with good affect. Consider restarting lasix and ACEi pending further resolution of renal function. # Bradycardia with CHB s/p PM: Admitted with HR of 28 and SBPs to the 70s. Pacemaker placed without complications. Hypotension resolved. Amiodarone continued. Patient has follow up with device clinic on # h/o Atrial Fibrilation: stable. Supratherapeutic INR during admission in setting of poor PO intake. Resolved after holding coumadin and giving 1 dose of vitamin K. Restarted on discharge at 1mg daily. # Heart Failure, Chronic, Systolic: diagnosis per documented history, most refect echo with EF 55-60% with trivial valvular disease. BB and ASA continued, ACEi and diuretics held [**1-31**] [**Last Name (un) **]. # Left Arm Hematoma: left upper arm swollen and purple in setting of supertherapeutic INR. U/S showing no evidence of DVT, edematous tissues without fluid collection. # Right Groin Pain: Patient admitted with 3 weeks of right hip and ischial pain after having sustained a mechanical fall. No evidence of fracture. Pain improved at time of discharge. # Hypernatremia: Patient intermittently hypernatremic. Thought likely [**1-31**] diarrhea vs possible poor water intake due to AMS. Resolved briefly with D5W, however sodium trending up to 146 at time of discharge. # Peripheral arterial disease: Stable with known claudication. No interventions appropriate at this point. Continued on aspirin and statin. Follow up with vascular as outpatient. # RA: No active signs of joint inflammation. Left shoulder largely immobile as previously noted. Hydroxychloroquine continued. Has Rheum follow up scheduled for [**2147-4-18**]. # BPH: Stable. Continued tamsulosin. # Transfer to LTAC: The patient was discussed with Dr. [**Last Name (STitle) 109411**] [**Name (STitle) 5193**] at [**Hospital1 **] prior to transfer. Immediate issues to address upon transfer include: -HCT check evening of transfer -INR, coumadin (restarted on 1mg day of discharge) -Hypernatremia (resolved with D5W, Na trending back up at 146 on day of discharge) Medications on Admission: -AMIODARONE 200 mg by mouth daily -CARVEDILOL 25 mg by mouth twice a day -DOXERCALCIFEROL 1 mcg daily -FUROSEMIDE 40 mg by mouth daily -HYDROXYCHLOROQUINE 200 mg by mouth daily -LISINOPRIL 5 mg by mouth daily -PRAVASTATIN 10 mg by mouth daily -TAMSULOSIN 0.4 mg by mouth at bedtime -WARFARIN 1-4 mg PO daily to maintain INR [**2-1**] -APAP PRN -ASA 81 mg PO daily -DOCUSATE SODIUM 100 mg by mouth daily -FERROUS SULFATE 650 mg daily -MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for Constipation. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] Discharge Diagnosis: PRIMARY: Bradycardia Acute on Chronic Renal Insufficiency Hypertension Hypernatremia SECONDARY: RA Discharge Condition: stable Discharge Instructions: It was a pleasure taking care of you during your admission at [**Hospital1 69**]. You were admitted for a slow heart rate. While you were here you had a pacemaker inserted. We also treated you for kidney problems as well as a low blood level. We have changed several of your medications during your admission. Please make the following changes: Please START taking the following medications: -Amlodipine, 10mg every morning, for your blood pressure -Sevelamer, three times a day, to help your body deal with phosphorus -Nephrocaps, which is a multivitamin for people with kidney problems -Thiamine, a vitamin that your body needs for several reasons Please STOP taking the following medications: -Lisinopril -Furosemide (Lasix) -Multivitamins We are stopping these medications due to your kidney function. You should discuss restarting these medications with your nephrologist, Dr. [**Last Name (STitle) 118**], at your follow up appointment on [**1-11**]. Finally, we have adjusted your dose of warfarin (Coumadin) to 1mg daily. You should continue to have your INR checked regularly and your dose of warfarin adjusted as needed. We did not change any of your OTHER medications while you were here. Please continue to take all of your previous medications exactly as prescribed. Please drink plenty of water. While you were here your bloodwork showed that you sometimes might not be drinking enough water. Try to drink [**6-6**] glasses of water every day unless told otherwise by your physicians. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2147-1-11**] 2:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-1-4**] 2:30 Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2147-2-16**] 10:00 Name: [**Known lastname **],[**Known firstname 947**] Unit No: [**Numeric Identifier 17936**] Admission Date: [**2146-12-28**] Discharge Date: [**2147-1-6**] Date of Birth: [**2061-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 211**] Addendum: additional lab results as below Pertinent Results: LABS ON FINAL DAY DISCHARGE: [**2147-1-6**] 06:40AM BLOOD WBC-10.2 RBC-2.86* Hgb-8.5* Hct-26.0* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.5 Plt Ct-114* [**2147-1-6**] 06:40AM BLOOD Plt Ct-114* [**2147-1-6**] 06:40AM BLOOD Glucose-88 UreaN-76* Creat-3.8* Na-146* K-3.5 Cl-116* HCO3-20* AnGap-14 [**2147-1-6**] 06:40AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.5 HEMATOCRIT TREND ACROSS HOSPITALIZATION: [**2147-1-6**] 06:40AM BLOOD WBC-10.2 RBC-2.86* Hgb-8.5* Hct-26.0* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.5 Plt Ct-114* [**2147-1-6**] 01:25AM BLOOD Hct-25.3* [**2147-1-5**] 07:35AM BLOOD WBC-10.1 RBC-2.51* Hgb-7.4* Hct-22.4* MCV-89 MCH-29.4 MCHC-33.0 RDW-15.3 Plt Ct-133* [**2147-1-4**] 05:50AM BLOOD WBC-9.6 RBC-2.83* Hgb-8.2* Hct-25.7* MCV-91 MCH-29.2 MCHC-32.1 RDW-15.4 Plt Ct-104* [**2147-1-3**] 09:45AM BLOOD WBC-8.4 RBC-3.29* Hgb-9.2* Hct-29.2* MCV-89 MCH-27.9 MCHC-31.4 RDW-15.5 Plt Ct-121* [**2147-1-3**] 05:55AM BLOOD WBC-8.1 RBC-3.15* Hgb-8.8* Hct-28.3* MCV-90 MCH-28.0 MCHC-31.2 RDW-15.4 Plt Ct-118* [**2147-1-2**] 05:45PM BLOOD Hct-27.8* [**2147-1-2**] 05:35AM BLOOD WBC-7.3 RBC-2.63* Hgb-7.2* Hct-23.3* MCV-89 MCH-27.4 MCHC-30.9* RDW-15.7* Plt Ct-108* [**2147-1-1**] 05:25AM BLOOD WBC-8.5 RBC-2.68* Hgb-7.6* Hct-24.0* MCV-90 MCH-28.4 MCHC-31.8 RDW-15.5 Plt Ct-109* [**2146-12-31**] 08:20AM BLOOD WBC-6.6 RBC-2.74* Hgb-7.5* Hct-24.4* MCV-89 MCH-27.4 MCHC-30.7* RDW-15.6* Plt Ct-122* [**2146-12-30**] 08:45AM BLOOD WBC-7.4 RBC-2.69* Hgb-7.7* Hct-24.1* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.5 Plt Ct-117* [**2146-12-29**] 03:22PM BLOOD Hct-25.3* [**2146-12-29**] 07:05AM BLOOD Hct-23.4* [**2146-12-29**] 04:08AM BLOOD WBC-8.3 RBC-2.65* Hgb-7.7* Hct-24.0* MCV-91 MCH-29.2 MCHC-32.2 RDW-15.3 Plt Ct-113* [**2146-12-28**] 10:55AM BLOOD WBC-10.2# RBC-3.29* Hgb-9.3* Hct-30.6* MCV-93 MCH-28.4 MCHC-30.6* RDW-15.6* Plt Ct-112* Discharge Disposition: Extended Care Facility: [**Hospital1 49**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2147-1-11**]

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Discharge summary

report

Admission Date: [**2106-11-26**] Discharge Date: [**2106-11-30**] Date of Birth: [**2066-1-30**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Augmentin / Cefaclor / Codeine Attending:[**First Name3 (LF) 3227**] Chief Complaint: Meningioma Major Surgical or Invasive Procedure: Right Frontal CRaniotomy for Tumor History of Present Illness: Ms. [**Known lastname 82851**] is a 40 y.o. F who was found to have a right frontal convexity meningioma as work up for headache in [**2098**]. This finding was followed with serial MR imaging. The most recent MR revealed interval enlargement of the tumor. She opted to proceed for a craniotomy for excision of this lesion. Past Medical History: Anxiety Social History: SH: works as a radiology assistant. Denied alcohol use or ilicit drug use. Distant history of smoking. Family History: FH: mother with a history of breast CA. Physical Exam: On admission: On examination, the patient is awake, alert, and appropriate. LTM: intact to home address and birthday STM: [**3-2**] at 3 minutes AS: intact to serial 3's Aware of current president and vice president Comprehension intact to simple and complex commands, speech fluent, Naming and repetition intact. EOMI. PERRL 2.5 mm. VFF. FS. Hearing and shoulder shrug symmetric. Tongue and uvula midline. Normal bulk and tone. Full strength throughout. Sensation intact to LT. Reflex 2 and symmetric. Normal gait. Romberg negative. Normal FTN. On discharge: Alert and oriented to person, place, and time. Remains neurologically intact. Incision C/D/I. MAE [**5-4**] Pertinent Results: [**2106-11-26**] 10:20AM TYPE-ART RATES-/10 TIDAL VOL-650 O2-50 PO2-204* PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2106-11-26**] 10:20AM GLUCOSE-129* LACTATE-2.3* NA+-139 K+-4.7 CL--108 [**2106-11-26**] 10:20AM HGB-13.7 calcHCT-41 O2 SAT-99 [**2106-11-26**] 10:20AM freeCa-1.01* [**2106-11-29**] 06:10AM BLOOD WBC-8.2 RBC-3.85* Hgb-12.0 Hct-33.7* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.6 Plt Ct-274 [**2106-11-29**] 06:10AM BLOOD Plt Ct-274 [**2106-11-29**] 06:10AM BLOOD Glucose-98 UreaN-16 Creat-0.7 Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 [**2106-11-29**] 06:10AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0 CT head [**2106-11-26**]: Stable post-op changes. MRI Brain [**2106-11-27**]: IMPRESSION: Postoperative changes following resection of right frontal meningioma. No residual nodular enhancement seen. No acute infarct identified. Expected post-surgical changes are seen. Brief Hospital Course: Ms. [**Name14 (STitle) 82852**] was admitted to [**Hospital1 18**] on [**2106-11-26**]. She underwent a Right Frontal craniotomy for meningioma. Frozen Section revealed some atypical features. She was extubated and trasnitioned to the SICU. Post-op CT showed the expected post-op changes. On [**2106-11-27**] She has some nausea and emesis. Her pain medication was changed form Dilaudid to Fentanyl. She is allergic to Codeine. Transfer orders for the floor were written. Her decadron taper was initiated. On [**2106-11-30**] she was neurologically stable and discharged home. Medications on Admission: Zoloft, Ativan PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/T>100/HA. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no BM 48hrs. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Until follow-up. Disp:*60 Tablet(s)* Refills:*2* 6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-1**] Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 9. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q8H (every 8 hours) for 5 days. Disp:*1 tube* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right Frontal Mass Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? 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. ?????? Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions You will need a follow-up appointment with Dr. [**First Name (STitle) **] in 4 weeks. You will also need to follow-up with Dr. [**First Name (STitle) **] in 3 months with a Brain MRI with and without contrast. Please call [**Location (un) 3230**] at [**Telephone/Fax (1) 3231**] to make this appointment. As of today, your pathology is still pending. We will notify you with results by Friday [**2106-12-3**] if available. Please call [**Telephone/Fax (1) 3231**] if you do not hear from us. Completed by:[**2106-11-30**]

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Discharge summary

report

Admission Date: [**2196-6-25**] Discharge Date: [**2196-7-14**] Date of Birth: [**2162-6-23**] Sex: F Service: MEDICINE Allergies: Humira / Toradol / Certolizumab Pegol / Meperidine Attending:[**First Name3 (LF) 633**] Chief Complaint: Abdominal Pain, Increased Ostomy Output, nausea/vomiting Major Surgical or Invasive Procedure: Right internal jugular triple lumen catheter placement, revision, and replacement by Interventional Radiology 1 unit packed red blood cell transfusion History of Present Illness: 34 yo F with pmhx significant for Crohn's disease s/p near-total colectomy and ileostomy, PE/UE DVT on lovenox with recent hospitalization [**2196-6-3**] - [**2196-6-18**] for stomal pain and found to have fungemia/bacteremia now s/p portacath removal who presents to the ED with persistent stomal pain, increased stool output and nausea/vomiting. . Patient was last admitted from [**Date range (3) 110642**] for abdominal pain, nausea, vomiting, and increased ostomy output. During that admission she underwent ileoscopy, endoscopy and flexible sigmoidoscopy which were normal and showed no signs of active crohns; infectious work-up was negative and MRE was unrevealing. Inflammatory markers were normal and her steroids were tapered (initially started on methylprednisolone 20 iv q8h for presumed crohns flare), which she finished on [**2196-6-20**]. Colorectal surgery thought patient had a stomal prolapse however should not be causing the degree of pain she reported. Ultimately thought that the pain was due to irritation of the stoma due to increased stool output. Patient offered reversal of ostomy and has appointment on [**2196-7-7**] with Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 **] to discuss (wanted infection to clear prior to OR). Patient started on loperamide to decrease stool output. Blood cultures during that admission grew Staph epidermidis as well as [**Female First Name (un) 564**], and she was started on a course of Linezolid and Fluconazole; Linezolid was planned to be finished on [**2196-6-26**] (although patient finished yesterday) and Fluconazole on [**2196-6-28**] (still taking). Patient's portacath was removed and a right IJ TLC was placed for acess during the remainder of her hospital stay. Patient has very poor access and has required multiple portacaths. Found to have a RUE axillary and left IJ DVT for which she is managed with lovenox, reportedly non-compliant as an outpatient (although denies this). While awaiting insurance authorization of Linezolid she left against medical advice, however obtained prior auth as an outpatient. Since discharge, the patient reports that she has continued to have stomal pain, worse with passage of stool. Pain describd as burning/pressure pain. Also with increased stool output, watery without any visible blood although reportedly guaiac positive at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] per patient. Patient finished her prednisone taper on [**2196-6-20**] with no change in symptoms. Also with one day of nausea/vomiting, unable to take po. Denies any fever, chills, cp or sob. . ED: initially seen at [**Hospital3 **] ED where a small piv was placed and patient given 500 cc of NS until iv access lost. Given po zofran and IM dilaudid. Labs drawn and significant for normal wbc's, sodium 133 and K+ 3.1. No LFTs drawn. Patient transferred to [**Hospital1 18**]. Vitals: 98.8 108P 107/61 16 99%RA. Given zofran 4mg ODT x 2 and dilaudid 1mg IM. . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: --Crohn's Disease - Previously on inflixamab, now s/p near total colectomy and ileostomy with recent extensive work-up showing no active Crohn's --Difficult access with portacath s/p removal [**6-15**] due to fungemia/bacteremia --DVTs (left IJ and right UE axillary) - provoked in setting of portacath --PE Social History: Lives with husband, and six children plus one granddtr. Denies alcohol use, tobacco use, and any history of illicit drugs. Works for family business - catering. Family History: No significant GI or hematologic history Physical Exam: VS: 97.0 127/88 107P 18 99%RA Appearance: alert, NAD, obese Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mm very dry, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, right side of abdomen with ttp, no distension, +bs, no rebound/guarding, stoma pink with mild prolapse Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: multiple scars on chest from previous portacaths, right upper arm small lesion with sutures after biopsy Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: No [**Hospital1 18**] labs available on admission. [**Hospital3 **] Labs: . 133 103 12 ------------< 88 3.1 22 0.7 . 6.9> 8.3/25.5 <181 mcv 79 . coags wnl . UA negative . [**2196-6-8**] MRE: 1. Chronic inflammatory changes in the terminal ileum without convincing evidence of acute disease. No definite fistula seen although this is a somewhat suboptimal study due to patient's difficulty drinking oral contrast. 2. Bilateral hemorrhagic ovarian cysts. Mild bilateral hydrosalpinges. . [**2196-6-7**] UE Doppler: Occlusive thrombus in the right axillary vein extending into the proximal basilic vein. The extent of clot is unchanged compared to [**2196-6-3**]. . [**2196-6-3**] bilateral UE doppler at [**Hospital3 **]: thrombosed left IJ, occlusive thrombus right axillary veing extending proximal basilic vein [**2196-7-14**] 05:50AM BLOOD WBC-5.1 RBC-2.80* Hgb-6.9* Hct-22.3* MCV-80* MCH-24.5* MCHC-30.8* RDW-18.6* Plt Ct-200 [**2196-7-13**] 05:52AM BLOOD WBC-4.3 RBC-2.87* Hgb-7.1* Hct-23.1* MCV-81* MCH-24.6* MCHC-30.5* RDW-19.1* Plt Ct-205 [**2196-7-12**] 04:26AM BLOOD WBC-4.4 RBC-2.82* Hgb-6.9* Hct-22.8* MCV-81* MCH-24.7* MCHC-30.5* RDW-18.9* Plt Ct-200 [**2196-7-10**] 04:10AM BLOOD WBC-5.8 RBC-2.99* Hgb-7.4* Hct-24.3* MCV-81* MCH-24.8* MCHC-30.6* RDW-19.0* Plt Ct-206 [**2196-7-9**] 06:21AM BLOOD WBC-6.0 RBC-2.99* Hgb-7.3* Hct-24.4* MCV-81* MCH-24.4* MCHC-29.9* RDW-19.3* Plt Ct-153 [**2196-7-8**] 06:10AM BLOOD WBC-4.7 RBC-3.03* Hgb-7.5* Hct-24.5* MCV-81* MCH-24.7* MCHC-30.5* RDW-19.7* Plt Ct-138* [**2196-7-6**] 06:26AM BLOOD WBC-3.8* RBC-3.10* Hgb-7.8* Hct-25.3* MCV-82 MCH-25.0* MCHC-30.7* RDW-19.5* Plt Ct-164 [**2196-7-5**] 01:12AM BLOOD WBC-4.1 RBC-3.04* Hgb-7.5* Hct-24.5* MCV-81* MCH-24.8* MCHC-30.8* RDW-19.1* Plt Ct-129* [**2196-7-4**] 04:40AM BLOOD WBC-4.5 RBC-2.83* Hgb-7.0* Hct-22.7* MCV-80* MCH-24.7* MCHC-30.8* RDW-19.3* Plt Ct-108* [**2196-7-3**] 06:17AM BLOOD WBC-5.0# RBC-2.37* Hgb-5.8* Hct-19.1* MCV-81* MCH-24.5* MCHC-30.4* RDW-20.5* Plt Ct-101* [**2196-7-2**] 09:20AM BLOOD WBC-2.8* RBC-2.86* Hgb-7.1* Hct-22.9* MCV-80* MCH-24.8* MCHC-31.0 RDW-20.3* Plt Ct-169 [**2196-7-1**] 05:33AM BLOOD WBC-2.5* RBC-2.50* Hgb-6.2* Hct-20.3* MCV-81* MCH-24.7* MCHC-30.3* RDW-20.5* Plt Ct-135* [**2196-6-30**] 12:18PM BLOOD WBC-2.9* RBC-2.72* Hgb-6.7* Hct-22.2* MCV-81* MCH-24.6* MCHC-30.2* RDW-20.7* Plt Ct-142* [**2196-6-29**] 04:01PM BLOOD WBC-3.3* RBC-2.76* Hgb-6.8* Hct-22.3* MCV-81* MCH-24.6* MCHC-30.4* RDW-22.1* Plt Ct-134* [**2196-6-29**] 06:25AM BLOOD WBC-2.8* RBC-2.54* Hgb-6.3* Hct-21.0* MCV-82 MCH-24.8* MCHC-30.1* RDW-20.7* Plt Ct-109* [**2196-6-28**] 04:32PM BLOOD WBC-3.6* RBC-2.95* Hgb-7.4* Hct-24.0* MCV-81* MCH-25.1* MCHC-31.0 RDW-21.9* Plt Ct-150# [**2196-6-27**] 05:58AM BLOOD WBC-3.8* RBC-2.64* Hgb-6.5* Hct-21.7* MCV-82 MCH-24.7* MCHC-30.0* RDW-21.5* Plt Ct-93* [**2196-6-26**] 12:00PM BLOOD WBC-4.7 RBC-2.94*# Hgb-7.4*# Hct-23.9*# MCV-81* MCH-25.2* MCHC-31.0 RDW-22.6* Plt Ct-136*# [**2196-6-26**] 03:04AM BLOOD WBC-3.5*# RBC-4.65# Hgb-11.3*# Hct-37.9# MCV-81* MCH-24.3* MCHC-29.9* RDW-22.4* Plt Ct-78* [**2196-7-8**] 06:10AM BLOOD Neuts-66 Bands-1 Lymphs-22 Monos-8 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 Plasma-1* [**2196-6-26**] 03:04AM BLOOD Neuts-68.4 Lymphs-24.3 Monos-6.3 Eos-0.6 Baso-0.3 [**2196-7-14**] 05:50AM BLOOD PT-11.3 PTT-86.0* INR(PT)-1.0 [**2196-7-3**] 06:17AM BLOOD Fibrino-347 [**2196-7-5**] 01:12AM BLOOD ESR-58* [**2196-6-26**] 03:04AM BLOOD ESR-20 [**2196-7-2**] 09:20AM BLOOD Ret Aut-3.3* [**2196-7-14**] 05:50AM BLOOD Glucose-89 UreaN-12 Creat-0.5 Na-137 K-3.6 Cl-103 HCO3-26 AnGap-12 [**2196-7-13**] 05:52AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-137 K-3.8 Cl-105 HCO3-25 AnGap-11 [**2196-7-12**] 04:26AM BLOOD ALT-16 AST-23 AlkPhos-75 TotBili-0.2 [**2196-7-11**] 08:00AM BLOOD ALT-11 AST-18 AlkPhos-69 TotBili-0.3 [**2196-7-6**] 06:26AM BLOOD ALT-23 AST-17 AlkPhos-89 TotBili-0.8 [**2196-7-5**] 01:12AM BLOOD ALT-32 AST-26 AlkPhos-89 TotBili-0.9 DirBili-0.3 IndBili-0.6 [**2196-7-3**] 06:17AM BLOOD ALT-47* AST-43* AlkPhos-104 TotBili-1.0 [**2196-7-2**] 09:20AM BLOOD ALT-61* AST-52* AlkPhos-112* TotBili-0.8 [**2196-7-1**] 05:33AM BLOOD ALT-58* AST-47* AlkPhos-108* TotBili-0.6 [**2196-6-30**] 12:18PM BLOOD ALT-62* AST-42* AlkPhos-117* TotBili-0.7 [**2196-6-29**] 06:25AM BLOOD ALT-77* AST-53* AlkPhos-129* TotBili-0.7 [**2196-6-28**] 04:32PM BLOOD ALT-93* AST-63* AlkPhos-135* TotBili-0.8 [**2196-6-27**] 12:54PM BLOOD ALT-105* AST-82* AlkPhos-139* TotBili-0.8 [**2196-6-26**] 03:04AM BLOOD ALT-102* AST-88* AlkPhos-133* Amylase-48 TotBili-0.9 [**2196-7-12**] 04:26AM BLOOD Lipase-41 [**2196-7-3**] 06:17AM BLOOD Lipase-11 [**2196-6-26**] 03:04AM BLOOD Lipase-29 [**2196-7-2**] 09:20AM BLOOD calTIBC-545* Ferritn-43 TRF-419* [**2196-6-27**] 12:54PM BLOOD VitB12-279 [**2196-7-2**] 09:20AM BLOOD TSH-0.21* [**2196-7-4**] 04:40AM BLOOD T4-6.4 [**2196-7-5**] 01:12AM BLOOD ANCA-NEGATIVE B [**2196-7-5**] 01:12AM BLOOD [**Doctor First Name **]-NEGATIVE [**2196-7-5**] 01:12AM BLOOD CRP-66.9* [**2196-6-26**] 03:04AM BLOOD CRP-13.5* [**2196-7-5**] 01:12AM BLOOD C3-137 C4-38 [**2196-6-26**] 03:04AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test Name . [**6-26**] CXR: IMPRESSION: Persistent unusual medial course of right internal jugular central venous catheter, which courses more medially than a previous right internal jugular venous catheter present on prior chest x-rays and CT scans in [**2196-5-15**]. Position on lateral view excludes internal mammary vein location and suggests a central venous location, but inadvertent arterial placement cannot be excluded. . KUB [**6-27**]: IMPRESSION: No evidence of obstruction or ileus. . [**6-27**] MRI chest: IMPRESSION: 1. Multifocal areas of thrombosis within the venous system of the upper extremities bilaterally including near total occlusion of the SVC and left brachiocephalic vein by thrombus, and non-occlusive thrombus in the right internal jugular and at the junction of the right internal jugular and subclavian veins on the right. Left internal jugular vein is completely occluded, with numerous collaterals visualized. 2. 2.5 x 1.6 cm retropharyngeal fluid collection in the cervical spine, concerning for reaccumulation of the patient's prior abscess. Re-evaluation with dedicated MR of the neck with contrast is recommended. 3. 3.3 x 1.9 cm subcutaneous hyperintense area relative to skeletal muscle on [**Name (NI) 91308**] images in the region of the prior placement of the port, presumed to be a hematoma. The pertinent findings were discussed Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the covering physician, [**Name10 (NameIs) **] telephone at 5:30 p.m. on [**2196-6-27**]. . [**6-28**] RUQ u/s: IMPRESSION: No evidence of intra- or extra-hepatic ductal dilatation to suggest cholestasis. . [**6-29**] replacement of TLC: IMPRESSION: 1. Uncomplicated SVC gram demonstrating near-complete occlusion of the mid to lower SVC, non-occlusive thrombus extending into the left brachiocephalic vein, multiple venous collaterals. 2. Uncomplicated replacement of the old 7 French 15 cm triple-lumen central venous catheter with a new 7 French 20-cm triple-lumen central venous catheter, with its tip in the upper right atrium. Catheter is ready for use. . [**7-4**] MRI c-spine: IMPRESSION: Study is quite limited by motion artifact, but demonstrates: 1. Ill-defined fusiform fluid/edema in the prevertebral space, extending from the C1 through C7 level. This is, overall, less marked than on the previous MR study of [**2196-5-17**] and demonstrates no definite rim- or internal enhancement to suggest true collection or abscess. 2. No finding to suggest spondylodiscitis or its complications, such as epidural phlegmon or abscess. 3. Normal cervical spinal cord caliber and intrinsic signal intensity. . COMMENT: These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Hospital1 18**] hospitalist, covering for Dr. [**Last Name (STitle) 776**], the requesting clinician) via telephone, at 1745 H on [**2196-7-3**]. Apparently, the patient has known "SVC syndrome" with documented venous thrombosis, over the entire time period dating to early [**Month (only) 547**], which likely accounts for the persistent retropharyngeal/prevertebral edema. As discussed, in this setting, the role of continued dedicated imaging of the cervical spine and soft tissues is unclear. . CT abd/pelvis [**7-3**]: IMPRESSION: 1. No evidence of obstruction or abscess. Stranding around ileostomy is unchanged since [**2196-5-29**] and is likely chronic. 2. Simple free fluid within the pelvis. 3. Hypodensity within the right lobe of the liver, too small to characterize, most likely a cyst. 4. Multiple collateral vessels in the right subcutaneous tissues which correlates with patient's history of known bilateral IJ and subclavian occlusion . [**7-5**] ECHO: The left atrium is normal in size. 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%). 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 stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. No vegetation seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [**2196-6-14**], findings are similar. . [**7-7**] R/IJ: CONCLUSION: 1. Placement of a triple-lumen central venous line into the right atrium over the guide wire through the existing access in the right internal jugular vein. 2. The line is ready to use. . [**7-10**] KUB: Bowel gas pattern is unremarkable. There is air and stool seen throughout colon. No dilated loops of small bowel are identified. Bony structures are intact. There is no free intra-abdominal gas seen on the left side downdecubitus radiographs. . [**7-11**] MRI necK: IMPRESSION: 1. Ill-defined fluid/edema in the prevertebral spaces from C1-C7 is significantly decreased since the prior exam. No evidence of abnormal enhancement. 2. Stable degenerative changes of the cervical spine, and mild downward displacement of the cerebellar tonsils. . [**2196-7-9**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-7-9**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-7-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-7-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2196-7-7**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2196-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROBACTER CLOACAE COMPLEX, ENTEROBACTER CLOACAE COMPLEX}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT [**2196-7-5**] 9:50 am BLOOD CULTURE Source: Line-IJ #2. **FINAL REPORT [**2196-7-9**]** Blood Culture, Routine (Final [**2196-7-9**]): Ertapenem Sensitivity testing [**First Name8 (NamePattern2) **] [**Last Name (un) **] PADIVAL #[**Numeric Identifier 19455**]. ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. 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. Ertapenem SENSITIVE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROBACTER CLOACAE COMPLEX. SECOND MORPHOLOGY. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. 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. Ertapenem SENSITIVE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | ENTEROBACTER CLOACAE COMPLEX | | CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2196-7-4**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2196-7-3**] STOOL C. difficile DNA amplification assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL INPATIENT [**2196-7-3**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROBACTER CLOACAE COMPLEX, ENTEROBACTER CLOACAE COMPLEX}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL INPATIENT [**2196-7-3**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROBACTER CLOACAE COMPLEX, ENTEROBACTER CLOACAE COMPLEX}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL INPATIENT [**2196-7-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2196-7-2**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROBACTER CLOACAE COMPLEX, ENTEROBACTER CLOACAE COMPLEX}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL INPATIENT [**2196-6-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2196-6-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2196-6-26**] URINE URINE CULTURE-FINAL INPATIENT [**2196-6-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2196-6-25**] STOOL C. difficile DNA amplification assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL; OVA + PARASITES-FINAL Brief Hospital Course: ## Venous thrombosis/SVC syndrome: MRV showed large amount of clot burden in upper central venous system with total occlusion of left IJ and subtotal occlusion of the right IJ and SVC. She was on Lovenox at home and was transitioned to a heparin gtt this admission. Given her difficult access, a right IJ was placed by the MICU attending on the floor prior to transfer. This was changed for a longer 20cm line by IR while in the [**Hospital Unit Name 153**] and was functioning well at the time of transfer. The etiology of her extensive clotting was thought to be a combination of hypercoagulability from her Crohn's, endothelial damage from her multiple prior ports and potentially a familial thrombophilia. Heme/onc was consulted regarding her extensive thrombus and recommended continuing heparin drip while in house with plans to transition to coumadin WHILE BRIDGING FOR A MINIMUM OF 48HRS. In addition, should the patient become subtherapeutic ever, she WILL REQUIRE REBRIDGING WITH IV HEPARIN OR LOVENOX AT 100MG [**Hospital1 **]. IR is planning to take her for angioplasty, kissing stent placement, and port placement for a planned admission to [**Hospital1 18**] the day after her IV antibiotic course is complete (see below). The vascular service was consulted, however, the team felt that there was no current indication for thrombectomy and no procedures should be performed until either the patient has been line free x1 month or at least until after her abx course is complete. She will need to be transitioned back to either lovenox or IV heparin prior to her IR admission. As all of the thromboses have been line-related, the Hematology service did not recommend ordering a hypercoagulable work-up, although this may be considered at a later date given the history of thrombophilia in her mother and brother. The hematology service will be following up with the patient in about 3weeks after discharge. -STARTING COUMADIN 5MG ON [**7-14**]. SHE HAS BEEN ON A CONTINUOUS IV HEPARIN INFUSION. SHE WILL NEED TO BE BRIDGED FOR AT LEAST 48HRS WHILE THERAPEUTIC. SHOULD ABSORPTION OR RECURRENT N/V BECOME AN ISSUE OR PT IS TO BECOME SUBTHERAPEUTIC, SHE WILL NEED TO BE BRIDGED WITH IV HEPARIN OR LOVENOX 100MG [**Hospital1 **]. SHOULD ABSORPTION BECOME A RECURRENT ISSUE, PT SHOULD THEN BE PLACED ON LOVENOX 100MG [**Hospital1 **] WITH A FACTOR 10A LEVEL TO BE CHECKED AFTER 3RD DOSE. . ## access issues-pt has very complicated vascular access. See above. There was much debate among the vascular service, IR, [**First Name4 (NamePattern1) 8817**] [**Last Name (NamePattern1) **] (line specialist), and ID as what would be the best approach for the patient. There was some consideration of removing the pt's R.IJ (that has been changed over a wire twice) and placing temporary, possibly tunneled, groin access. However, this was felt to place the patient at high risk for infection given her prior infections and prolonged planned course of IV abx. In addition, should she clot groin access, she will be left in a difficult place as she no longer has any upper extremity access (other than R.IJ above).Therefore, it was decided to keep her current temporary R.IJ in place while continuing antibiotic therapy and anticoagulation. Then, the patient is to return for a scheduled admission to [**Hospital1 18**] the day after her antibiotics are complete ([**2196-8-5**] or [**2196-8-8**]) for an IR procedure to place kissing stents, angioplasty and for port placement. . ## High-grade Enterobacter bacteremia: Patient developed worsening abdominal pain and fevers. Blood cultures grew pan-sensitive Enterobacter. Started on Zosyn but was persistently bacteremic. Thus, the ID service recommended switching to Meropenem for better clot penetration as there was concern of superinfected thrombosis. (there is no plan for thrombectomy/intervention at this time) At that time, the original internal jugular catheter was exchanged over a wire. THis was then performed a second time. The first negative blood culture after these measures were taken was [**2196-7-8**]. Surface ECHO was negative for vegetations. CT abdomen was unremarkable for intraabdominal fluid collection to suggest a GI source. The ID team followed the patient closely during admission. The ID team has recommended 4 weeks of IV meropenem. Pt should have weekly safetly labs (cbc with diff, chem 7, LFTs) while on meropenem. Pt should have a repeat blood culture with gram stain the day the antibiotics are to be completed. Last day of therapy for 4 week course is [**2196-8-5**]. PT WILL NEED REPEAT BCX AND GRAM STAIN DAY ABX COURSE IS COMPLETE. ## Retropharyngeal fluid collection on MRI: Concern for abscess. ENT/IR felt this was a reaccumulation of a previous hematoma from port placement and thought that instrumentation to that area could introduce infection. With no fevers/leukocytosis it was decided to have repeat neck imaging which showed a decrease in the size of the fluid collection. ## Elevated LFTs: RUQ was unremarkable and her LFTs were stable, it was thought to be [**3-17**] her recent antifungals. Hep B showed immunization, Hep C was negative. ## Stomal pain/increased stool output: She had an extensive work-up for her stoma pain and high ostomy output last admission, all of which was negative, with no evidence for an active Crohn's flare. Surgery was consulted but did not feel that an ostomy take down was indicated at this time. Pt is under the assumption that she can be considered for take down after her acute medical issues have resolved. GI was following and did not have any further recommendations. -pain regimen includes gabapentin, lidocaine patch, PO dilaudid prn. Of note, pt reports pain at times despite the regimen. There was concern at one point during her hospitalization that she was tampering with her infusion of IV dilaudid, as they are hung in a minibag and not pushed. She has periods of "Stoma" pain with n/v that seem to be cyclical in nature and last for a few days then resolve without intervention. During periods of quiescence she does not require any pain medication. Zofran and compazine were given for nausea. Pt was started on gabapentin and a lidocaine patch. . ## Prior [**Female First Name (un) 564**] fungemia, Staph epidermidis bacteremia: per discharge summary patient was to continue linezolid for 10 days after port removal which was [**2196-6-24**] (port removed [**2196-6-15**]) and fluconazole for 14 days after port removal until [**2196-6-28**]. She was switched to Micafungin through the end of her course given LFT abnormalities. Courses complete. ## Anemia: microcytic, hct within baseline, no brbpr or melena but guaiac + stool at [**Hospital1 **] per patient. Hct initially 37, but dropped to 23 with hydration which was previous baseline. Given 1U PRBC transfusion for Hct 19 but not actively bleeding at that time. HCT was 22.3 on the day of DC. Further work up can be pursued in the outpatient setting. ## Sinus tach: HR mostly in the 90-110s, which is chronic and likely due to her extensive clot burden. Resolved. . #hypercoagulability-recurrent DVT-catheter associated. Vasculitis thought to be unlikely given normal ANCA, [**Doctor First Name **], complement levels. Medications on Admission: enoxaparin 80mg q12h cholecalciferol 1000 units daily loperamide 2mg tid zofran 4mg q8h prn fluconazole 400mg q24h Discharge Medications: 1. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 21 days: 4 WEEK COURSE. DAY 1= [**7-8**]. lAST DAY [**8-5**]. 2. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 3. IV HEPARIN IV HEPARIN CONTINUOUS INFUSION UNTIL INR THERAPEUTIC >48HRS. -CURRENT RATE 1300 UNITS/HR 4. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for flush. 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for severe pain. 7. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: DAY 1=[**7-14**]. 12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 14. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Superior vena cava syndrome Upper extremity deep vein thrombosis Enterobacter bacteremia Hypercoagulability stoma pain . Chronic reported history of crohns. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with worsening abdominal pain and evaluated by surgery and gastroenterology. There were no abnormalities noted, including no evidence of colitis. Your pain is thought to be related to your stoma. For this, you should follow up with the surgical team after your current treatment for clot and infection. During the hospitalization you had worsening of your known blood clots and had to have a new catheter placed for IV access. You were started on IV heparin and coumadin and will need to take either coumadin or lovenox at a minimum of 100mg twice a day for life. You also were found to have bacteria in your blood, developing during the hospitalization. You were treated with IV antibiotics and will need to continue this upon discharge for at least 4 week's time. Your last day of therapy will be [**2196-8-5**]. . Medication changes: 1.start coumadin and continue IV heparin 2.start IV meropenem 3.start gabapentin for pain Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2196-8-12**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], 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: SURGICAL SPECIALTIES When: THURSDAY [**2196-7-21**] at 10:15 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 11714**], MD [**Telephone/Fax (1) 160**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: THURSDAY [**2196-8-4**] at 1:45 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2196-8-12**] at 9:30 AM With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . INTERVENTIONAL RADIOLOGY-Phone: ([**Telephone/Fax (1) 110643**] . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]-Office Phone: ([**Telephone/Fax (1) 110644**] PLEASE CALL FOR ANY QUESTIONS OR ISSUES RELATED TO IV ACCESS AND SCHEDULING UPCOMING PROCEDURES. . PLEASE CALL YOUR PCP FOR AN APPOINTMENT UPON DISCHARGE FROM REHAB [**Last Name (LF) 3576**],[**First Name3 (LF) 3577**] R. [**Telephone/Fax (1) 3581**] . PLEASE CALL THE INFECTIOUS DISEASES DEPARTMENT Phone: ([**Telephone/Fax (1) 4170**] FOR ANY ISSUES OR QUESTIONS REGARDING YOUR ANTIBIOTIC TREATMENT.

[ "276.1", "276.8", "787.91", "V58.61", "V44.2", "569.69", "285.29", "V12.51", "995.91", "284.12", "453.76", "285.9", "555.9", "459.2", "998.12", "038.49", "E879.8", "112.5", "V45.72", "996.74", "453.75", "V26.51", "286.9", "V12.55", "453.77", "E930.8", "999.32", "276.2", "427.89", "790.6" ]

icd9cm

[ [ [] ] ]

[ "88.51", "38.97" ]

icd9pcs

[ [ [] ] ]

28671, 28744

19797, 27039

367, 520

28945, 28945

4862, 19774

30067, 31923

4127, 4169

27205, 28648

28765, 28924

27065, 27182

29096, 29932

4184, 4843

29952, 30044

271, 329

548, 3602

28960, 29072

3624, 3933

3949, 4111

29,225

197,166

31786

Discharge summary

report

Admission Date: [**2186-10-4**] Discharge Date: [**2186-10-9**] Date of Birth: [**2129-12-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Decreased exercise tolerance Major Surgical or Invasive Procedure: [**2186-10-4**] Four Vessel CABG(LIMA to LAD, SVG to PDA, SVG to OM with vein to vein graft to diagonal artery) History of Present Illness: Mr. [**Known lastname **] is a 56 year old male with strong family history of premature coronary artery disease and several additional cardiac risk factors. He has undergone surveillance stress testing in the past with normal results. Approximately one month ago, he began to notice a decrease in exercise tolerance. Subsequent stress test was abnormal. He therefore underwent cardiac cathterization on [**2186-9-28**] which revealed severe three vessel coronary artery disease. LVEDP was 23mmHg and LV gram showed an EF of 52% with mild inferior hypokinesis. Based upon the above, he was referred for surgical revascularization. Past Medical History: Coronary artery disease Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Gastroesophogeal Reflux Disease Knee Arthritis s/p right knee surgery Hemorrhoids Seasonal Allergies Social History: Denies tobacco history. Married with two children. Works as a bus driver. Family History: Brother died from MI at age 37. Father had angina but died of cancer in his 50's. Physical Exam: General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2186-10-4**] INTRAOP TEE PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**2186-10-4**] INTRAOP TEE POST-BYPASS: 1. Biventricular function is maintained (LVEF 50-55%). 2. Aortic contours are intact post-decannulaton. CHEST (PA & LAT) [**2186-10-9**] 8:16 AM There has been previous median sternotomy and coronary artery bypass surgery. Postoperative mediastinal widening has improved with only minimal residual widening remaining compared to the preoperative radiograph. Very small left apical pneumothorax is present and is in retrospect unchanged from the previous study but was more difficult to identify prospectively due to portable technique on the previous exam. Bibasilar retrocardiac areas of atelectasis are present, with slight improvement in the left retrocardiac area. Bilateral small pleural effusions are present, left greater than right. On the lateral view, a small focus of gas is present in the retrosternal region, and is likely related to recent surgery. IMPRESSION: 1. Very small left apical pneumothorax. 2. Bibasilar atelectasis and small pleural effusions, left greater than right. [**2186-10-9**] 07:10AM BLOOD WBC-6.4 RBC-3.58* Hgb-10.9* Hct-31.7* MCV-89 MCH-30.4 MCHC-34.2 RDW-13.4 Plt Ct-294# [**2186-10-7**] 01:20PM BLOOD WBC-7.0 RBC-3.42* Hgb-10.4* Hct-30.2* MCV-88 MCH-30.5 MCHC-34.5 RDW-13.3 Plt Ct-193# [**2186-10-9**] 07:10AM BLOOD Plt Ct-294# [**2186-10-7**] 01:20PM BLOOD Plt Ct-193# [**2186-10-5**] 02:19AM BLOOD PT-12.9 PTT-30.0 INR(PT)-1.1 [**2186-10-9**] 07:10AM BLOOD Glucose-96 UreaN-19 Creat-1.0 Na-144 K-4.3 Cl-106 HCO3-30 AnGap-12 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent four vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. He developed atrial fibrillation on postoperative day two and was treated with an increase in his beta blockade and amiodarone. He remained in a sinus rhythm and was ready for dicharge home on POD #5. Medications on Admission: Aspirin 81 qd, Lotrel 10/20 qd, Crestor 10 qd, Metoprolol Succinate 25 qd, Vitamin E 400 IU qd, Viagra prn, Zantac prn, Fexofenadine prn, Motrin prn, Flexeril prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 mg [**Hospital1 **] x 3 day then 400 mg daily x 1 week, then 200 mg ongoing until discontinued by Dr. [**Last Name (STitle) 4469**]. Disp:*120 Tablet(s)* Refills:*0* 7. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary artery disease - s/p CABG Postop Atrial Fibrillation Hypertension Hypercholesterolemia History of possible lacunar infarction [**2179**] Discharge Condition: Good Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-16**] weeks, call for appt Dr. [**Last Name (STitle) 4469**] in [**1-14**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-16**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 4469**] in [**1-14**] weeks, call for appt [**Telephone/Fax (1) 4475**] Wound check appointment - please schedule with RN [**Telephone/Fax (1) 3633**] Completed by:[**2186-10-9**]

[ "530.81", "V17.3", "427.31", "V15.09", "272.0", "401.9", "414.01", "411.1", "455.0", "V12.59" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6159, 6210

4035, 4684

350, 464

6400, 6413

1898, 4012

6749, 7185

1463, 1546

4897, 6136

6231, 6379

4710, 4874

6437, 6726

1561, 1879

282, 312

492, 1123

1145, 1356

1372, 1447

75,824

140,160

4580

Discharge summary

report

Admission Date: [**2146-4-25**] Discharge Date: [**2146-4-30**] Service: MEDICINE Allergies: Levsin / Shellfish Attending:[**First Name3 (LF) 2763**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 19463**] is an 88 year old gentleman with a past medical history significant for metastatic SCC with unknown primary, CAD, AS, AF on coumadin, and a recent inguinal surgery complicated by Pseudomonal and Enterococcal seroma on pip/tazo and NSTEMI with newly depressed LVEF to 35% now admitted for hypoxemic respiratory distress. The patient was diagnosted with a pneumonia on [**4-22**] by CXR after developing fever and dyspnea while at rehab treated with vancomycin, azithro, and continued on pip/tazo. This morning, he was noted to be febrile at [**Doctor Last Name **] house to 101.3 and hypoxemic with SaO2 88-92% NRB. Over the last several days his SBPs were running 80s to 90s. He received 40 mg lasix, and was transferred to [**Hospital1 18**] for further evaluation. . Of note, the patient was admitted to [**Hospital1 18**] [**Date range (1) 19464**] under Surgery, after initially underoing right inguinal-femoral lymphadenectomy complicated by seroma formation. At that time, he was transferred to the ICU for hypotension, and was also noted to have an atrial tachycardia and troponinemia felt to be an NSTEMI with peak CK 567, MB 49, TnT 2.23. He has undergone IR drainage and drain placement, with serial cultures demonstrating Pseudomonas and Enterococcus, with plan for prolonged pip/tazo therapy with ID follow-up. . In the [**Hospital1 18**] ED, initial VS 98.1, 88, 101/57, 24 89%NRB. Labs were notable for WBC 16, INR 3.8, and creatinine 1.7. A CXR demonstrated bilateral airspace opacities, he received cefepime, and was briefly placed on NIPPV. He was then admitted to the MICU for further management. . Currently, the patient continues to complain of dyspnea. He denies any CP, palpitations, orthopnea, PND. Past Medical History: PMH: - metastatic squamous cell carcinoma (unknown primary lesion) - CAD s/p MI (remote), EF 50% - Aortic stenosis - Afib on coumadin - HTN - BPH - L retinal artery occlusion in [**2134**] (secondary to emoblic disease) PSH: - R inguinal lymph node dissection ([**2146-2-10**]) - L inguinal hernia repair ([**2135**]) Social History: nonsmoker, lives with wife, no EtOH Family History: CAD in multiple family members Physical Exam: VS: 98 83 104/53 28 95%NRB Gen: Mild respiratory distress HEENT: NRB in place CV: Nl S1+S2, II/VI systolic murmur loudest at the base. JVP ~8-10 cm Pulm: Diffuse bilateral rales Abd: S/NT/ND +bs Ext: 3+ pitting edema, chronic per wife. Neuro: AOx3. CN non-focal Groin: Right groin with open wound, no purulence. Skin: Right PICC in place. Pertinent Results: [**2146-4-25**] 10:30AM cTropnT-0.39* [**2146-4-25**] 10:39AM LACTATE-1.4 [**2146-4-25**] 11:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2146-4-25**] 10:30AM WBC-16.3*# RBC-3.35* HGB-10.5* HCT-30.4* MCV-91 MCH-31.4 MCHC-34.6 RDW-15.3 [**2146-4-25**] 10:30AM CK-MB-3 proBNP-[**Numeric Identifier 19465**]* Brief Hospital Course: addmitted [**4-25**] with hypoxia and 3/29/11tolerating NRB mask with troponin bump from 0.39 > 0.47 > 0.63 > 0.69, but flat CK (cycling CE after likely tachycardia-induced anterior EKG repolarization abnormalities). Outpatient cardiologist recomended continuation of previous cardiac regimen. [**4-27**] broadened to vanco/meropenem due to worsening pneumonia on CXR per ID recs. Persistenly hypoxic, on BiPAP intermittently and NRB, gas showing P02 60. Lasix for presumed element of CHF> goal negative 1 liter. [**2146-4-28**] worsening CXR with possible ARDS pt DNR/DNI after family meeting. 6L negative through hospital course to this point. [**2146-4-29**] pt made CMO after conversation with patient, his wife, and PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Abx stopped, written for morphine, increased dose overnight given increasing discomfort/work of breathing. Pt expired [**4-30**] in morning after cardiac arrest while recieving morphine for comfort. Medications on Admission: - Dexamethasone 4mg PO Q6H - Furosemide 60mg PO daily - Gabapentin 100 mg PO TID - ASA 325 mg PO daily, stopped [**4-20**] - Insulin glargine 20 units SQ HS - SSI - Sinemet 25/100 PO TID - Albuterol nebs PRN - Ferrous sulfate 325 mg PO daily - Procrit - Calcitonin - MVI - Vit B12 - Vit B1 - Thalomide - Oxycodone - Vicodin - Trazadone - Miralax - Colace - Senna - Bisacodyl Discharge Disposition: Expired Discharge Diagnosis: ARDS Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2146-4-30**]

[ "041.7", "518.81", "424.1", "998.51", "199.1", "410.72", "403.90", "196.5", "428.21", "427.31", "600.00", "414.01", "585.9", "285.21", "428.0", "E878.8", "V58.61", "486", "041.04" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4677, 4686

3265, 4251

234, 240

4734, 4743

2857, 3242

4799, 4929

2449, 2482

4707, 4713

4277, 4654

4767, 4776

2497, 2838

187, 196

268, 2027

2049, 2379

2395, 2433

17,837

184,230

3019+3039

Discharge summary

report+report

Admission Date: [**2116-4-21**] Discharge Date: [**2116-4-29**] Date of Birth: [**2066-10-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: resp distress, altered mental status Major Surgical or Invasive Procedure: intubation paracentesis thoracentesis central line History of Present Illness: 49M w/ HCV cirrhosis c/b refractory ascites, presumed hydrothorax and hepato-renal syndrome, recently left AMA after evaluation for above issues, now being admitted to [**Hospital Unit Name 153**] for resp distress, hyperkalemia, and worsening renal dysfunction. Review of [**Hospital Unit Name **] indicates that pt hospitalized in [**2-3**] with new onset ascites and presumed to have HCV cirrhosis (based on immunology/imaging). Initiated on diuretic therapy with aldactone and lasix. Readmitted in early [**4-4**] with recurrent ascites and also increased shortness of breath. Hospital course notable for challenging interactions between patient and healthcare providers. During course, ultimately did undergo 2 large volume paracentesis reported to be consistent with chylous ascites. Peritoneal cultures were negative. Also found w/ large right sided pleural effusion for which underwent thoracentesis on [**4-6**] - analysis suggested transudative process and post-procedure, pt transferred to MICU for hypoxia, sedation thought to be med related. During the later portion of course, noted to have rapidly progressive deterioration in renal dysfunction with creatinine peaking at 5.6 on [**4-14**]. Treated with octreotide and midodrine for presumed hepato-renal syndrome. Also noted to have increased hyponatremia to 119 from admission value of 132. Apparently, there had been discussions about consideration of TIPS but pt had refused and ultimately left AMA on [**4-14**]. Per [**Name (NI) **], pt had been seen in clinic on [**4-17**] with requests for methodone refills but had declined to return to ED as advised. Continued to take 40 mg qd methadone from personal stock. Over the last several days, noted to have increased confusion and lethargy per brother at home. As per report, pt. lay on couch most of the day, barely eating, minimally communicative, growing more disoriented. On day of admission, pt. had not had a BM in > 24 hours and was disoriented to time. Did not recognize surroundings. Noted to have some respiratory distress and EMS called. In [**Name (NI) **], pt. c vitals: 100/70, 60, 94.6, 33. Received naloxone with some response. Intubated for airway protection. Noted to have K of 7.2, Cr 6.9; treated emergently with calcium, insulin, bicarb, dextrose, kayexelate. Renal consulted; thought given to hepatorenal vs. prerenal [**1-2**] intravascular volume depletion; received IVF (4L NS). Repeat K 6.3 and decision made to defer HD. Received levofloxacin/metronidazole for possible SBP and ? asp. PNA on CXR. Also noted to have complete white out of R lung on CXR. Admitted to [**Hospital Unit Name 153**] intubated on propofol. Had hypotension on higher doses of propofol in ED/transport and started on levophed. Past Medical History: 1. presumed HCV cirrhosis c/b massive ascites (VL 155K [**2-3**]) 2. known grade 1 varicies on egd [**2-3**] 3. presumed hepatorenal syndrome 4. thrombocytopenia (low 100's) 5. ivda (heroin) 6. transudative right pleural effusion 7. cholithiasis on abd ct 8. hiatal hernia 9. panic attacks 10. hyponatremia Social History: lives w/ mother in [**Name2 (NI) **], remote heavy EtOH, quit 10 y/a, recent iv heroin (?date) Family History: Mother is living, 86 years old, with hypertension. He has a sister and a brother in good health. Physical Exam: VS - in ICU: 97.6, 98/60, 86, 15, 100% on A/C - 500*12, 0.8*5 HEENT - sclerae muddy, ETT in place. scleral injection. LUNGS - R c decreased BS and dullness to percussion. L clear CHEST - +gynecomastia, RRR, S1, S2, no rmg ABD - distended, + fluid wave, NT, BS+ EXT - denuded of hair distally. no edema. wwp NEURO - no clonus. difficult to assess for asterixis. Pertinent Results: [**2116-4-21**] WBC-7.6 RBC-4.53* Hgb-15.2 Hct-42.5 MCV-94 MCH-33.5* MCHC-35.6* RDW-17.2* Plt Ct-159 [**2116-4-21**] PT-16.6* PTT-34.7 INR(PT)-1.5* [**2116-4-21**] Glucose-58* UreaN-112* Creat-6.9*# Na-119* K-7.3* Cl-84* HCO3-19* AnGap-23* [**2116-4-21**] ALT-49* AST-67* AlkPhos-129* Amylase-509* TotBili-2.4* [**2116-4-25**] TotBili-1.0 [**2116-4-21**] Lipase-517* [**2116-4-22**] Lipase-275* [**2116-4-23**] Lipase-101* [**2116-4-21**] TotProt-7.8 Calcium-8.3* Phos-8.2*# Mg-3.3* [**2116-4-25**] Calcium-8.0* Phos-8.7* Mg-3.4* [**2116-4-23**] calTIBC-143* Ferritn-212 TRF-110* [**2116-4-21**] Ammonia-84* [**2116-4-21**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2116-4-21**] Lactate-6.1* K-5.9* Brief Hospital Course: A/P: 49 yo M c hx hepatits C cirrhosis admitted with worsening renal failure, hyperkalemia, ascites, hypotension, altered mental status. Pt was managed aggressively in ICU upon admission but his clinical status continued to deteriorate, most noteably acute renal failure from hepatorenal syndrome despite attempts to correct this. Given overall grave prognosis, after a long discussion between the ICU team and the patient's family (brother [**Name (NI) 1312**] was health care proxy), patient was made 'comfort measures only' and transferred to a private the medicine floor. Patient was made comfortable with medications and passed away on [**2116-4-29**] with his brother at the bedside. . 1. Acute Renal Failure - Secondary to worsening hepatorenal syndrome and pre-renal azotemia. Pt was hydrated for CVP greater than 12 without improvement in Cr. Renal service consulted with whom discussions of dialysis were approached. [**Name (NI) 14397**] Pt's end stage liver disease and poor prognosis, hemodialysis not ideal. After discussion with family and involved team members; decision was made not to proceed with dialysis. Cr remained stable around 6 without concominant electrolyte abnl. Given grave overall prognosis, patient was made 'comfort measures only' and no further electrolytes were checked. . 2. Hyperkalemia - secondary to worsening renal failure. Improved with kayexelate/D50/Insulin and cell mb stabilized with Ca++. Given grave overall prognosis, patient was made 'comfort measures only' and no further electrolytes were checked. . 3. Hypotension - Multifactoprial including decreased intravascualar volume and sedation. Started on Levophed/Vasopressin which was titrated off over several days. Afterwards remained hemodynamically stable. Given grave overall prognosis, patient was made 'comfort measures only.' . 4. Liver failure/Ascites - Likely had worsening of primary liver disease. Child class C, MELD 28. Pt was started on lactulose for HE. Liver team followed him closely. Pt was not a TIPS candidate and has refused this in the past. Also not a candidate for liver transplant. Complicated by ascites and associated pleural effusion. S/P large volume thoracentesis with subsequent reacummulation. . 5. Hyponatremia - Likely [**1-2**] hypervolemic hyponatremia from liver disease. . 6. Code: Pt DNR/DNI. After long discussion with family, PCP, [**Name10 (NameIs) **] work and consultants decision made to concentrate on comfort. Patient passed away on [**2116-4-29**]. Medications on Admission: Meds on Transfer: Lorazepam 1-2 mg IV Q4H:PRN agitation Midazolam HCl 2-4 mg/hr IV DRIP TITRATE TO comfort Fentanyl Patch 50 mcg/hr TP Q72H Discharge Medications: none; expired Discharge Disposition: Expired Discharge Diagnosis: acute renal failure liver failure / cirrhosis hepatic encephalopathy respiratory failure requiring intubation hyperkalemia hyponatremia Discharge Condition: not applicable. Patient expired. Discharge Instructions: not applicable. Patient expired. Followup Instructions: not applicable. Patient expired. Completed by:[**2116-4-29**] Admission Date: [**2116-4-21**] Discharge Date: [**2116-4-29**] Date of Birth: [**2066-10-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: resp distress, altered mental status Major Surgical or Invasive Procedure: intubation paracentesis thoracentesis central line History of Present Illness: 49M w/ HCV cirrhosis c/b refractory ascites, presumed hydrothorax and hepato-renal syndrome, recently left AMA after evaluation for above issues, now being admitted to [**Hospital Unit Name 153**] for resp distress, hyperkalemia, and worsening renal dysfunction. Review of [**Hospital Unit Name **] indicates that pt hospitalized in [**2-3**] with new onset ascites and presumed to have HCV cirrhosis (based on immunology/imaging). Initiated on diuretic therapy with aldactone and lasix. Readmitted in early [**4-4**] with recurrent ascites and also increased shortness of breath. Hospital course notable for challenging interactions between patient and healthcare providers. During course, ultimately did undergo 2 large volume paracentesis reported to be consistent with chylous ascites. Peritoneal cultures were negative. Also found w/ large right sided pleural effusion for which underwent thoracentesis on [**4-6**] - analysis suggested transudative process and post-procedure, pt transferred to MICU for hypoxia, sedation thought to be med related. During the later portion of course, noted to have rapidly progressive deterioration in renal dysfunction with creatinine peaking at 5.6 on [**4-14**]. Treated with octreotide and midodrine for presumed hepato-renal syndrome. Also noted to have increased hyponatremia to 119 from admission value of 132. Apparently, there had been discussions about consideration of TIPS but pt had refused and ultimately left AMA on [**4-14**]. Per [**Name (NI) **], pt had been seen in clinic on [**4-17**] with requests for methodone refills but had declined to return to ED as advised. Continued to take 40 mg qd methadone from personal stock. Over the last several days, noted to have increased confusion and lethargy per brother at home. As per report, pt. lay on couch most of the day, barely eating, minimally communicative, growing more disoriented. On day of admission, pt. had not had a BM in > 24 hours and was disoriented to time. Did not recognize surroundings. Noted to have some respiratory distress and EMS called. In [**Name (NI) **], pt. c vitals: 100/70, 60, 94.6, 33. Received naloxone with some response. Intubated for airway protection. Noted to have K of 7.2, Cr 6.9; treated emergently with calcium, insulin, bicarb, dextrose, kayexelate. Renal consulted; thought given to hepatorenal vs. prerenal [**1-2**] intravascular volume depletion; received IVF (4L NS). Repeat K 6.3 and decision made to defer HD. Received levofloxacin/metronidazole for possible SBP and ? asp. PNA on CXR. Also noted to have complete white out of R lung on CXR. Admitted to [**Hospital Unit Name 153**] intubated on propofol. Had hypotension on higher doses of propofol in ED/transport and started on levophed. Past Medical History: 1. presumed HCV cirrhosis c/b massive ascites (VL 155K [**2-3**]) 2. known grade 1 varicies on egd [**2-3**] 3. presumed hepatorenal syndrome 4. thrombocytopenia (low 100's) 5. ivda (heroin) 6. transudative right pleural effusion 7. cholithiasis on abd ct 8. hiatal hernia 9. panic attacks 10. hyponatremia Social History: lives w/ mother in [**Name2 (NI) **], remote heavy etoh, quit 10 y/a, recent iv heroin (?date) Family History: Mother is living, 86 years old, with hypertension. He has a sister and brother in good health. Physical Exam: VS - in ICU: 97.6, 98/60, 86, 15, 100% on A/C - 500*12, 0.8*5 HEENT - sclerae muddy, ETT in place. scleral injection. LUNGS - R c decreased BS and dullness to percussion. L clear CHEST - +gynecomastia, RRR, S1, S2, no rmg ABD - distended, + fluid wave, NT, BS+ EXT - denuded of hair distally. no edema. wwp NEURO - no clonus. difficult to assess for asterixis. Pertinent Results: [**2116-4-21**] 01:25PM WBC-7.6 RBC-4.53* HGB-15.2 HCT-42.5 MCV-94 MCH-33.5* MCHC-35.6* RDW-17.2* [**2116-4-21**] 01:25PM NEUTS-78.9* LYMPHS-11.7* MONOS-8.3 EOS-0.2 BASOS-0.9 [**2116-4-21**] 01:25PM PLT COUNT-159 [**2116-4-21**] 01:25PM AMMONIA-84* [**2116-4-21**] 01:25PM ALBUMIN-2.7* [**2116-4-21**] 01:25PM LIPASE-517* [**2116-4-21**] 01:25PM ALT(SGPT)-49* AST(SGOT)-67* ALK PHOS-129* AMYLASE-509* TOT BILI-2.4* [**2116-4-21**] 01:25PM GLUCOSE-58* UREA N-112* CREAT-6.9*# SODIUM-119* POTASSIUM-7.3* CHLORIDE-84* TOTAL CO2-19* ANION GAP-23* [**2116-4-21**] 01:34PM LACTATE-4.7* K+-7.2* [**2116-4-21**] 03:09PM PT-16.6* PTT-34.7 INR(PT)-1.5* [**2116-4-21**] 03:19PM GLUCOSE-63* LACTATE-5.7* K+-6.3* [**2116-4-21**] 04:30PM LACTATE-6.1* K+-5.9* [**2116-4-21**] 07:17PM URINE RBC-23* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2116-4-21**] 07:17PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2116-4-21**] 07:17PM PT-16.9* PTT-36.1* INR(PT)-1.6* [**2116-4-21**] 07:17PM PLT COUNT-213 [**2116-4-21**] 07:17PM WBC-13.9*# RBC-4.44* HGB-14.7 HCT-41.9 MCV-94 MCH-33.1* MCHC-35.1* RDW-17.2* [**2116-4-21**] 07:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2116-4-21**] 07:17PM OSMOLAL-305 [**2116-4-21**] 10:35PM LACTATE-3.4* NA+-127* K+-5.2 [**2116-4-21**] 11:00PM CORTISOL-11.7 Brief Hospital Course: 49 yo M c hx hepatits C cirrhosis admitted with worsening renal failure, hyperkalemia, ascites, hypotension, altered mental status. Pt was managed aggressively in ICU upon admission but his clinical status continued to deteriorate, most noteably acute renal failure from hepatorenal syndrome despite attempts to correct this. Given overall grave prognosis, after a long discussion between the ICU team and the patient's family (brother [**Name (NI) 1312**] was health care proxy), patient was made 'comfort measures only' and transferred to a private the medicine floor. Patient was made comfortable with medications and passed away on [**2116-4-29**] with his brother at the bedside. . 1. Acute Renal Failure - Secondary to worsening hepatorenal syndrome and pre-renal azotemia. Pt was hydrated for CVP greater than 12 without improvement in Cr. Renal service consulted with whom discussions of dialysis were approached. [**Name (NI) 14397**] Pt's end stage liver disease and poor prognosis, hemodialysis not ideal. After discussion with family and involved team members; decision was made not to proceed with dialysis. Cr remained stable around 6 without concominant electrolyte abnl. Given grave overall prognosis, patient was made 'comfort measures only' and no further electrolytes were checked. . 2. Hyperkalemia - secondary to worsening renal failure. Improved with kayexelate/D50/Insulin and cell mb stabilized with Ca++. Given grave overall prognosis, patient was made 'comfort measures only' and no further electrolytes were checked. . 3. Hypotension - Multifactoprial including decreased intravascualar volume and sedation. Started on Levophed/Vasopressin which was titrated off over several days. Afterwards remained hemodynamically stable. Given grave overall prognosis, patient was made 'comfort measures only.' . 4. Liver failure/Ascites - Likely had worsening of primary liver disease. Child class C, MELD 28. Pt was started on lactulose for HE. Liver team followed him closely. Pt was not a TIPS candidate and has refused this in the past. Also not a candidate for liver transplant. Complicated by ascites and associated pleural effusion. S/P large volume thoracentesis with subsequent reacummulation. . 5. Hyponatremia - Likely [**1-2**] hypervolemic hyponatremia from liver disease. . 6. Code: Pt DNR/DNI. After long discussion with family, PCP, [**Name10 (NameIs) **] work and consultants decision made to concentrate on comfort. Patient passed away on [**2116-4-29**]. Medications on Admission: Lorazepam 1-2 mg IV Q4H:PRN agitation Midazolam HCl 2-4 mg/hr IV DRIP TITRATE TO comfort Fentanyl Patch 50 mcg/hr TP Q72H Discharge Medications: none; expired Discharge Disposition: Expired Discharge Diagnosis: acute renal failure liver failure / cirrhosis hepatic encephalopathy respiratory failure requiring intubation hyperkalemia hyponatremia Discharge Condition: not applicable. Patient expired. Discharge Instructions: none, expired Followup Instructions: not applicable. Patient expired.

[ "276.2", "304.01", "572.2", "571.5", "305.03", "458.9", "276.7", "518.81", "070.71", "789.5", "511.9", "276.1", "V66.7", "070.20", "287.5", "584.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.72", "34.91", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

16282, 16291

13566, 16072

8347, 8400

16471, 16506

12132, 13543

16568, 16604

11638, 11735

16244, 16259

16312, 16450

16098, 16221

16530, 16545

11750, 12113

8271, 8309

8428, 11179

11201, 11510

11526, 11622

7440, 7564

10,399

142,286

45182

Discharge summary

report

Admission Date: [**2169-8-9**] Discharge Date: [**2169-9-1**] Date of Birth: [**2101-10-11**] Sex: F Service: TRANSPLANT SURGERY ADMISSION DIAGNOSES: 1. End-stage renal disease. 2. Focal segmental glomerulosclerosis. 3. Gaucher's disease. 4. Depression. 5. Avascular necrosis of left hip. 6. Status post left total hip replacement. 7. Status post partial hysterectomy. 8. Status post appendectomy. 9. Status post living related kidney transplant. HISTORY OF PRESENT ILLNESS: Patient is a 67-year-old female, who underwent a living related kidney transplant on the [**2169-8-2**], who was discharged to home on the [**8-6**], and at that time had a urine output about 3 liters per day and a serum creatinine that had stabilized at 0.9. On the day of admission, the patient was receiving a Cerezyme treatment for her Gaucher's disease through a right Permacath, and at this time she experienced a fever and severe shaking chills. Because of this finding, she was admitted to the hospital for evaluation of her possible infection or bacteremia. PAST MEDICAL HISTORY: 1. End-stage renal disease secondary to focal segmental glomerulosclerosis. 2. Gaucher's disease. 3. Depression. 4. Avascular necrosis of her left hip. PAST SURGICAL HISTORY: 1. Left total hip replacement. 2. Partial hysterectomy. 3. Appendectomy. 4. Living related kidney transplant. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT TIME OF ADMISSION: 1. CellCept 1,000 mg [**Hospital1 **]. 2. Valcyte 450 mg daily. 3. Colace 100 mg po bid. 4. Nystatin 5 mg qid. 5. Ambien 10 mg po q hs prn. 6. Lipitor 20 mg po daily. 7. Trazodone 50 mg q hs prn. 8. Zoloft 200 mg po daily. 9. Estrace 1 mg po daily. 10. Xanax 0.5 mg tid. 11. Tums 500 mg po tid. 12. Multivitamin. 13. Vitamin E. 14. Vitamin B6. 15. Vitamin B12 daily. 16. Levaquin 250 mg po daily for seven days. 17. Lopressor 75 mg po bid. 18. Tacrolimus 4 mg po bid. 19. Dilaudid prn to control her pain from the incision. SOCIAL HISTORY: The patient is married with two sons and denies ingestion of alcohol or tobacco. FAMILY HISTORY: Noncontributory. DETAILS OF HOSPITAL COURSE: The patient was admitted and had pancultures, and had her Permacath removed. She was treated with antibiotics and her immunosuppressives were continued and she was followed with daily laboratories. She received 2 units of packed red blood cells for a low hematocrit at 25.2. Patient's creatinine on admission had risen to 2.2 and there was concern that the patient may have undergone a rejection episode, and so a kidney biopsy was performed. This biopsy revealed a neutrophilic infiltrate, which was consistent with an acute humoral rejection. Patient was pulsed with steroids and at this time, the crossmatch tissue typing laboratory came back as strongly positive for B cell and so a diagnosis of humoral-related rejection was confirmed. Because of this, the course of action to treat this, it was decided upon, was plasmapheresis. Given that the patient had her Permacath removed for fear of sepsis and bacteremia, a temporary pheresis catheter was attempted. A CXR demonstrated that the catheter kinked and turning back on itself. The patient was taken to Interventional Radiology for manipulation under fluoroscopy and with contrast injection it appeared the catheter was in the carotid artery. Immediately following this, a Vascular Surgery consultation was obtained and the patient, who remained neurologically intact and had been started on a Heparin drip was taken to the operating room, where she underwent a neck exploration. This was performed by Dr. [**Last Name (STitle) **], and please see his operative note for details of this procedure. The catheter was found to be in the vertebral artery at this exploration and safe removal of the catheter necessitated a partial sternotomy, which was performed during the case by the Thoracic Surgery team, who were consulted intraoperatively. The patient tolerated this procedure well, however, because of the prior heparinization, was found to be oozing at the conclusion of the case. Hemostasis was obtained, but because of the concern for mediastinal hematoma compromising her airway, she was transferred to the Surgical Intensive Care Unit for closer monitoring. In the Surgical Intensive Care Unit, she received her plasmapheresis, and her kidney function began to improve. She was continued on her antibiotics. With her rejection episode coming under control and the patient beginning to stabilize, she was able to be transferred to the floor. An MRI was obtained that demonstrated a vertebral internal jugular fistula and an stenosis/intimal flap of the carotid artery. The latter was successfully stented by Dr. [**Last Name (STitle) 1132**] in Neurosurgery. The approach to the fistula is still under discussion the options being continued f/u (Neurology recommendation - Dr. [**Last Name (STitle) 656**], endovascular embolization or operative repair with high ligation of the vertebral artery. A second opinion has been requested from [**Hospital1 2025**] and the information is being sent there for evaluation. The patient continued to recover, while her kidney function remained good with a creatinine at 0.5. Her immunosuppression levels were adjusted appropriately, and by the [**8-1**], she was deemed stable for discharge home, and she was discharged home in stable condition. The patient was neurologically stable at the time of discharge. She was discharged home on all of her preoperative medications. POSTOPERATIVE DIAGNOSES: 1. End-stage renal disease. 2. Focal segmental glomerulosclerosis. 3. Gaucher's disease. 4. Depression. 5. Avascular necrosis of left hip. 6. Status post left total hip replacement. 7. Status post partial hysterectomy. 8. Status post appendectomy. 9. Status post living related kidney transplant. 10. Status post right neck exploration with vertebral artery ligation. 11. Status post sternotomy. 12. Status post angioplasty and stenting of a right common carotid intimal flap. FOLLOW-UP INSTRUCTIONS: The patient had plans to followup after having received her second opinion from the [**Hospital6 1129**] for embolization of her vertebral jugular fistula by Dr. [**Last Name (STitle) 1132**] in two weeks' time. CONDITION ON DISCHARGE: She was discharged home in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 96566**] MEDQUIST36 D: [**2169-9-1**] 16:01 T: [**2169-9-5**] 10:57 JOB#: [**Job Number 96567**] cc:[**Last Name (NamePattern4) 96568**]

[ "E878.0", "584.9", "996.81", "997.2", "280.0", "998.6", "998.2", "996.62", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.82", "39.90", "96.6", "34.02", "99.71", "55.23", "33.22", "38.93", "39.50", "99.77", "88.41" ]

icd9pcs

[ [ [] ] ]

2102, 2131

2149, 6055

1262, 1986

167, 465

494, 1064

6080, 6293

1086, 1239

2003, 2085

6318, 6668

8,365

144,602

11192

Discharge summary

report

Admission Date: [**2156-10-14**] Discharge Date: [**2156-10-17**] Date of Birth: [**2112-10-28**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old female with a two month history of visual disturbances and now with a fall three weeks prior to admission. Visual disturbances worsened and she complained of right arm shaking. An MRI showed left frontal lesion consistent with meningioma and surrounding edema and she was admitted on the morning of the [**2156-10-14**] for a craniotomy and resection of tumor. PREVIOUS MEDICAL HISTORY: History of panic attacks and anxiety, history of depression, history of uterine polyps, history of a breast lump and a history of kidney stone PAST SURGICAL HISTORY: Breast lumpectomy. ALLERGIES: There is no history of known drug allergies. MEDICATIONS AT HOME PRIOR TO ADMISSION: Celexa, Dilantin, Decadron and Zantac. PHYSICAL EXAMINATION: Vital signs: Blood pressure 129/63. Heart rate 62 in normal sinus rhythm. Respiratory rate 19. Oxygen saturation 100% on room air. She was a pleasant white female in no acute distress. She was appropriate in all regards and was alert and oriented times three. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements were intact. Chest was clear to auscultation. Heart rate was regular in rhythm. Abdominal exam was unremarkable. There was no cyanosis, clubbing or edema of the extremities. Strength of all extremities was [**5-1**]. Sensory exam was intact. HOSPITAL COURSE: Due to the clinical findings, the patient was taken to the Operating Room on the morning of the [**2156-10-14**] where under general endotracheal anesthetic the patient underwent a left frontal craniotomy with excision of meningioma performed by Dr. [**Last Name (STitle) 6910**]. The patient tolerated the procedure well and went to the Post Anesthesia Care Unit in stable condition. A postoperative check showed the patient to be afebrile, vital signs stable, wound and dressing were clean, dry, flat and intact. There was moderate left temporal edema, but she was awake and alert, oriented times three, conversant with fluid speech, tongue was midline, smile was equal, extraocular movements were intact. There was no drift of the upper extremities and strength was within normal limits in all groups. Patient was transferred to the floor on postoperative day one and the remainder of her postoperative hospitalization was essentially unremarkable. She was subsequently discharged home on the morning of the [**10-17**] in stable condition. DISCHARGE DIAGNOSIS: Meningioma. DISCHARGE MEDICATIONS: 1. Tapering dose of Decadron. 2. Zantac 150 mg po b.i.d. 3. Dilantin 100 mg po t.i.d. 4. Percocet 5 mg 1 tablet po q. 4-6 hours prn for severe pain. 5. Tylenol for relief of mild pain. 6. The Decadron taper included 2 mg po t.i.d. times three days, followed by 2 mg b.i.d. times two days, followed by 2 mg times one at hour of sleep on the final day. This would be a taper over five days. CONDITION ON DISCHARGE: Stable and improved. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Doctor Last Name 7239**] MEDQUIST36 D: [**2156-10-18**] 14:41 T: [**2156-10-18**] 14:41 JOB#: [**Job Number 36002**]

[ "300.00", "225.2", "311" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

2671, 3068

2635, 2648

1562, 2613

760, 919

942, 1544

172, 736

3093, 3352

32,050

150,375

31685

Discharge summary

report

Admission Date: [**2122-11-8**] Discharge Date: [**2122-11-13**] Date of Birth: [**2064-2-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 477**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: CC: SOB x1 day . HPI: This is a 58 year-old male with a history of stage IV non-small cell lung CA with mets to adrenals who received cycle 3 day 1 of DFHCC 07-369 protocol on [**2122-10-29**] presents with shortness of breath. Patient reports gradual development of SOB and increasing O2 requirement to 3 L from 2L over the course of today. He was feeling at his baseline prior to this morning, though his noted some tachypnea over the past two days. He denies cough, sputum production, fevers, chills, or sick contacts. [**Name (NI) **] has nausea, night sweats, and persistent chest pain on the right w/ radiation down his right shoulder to elbow at baseline. An old right chest tube site drains serous fluid chronically. . In the ED, VS Tm 100.9 BP 140/64 HR 87 RR 24 POx 96% on 3L. He was found to have lactate of 6.2 which improved to 4.8 after 3L IVF. He received Vanc/zosyn for concern for RUL PNA, tylenol for fever, and two packets neutra-phos. Patient was transferred to the [**Hospital Unit Name 153**] for close monitoring. Onc History: Stage IV non-small cell lung carcinoma with right pleural, mediastinal nodes and adrenal glands as sites of metastasis Hypercalcemia of malignancy, on pamidronate. Treatment for his malignancy: On clinical trial 07-369 Status post 2 cycles of chemotherapy. Cycle 1 of carboplatin 6 AUC, paclitaxel 200 mg/m2, bevacizumab 15 mg/m2 in [**2122-9-17**]. Cycle 2 of carboplatin 4.5 AUC, paclitaxel 180 mg/m2, bevacizumab 15 mg/m2 in [**2122-10-8**]. Receiving daily anamorelin HCl 150 mg vs placebo (randomized) since [**2122-9-17**]. Past Medical History: 1. Stage IV NSCLC - as above 2. CAD s/p STEMI [**10/2121**] with two stents in RCA 3. H/o bradycardia 4. Hypertension 5. Hyperlipidemia 6. Diastolic dysfunction 7. Depression/Anxiety 8. H/o EtOH abuse; none x15yrs Social History: Separated with two children; currently living with wife and daughter [**Name (NI) 1403**] in commercial laundry [**Name (NI) **]: 60 pack-yrs; quit [**10/2121**] EtOH: history of abuse, none x15yrs Family History: No family history of malignancy Mother stroke, alive at 84yrs Father died of alcoholic cirrhosis Brother, sister and two children without health concerns Physical Exam: Vitals: T:98.3 BP:105/62 HR:93 RR:22 O2Sat: 97% on 6L GEN: ill-appearing, well-nourished, anxious, audible whistling [**Year (4 digits) 4459**]: [**Year (4 digits) 3899**], PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased BS throughout right lung field, left CTA, + dullness on right, no W/R/R, right chest wall 2cm gaping incision w/out erythema, non-tender, serous drainage ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: WWP, trace LE edema b/l, No C/C, no palpable cords NEURO: alert, oriented to person, place, and time. easily distracted, visibly anxious. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2122-11-8**] 04:50PM PLT SMR-LOW PLT COUNT-107* [**2122-11-8**] 04:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SCHISTOCY-OCCASIONAL PENCIL-OCCASIONAL [**2122-11-8**] 04:50PM NEUTS-79* BANDS-1 LYMPHS-9* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-2* [**2122-11-8**] 04:50PM WBC-5.9# RBC-3.20* HGB-9.3* HCT-28.0* MCV-88 MCH-29.1 MCHC-33.3 RDW-16.1* [**2122-11-8**] 04:50PM CALCIUM-9.3 PHOSPHATE-0.6* MAGNESIUM-1.4* URIC ACID-5.1 [**2122-11-8**] 04:50PM ALT(SGPT)-18 AST(SGOT)-36 LD(LDH)-443* ALK PHOS-97 TOT BILI-0.4 [**2122-11-8**] 04:50PM estGFR-Using this [**2122-11-8**] 04:50PM GLUCOSE-138* UREA N-7 CREAT-0.5 SODIUM-132* POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-19* ANION GAP-19 [**2122-11-8**] 04:54PM LACTATE-6.2* [**2122-11-8**] 04:54PM COMMENTS-GREEN TOP [**2122-11-8**] 06:55PM LACTATE-4.8* [**2122-11-8**] 06:55PM COMMENTS-GREEN TOP [**2122-11-8**] 08:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-11-8**] 08:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2122-11-8**] 11:20PM CALCIUM-8.7 PHOSPHATE-0.7* MAGNESIUM-1.2* [**2122-11-8**] 11:20PM GLUCOSE-97 UREA N-4* CREAT-0.4* SODIUM-135 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-17* ANION GAP-19 [**2122-11-8**] 11:56PM LACTATE-5.3* [**2122-11-8**] 11:56PM COMMENTS-GREEN TOP CXR [**2122-11-9**]: FINDINGS: In comparison with study of [**11-8**], allowing for somewhat lower lung volumes, there is little overall change. Large soft soft-tissue mass is again seen filling much of the upper right hemithorax with extension along the right lateral chest wall, consistent with the patient's known malignancy. Enlargement of the hila is again seen and there is relatively little aeration of the right lung. Opacification at the right base is also noted and unchanged. The left lung is essentially clear. IMPRESSION: Little overall change. Brief Hospital Course: Mr. [**Known lastname 20179**] is a 58 year-old male with a history of stage IV non-small cell lung CA with mets to adrenals who presents with shortness of breath with fever, left shift w/ bands, and new O2 requirement. . Plan: # SOB/Hypoxia:Patient on 2L home O2 with increasing requirement over last day. Patient with fever in the ED in absence of cough or sputum production. CXR demonstrating worsening opacity of the right lung concerning for post-obstructive pneumonia vs. hemorrhage (Hct has dropped 35-->28 but in setting of chemo 10 days ago) vs. edema/effusion, though no other evidence systemically vs. disease progression, unclear if this would also be causing fever, lactate rise. Patient received vanc/zosyn in the ED for possible HAP/post-obstructive. Initially started on vancomycin for concerns for possible pnuemonia, however no evidence clinically to suggest infection here in the ICU. Patient was afebrile. Team felt that likely source of worsening oxygen requirement was progression of disease so antibiotics were discontinued. Patient started on nebs and written for sputum culture. Urine culture no growth, blood culture pending at this time. Will trend lactate as elevated on admission. IVF boluses with NS PRN. . # Anion Gap metabolic acidosis: In setting of lactate of 6. No hyperglycemia, no ingestions, no uremia, no meds. - monitor closely as lactate improves . # Hypophosphatemia: Patient with recurrent hypophos since [**9-25**] presumed to be related to rapid correction of hypercalcemia with pamidronate resulting in deposition of calcium and phosphate - continue agressive IV/po phosphate repletion . # Right Back/Shoulder Pain: Chronic, seen by palliative care for pain control. - continue oxycontin/oxycodone, lidoderm at outpatient regimen . # Pancytopenia/ONC: Since last chemo on [**10-29**], HCT drop 35-->28, Plts 200-107, WBC 22--5. Likely [**3-21**] chemo now that pt at 10 day point post-chemo - will continue to monitor closely - appreciate onc recs - started on b12, folate as per oncology . # hyperlipidemia: Continue statin . # hypertension: borderline hypotension on admission to [**Hospital Unit Name 153**] - holding home ACE in this setting, will re-start when stable . # CAD/mild diastolic heart dysfunction: H/o VT post-MI on acebutolol. No evidence of ischemia on history, EKG. No volume overload on exam. - continue ASA, statin, acebutolol - will hold ACE as above . # depression/anxiety: Clearly struggling with anxiety at home. Daughter reports medicating Q2H w/ ativan prn symptoms. Patient w/ h/o ETOH abuse, remote. - continue citalopram - trial of haldol for anxiety/agitation, prn ativan if patient not responsive He was transferred to the oncology service, where he continued to be short of breath with minimal exertion. After a discussion with his family, the decision not to pursue more treatment and make comfort the goal was made. He was placed on a morphine drip on [**11-12**] and passed away at 9:36 on [**2122-11-13**], with his family at the bedside. Medications on Admission: ACEBUTOLOL - 200 mg Capsule [**Hospital1 **] ANAMORELIN - Dosage uncertain ATORVASTATIN [LIPITOR] - 80 mg Tablet - daily CITALOPRAM [CELEXA] - 20 mg Tablet - daily GABAPENTIN - 300 mg Capsule - TID LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch LISINOPRIL - 2.5 mg Tablet - daily LORAZEPAM - 1 mg Tablet - q6H prn nausea/anxiety ONDANSETRON HCL [ZOFRAN] - 8 mg Tablet - Q8H prn nausea OXYCODONE - 5 mg Tablet - [**2-18**] Tablet(s) Q4H prn OXYCODONE [OXYCONTIN] - 20 mg Tablet Sustained Release 12 hr [**Hospital1 **] PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg q8H prn nausea ASPIRIN - 81 mg daily BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - 2 Tablet daily MILK OF MAGNESIA SENNA - 8.6 mg Tablet - [**Hospital1 **] Pamidronate IV - received 2 weeks ago Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Metastatic stage IV lung cancer Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "272.4", "414.01", "196.1", "198.7", "300.4", "E933.1", "197.2", "V45.82", "284.89", "401.9", "518.84", "V10.11", "276.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9392, 9401

5513, 8540

335, 341

9476, 9485

3527, 5490

9537, 9638

2431, 2586

9364, 9369

9422, 9455

8566, 9341

9509, 9514

2601, 3508

276, 297

369, 1952

1974, 2197

2213, 2415

18,035

185,659

10879

Discharge summary

report

Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-20**] Date of Birth: [**2117-3-29**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 33 year-old Haitian male with a history of hepatitis C, cirrhosis and hepatocellular carcinoma status post chemotherapy with last treatment in [**2149-10-7**] who presents to the Emergency Room after an episode of hematemesis. The patient with a reported increased abdominal girth over the past month and intermittent low grade temperature over the last five days. The patient notes decreased po intake over the last 48 hours and some weight loss. The patient in the process of attempting to have a bowel movement felt nauseous and vomited blood. He called his oncologist who recommended going to the Emergency Room, however, the patient did not do so, because he felt too weak. On the day of admission the patient had two further episodes of hematemesis. He denied any dizziness or lightheadedness or chills. He also noted bright red blood per rectum and melena yesterday times one. The patient had no increase in his abdominal pain. The patient does not some dark urine over the past 24 hours and jaundice. In the Emergency Room the patient was with hematemesis and was unable to tolerate nasogastric tube for lavage. Two large bore intravenouses were placed. The patient was typed and crossed for 2 units and was seen by the hepatology service. PAST MEDICAL HISTORY: 1. Hepatitis C complicated by cirrhosis complicated by hepatocellular carcinoma diagnosed in [**2149-3-7**]. The patient is status post Cisplatin, Adriamycin, which was complicated by pancytopenia. The patient had a total of three cycles. Subsequently he had Gemcitabine and platinum in [**2149-10-7**]. Then his chemotherapy was discontinued and since then the patient has been on Sexessiac, which is an alternative herbal medication. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in oncology. 2. History of positive PPD treated with INH of an incomplete course in the past and negative chest x-ray. 3. History of rectal bleeding. ALLERGIES: Morphine that causes vomiting. MEDICATIONS: 1. Duragesic patch 50 micrograms q 72 hours. 2. Dilaudid 2 mg q 4 hours prn. 3. Compazine prn. 4. Benadryl prn. 5. Ativan prn nausea. SOCIAL HISTORY: The patient is originally from [**Country 2045**] and immigrated to the United States in [**2142**]. He denies any alcohol or intravenous drug use and quit tobacco in [**2148**]. He currently has a supportive fiance who is very involved in medical decision making. FAMILY HISTORY: Brother with hepatitis B and hepatocellular carcinoma. PHYSICAL EXAMINATION: In general, the patient is a pleasant young male in no acute distress, lethargic. HEENT positive scleral icterus. Mucous membranes are moist. Pupils are equal, round, and reactive to light and accommodation. Cardiovascular normal S1 and S2. 2 out of 6 systolic ejection murmur, regular rate and rhythm. Respiratory clear to auscultation bilaterally. Abdomen decreased bowel sounds, soft, tender with right upper quadrant with slight shifting dullness, liver palpable at 3 cm below the right costal margin. Extremities no clubbing, cyanosis or edema. Neurological no asterixics. Alert and oriented times three. LABORATORY DATA ON ADMISSION: White blood cell count 9.9, hematocrit 32.9 (last hematocrit 42.6 in [**2150-3-7**]), platelets 139, PT 16.7, INR 1.9, PTT 31.6. Sodium 132, potassium 4.7, chloride 97, bicarb 24, BUN 20, creatinine 0.8, glucose 99. ALT 69, AST 213, alkaline phosphatase 229, amylase 103, lipase 213, T bili 8.4 (increased form 2.4 in [**2150-3-7**]), albumin 3.1. MRI of the abdomen done in [**2150-3-7**], extensive infiltrating hepatocellular carcinoma involving almost the entire right lobe of the liver with portions of the left lobe of the liver also involved. Significant progression since [**2149-8-7**]. Tumor invasion into the gallbladder with hemorrhage into the gallbladder, portal vein thrombosis with a cavernous transformation. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. 1. Gastrointestinal: The patient was treated with a total of 3 units of packed red blood cells and 2 units of fresh frozen platelets. He underwent an esophagogastroduodenoscopy that showed grade 2 to 3 varices with positive stigmata of recent bleeding with red whale signs, four bands were successfully placed. There was only a small amount of clotted blood and coffee grounds in the fundus of the stomach. The patient was placed on proton pump inhibitor b.i.d. and was started on an Octreotide drip. He was kept NPO. The patient was followed by the hepatology service. The patient was placed on Ciprofloxacin intravenous for SBP prophylaxis. The patient was also treated with Carafate flurry 10 cc po q.i.d. subsequent to his banding of esophageal varices. The patient with significant constipation after Intensive Care Unit stay and transfer to the medical floor. The patient was treated successfully with an aggressive bowel regimen of Colace, Senna, Dulcolax and Lactulose with decreased abdominal discomfort. The patient had an abdominal CT, which showed a large amount of ascites into the pelvis, liver extensively cirrhotic with multiple nodules likely secondary to hepatocellular carcinoma, positive portal vein thrombosis, gallbladder with two infiltrations, spleen with a normal and diffuse colonic thickening consistent with either C-diff versus a low protein state. The patient will follow up with hepatology clinic for potential paracentesis as an outpatient. 2. Infectious disease: The patient has noted above was continued on Ciprofloxacin for SBP prophylaxis and was discharged on an additional three days of SBP prophylaxis with 500 mg po b.i.d. 3. Oncology: The patient was followed by the oncology service and specifically he was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Per discussion with oncologist it seems as though the patient although aware of diagnosis and prognosis is still wiling to consider treatment options with herbal therapy, which he has been doing over the past several months. The patient although may be progressing pass palliative care currently not ready to proceed with arrangements for VNA with bridge to hospice or hospice care specifically. The patient will follow up as an outpatient with oncologist. DISCHARGE DIAGNOSES: 1. Hepatitis B. 2. Cirrhosis. 3. Hepatocellular carcinoma. 4. Upper gastrointestinal bleed secondary to varices. 5. SBP prophylaxis. DISCHARGE MEDICATIONS: 1. Ativan prn. 2. Colace 100 mg po b.i.d. 3. Senna two tabs b.i.d. 4. Lactulose 30 cc q.i.d. 5. Sucralfate 1 gram po q.i.d. for an additional two weeks. 6. Protonix 40 mg po q.d. 7. Dilaudid prn. 8. Reglan 10 mg q.i.d. 9. Dulcolax 10 mg po q.h.s. 10. Cipro 500 mg po b.i.d. for an additional three days. FOLLOW UP: 1. The patient should follow up with his primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital 191**] Clinic. 2. The patient should follow up with his oncologist Dr. [**First Name (STitle) **]. 3. The patient should follow up in the liver clinic or his hepatologist Dr. [**Last Name (STitle) **]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 231**] MEDQUIST36 D: [**2150-4-21**] 03:01 T: [**2150-4-22**] 07:24 JOB#: [**Job Number 35418**]

[ "070.32", "453.2", "789.5", "571.5", "456.20", "070.54", "197.8", "155.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "42.33" ]

icd9pcs

[ [ [] ] ]

2647, 2703

6514, 6653

6676, 6991

4125, 6493

7002, 7641

2726, 3361

166, 1443

3376, 4107

1465, 2345

2362, 2630

27,810

118,521

45594

Discharge summary

report

Admission Date: [**2122-7-26**] Discharge Date: [**2122-8-10**] Date of Birth: [**2045-2-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Right hip fracture Major Surgical or Invasive Procedure: [**2122-7-27**]: ORIF Right hip fracture with long gamma nail History of Present Illness: Ms. [**Known lastname **] is a 77 year old female who suffered a fall at her nursing home on [**2122-7-25**]. She was complaining of Right hip pain and was taken to the [**Hospital1 18**] for further evaluation. Past Medical History: B12 deficiency Osteoporosis Hearing Loss with chronic tinnitus Migraines GERD Chronic Back Pain s/p appendectomy Psychiatric Hospitalization from (sectioned 12) [**Date range (3) 97246**] for inability to care for self. During admission, she was court ordered to receive antipsychotic medications against her will and guardianship was appointed. Social History: Court ordered guardian [**Name (NI) **] [**Name (NI) 84227**] [**Telephone/Fax (1) 84228**] (cell) [**Telephone/Fax (1) 84229**] (home) Resident at [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home. Family not involved her her care. Family History: n/a Physical Exam: After operation: VITALS: Tc 98.5, Tm 99.0, 78, 120/50, 19, 97%RA GEN: resting comfortably. When asked questions or permission to examine, pt states, "go away" and was uncooperative with majority of exam HEENT: unable to assess due to lack of patient cooperation NECK: No JVD CV: Irreguarly irregular but rate controlled. III/VI SEM at RUSB radiates to neck. PULM: limited exam due to lack of cooperation but anteriorly clear with decreased BS bilaterally ABD: Soft, NT, ND, +BS. EXT: 1+ pedal edema, R>L. R hip with clean dressing, not removed Pertinent Results: [**2122-7-26**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2122-7-26**] 02:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-7-26**] 02:30PM URINE RBC-[**2-4**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2122-7-26**] 02:30PM URINE HYALINE-0-2 [**2122-7-26**] 02:30PM URINE MUCOUS-MOD [**2122-7-26**] 01:13PM GLUCOSE-197* K+-3.8 [**2122-7-26**] 01:00PM GLUCOSE-210* UREA N-39* CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [**2122-7-26**] 01:00PM estGFR-Using this [**2122-7-26**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.1 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2122-7-26**] 01:00PM WBC-6.8 RBC-3.33* HGB-10.1* HCT-28.7* MCV-86 MCH-30.4 MCHC-35.3* RDW-12.8 [**2122-7-26**] 01:00PM NEUTS-83.0* LYMPHS-11.2* MONOS-5.6 EOS-0.1 BASOS-0.1 [**2122-7-26**] 01:00PM PLT COUNT-223 [**2122-7-26**] 01:00PM PT-15.1* PTT-24.1 INR(PT)-1.3* Brief Hospital Course: Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2122-7-26**] from her nursing home after suffering a fall on [**2122-7-25**]. She was evaluated by the orthopaedic and medicine services and cleared for surgery. On [**2122-7-27**] she was taken to the operating room and underwent an ORIF of her hip fracture. She tolerated the procedure well, was extubated, and transferred to the recovery room. In the recovery room she was tachycardic which improved with lopressor and agitated which improved with haldol. She was brought to the floor from the recovery room but was noted to have increased sedation and was brought back to the recovery room for further monitoring. She had increased alertness and was then transferred to the floor. On [**2122-7-28**] she was transfered with 1 unit of packed red blood cells due to acute blood loss anemia. She was also seen by physical therapy to improve her strength and mobility. On [**2122-7-28**] a chest x-ray noted an egg shaped mass. On [**2122-7-29**] she was transfused with 2 units of packed red blood cells due to acute blood loss anemia. She was also evaluated for dysphagia. Unfortunately on [**2122-7-29**] she was at risk for aspiration and did not eat. #. Transferred to ICU s/p CODE BLUE for A-fib RVR: On [**2122-7-29**], HR was noted to be in 200s, CODE BLUE was called. Patient was given 2X 150mg Amiodarone and converted spontaneously to sinus rhythm with HR in 90s. Patient was maintained in SR on amio gtt for 12hours then switched to IV lopressor for rate control. Anticoagulation was held because of recent surgery and anemia. She was transfered to a general medical floor with a plan to transition her to PO Bblockers and eventually resume anticoagulation with the help of ortho consult. Transferred out of ICU and to floor and was noted to have episodes of Tachycardia. This initially was controlled with beta blockade in IV, but persisted after transition to PO. On [**2122-8-6**] she developed symptomatic palpitations and CT chest revealed PE in segmental R posterior [**Doctor First Name **] and subsegmental in lingula. She was placed on heparin drip and converted to IV metoprolol as patient had been cheeking her pills. On [**8-7**] she was transferred to Lovenox SQ due to access and compliance issues. She was also moved to the [**Hospital Unit Name 196**] service given persistent ectopy in face of maximum beta blockade and blood pressure limitations. Was again transferred to the MICU on [**8-8**] for continuing SVT. She was loaded with dig and given IV metoprolol. On [**8-9**] her rates were 70s-90s and she was called out to the floor. Prior to transfer, changed IV metoprolol to po. [**Name8 (MD) **] RN, she would take crushed pills in applesauce. #Proteus UTI -Cipro 7 day course on day beginning [**2122-8-1**] ([**5-9**]) increased dose to 500 mg [**Hospital1 **] -Changed foley on day 2. Pulled foley day 4. -Repeat UA [**2122-8-5**] -no evidence UTI-Cx grew coag neg staph. Could represent contamination, though not in mixed picture, currently on antibiotics and UA neg. - [**8-7**] UA- gram positive bacteria, started bactrim, but patient initially refused, she was given 2 days of IV Ceftriaxone and will be discharged on Bactrim to complete 5 more days. . #Vulvitis -Given Fluconazole PO once, and Miconazole 2 % topical [**Hospital1 **] for burning. . #. Demand ischemia. Patient had trop 0.02->0.13->0.11 thought likely [**1-3**] demand ischemia in setting of anemia, surgery, and afib with RVR. Checked serial cardiac enzymes. EKG with no st elevations or changes. Did not give heparin because of recent surgery. Started BB and gave morhpine for pain prn. Statin and ASA. # Acute blood loss anemia: Received 1unit prbcs hct up only 1 point. Serial hcts checked. Hcts were stable and even increasing as of discharge from the MICU (28.5->29.8->30.0). . # Femoral fracture: Ortho continued to consult. Morphine was given PRN for pain. Staples removal [**2122-8-10**], steri-strips in place . # HTN: HCTZ was held as lopressor was started. Per last d/c summary she has intermittent hypertensive episodes. . # GERD: Continue PPI. Maalox prn. Per last d/c summary she has a tendency to frequently complain of loose stools and burning abdominal pain which she refers to as "my ulcer" but refuses further treatment. . # Wound care: Sacral skin breakdown noted on last admission likely exacerbated by baseline incontinence. Continue Gaymar Overlay and Corticaid Ointment. Wound care consult. . # Hearing loss with chronic tinnitus: During recent hospitalization the patient had an ENT consult to evaluate her hearing as well as Audiogram with recommendation for hearing aid placement. She was fitted on [**2122-7-15**] [**Hospital **] clinic ([**First Name8 (NamePattern2) 17132**] [**Last Name (NamePattern1) 1617**], [**Telephone/Fax (1) 97242**]) a follow up appointment has been scheduled . # Psych: Psychosis NOS and paranoia. Currently under Section 7,8,8b and with a court-appointed guardian. [**Name (NI) **]-ordered to take anti-psychotics with current regimen of IM Risperdal. - Continue IM Risperdal Consta-dosed every three weeks. Last dose given [**2122-8-10**] - Psych consult . # FEN: replete 'lytes prn S&S saw her and recommended thin liquids and regular solids with suprevision during pos and keeping meds IV. # PPX: heparin sc tid, PPI, bowel regimen # Code: FULL? # Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 84227**] (guardian: cell [**Telephone/Fax (1) 84228**] or [**Telephone/Fax (1) 97244**], home [**Telephone/Fax (1) 84229**]) Medications on Admission: Calcium Carbonate 500mg TID Risperdal 12.5mg IM Prilosec 20mg daily Vitamin D 400units daily HCTZ 12.5mg daily Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for vulvar infection. 11. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. 12. Risperidone Microspheres 25 mg/2 mL Syringe Sig: One (1) Syringe Intramuscular ONCE (Once) for 1 doses: Dose every 3 weeks. Next dose [**2122-8-31**]. Increase to 25 mg. 13. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: s/p fall Right hip fracture Acute Blood Loss Anemia b/l DVT Pulmonary embolism Atrial fibrillation with RVR Supraventricular tachycardia Discharge Condition: Stable Discharge Instructions: Continue to be weight bearing as tolerated on your right leg Continue your lovenox injections for a total of 4 weeks after surgery Dry sterile dressing daily or as needed for drainge or comfort If you have any increaed redness, drainage, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics on [**8-18**] at 12:40 PM, please call [**Telephone/Fax (1) 1228**] change schedule for that appointment. Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 2472**] in 1 week. You can call [**Telephone/Fax (1) 17896**] to change this appointment. Please follow up with [**First Name8 (NamePattern2) 17132**] [**Last Name (NamePattern1) 1617**] at [**Hospital3 2005**] for your hearing aid fitting Tuesday, [**8-18**] at 1 PM. You can call [**Telephone/Fax (1) 97247**] if you have problems with this appointment. Completed by:[**2122-8-10**]

[ "453.41", "733.00", "427.31", "415.11", "298.9", "E888.9", "599.0", "388.30", "285.1", "997.2", "266.2", "041.6", "530.81", "616.10", "820.22", "707.03" ]

icd9cm

[ [ [] ] ]

[ "79.35", "99.04" ]

icd9pcs

[ [ [] ] ]

9924, 10078

2903, 7252

333, 398

10259, 10268

1897, 2880

10678, 11356

1310, 1315

8684, 9901

10099, 10238

8549, 8661

10292, 10655

1330, 1878

275, 295

7264, 8523

426, 640

662, 1010

1026, 1294

24,975

101,092

29644

Discharge summary

report

Admission Date: [**2185-6-24**] Discharge Date: [**2185-7-21**] Date of Birth: [**2107-8-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubated ([**2185-6-24**]) History of Present Illness: History of Present Illness: 77M history of schizophrenia, neurogenic bladder presenting from NH with ACS with resuscitation at [**Hospital1 2177**] 1 month ptp, brought in by EMS due to hypoxia, concern for PNA at nursing home. The patient is schizophrenic per history and is unable to provide a history of his own. Per discussion with the floor nurse from his nursing home, a CXR was obtained 4 days prior to admission for a cough that was consistent with a pneumonia. He was started on a Z-pack. One day prior to admission, he developed tachypnea and started to desaturated in the the low 80's. EMS were call and he was stat low 90's on a NRB. He was brought in by Ambulance. In the ED, initial VS were T 99, HR 120, BP 104/79, RR 24 satting 92% on NRB. Labs showed WBC of 10.1, HCT of 43, plts 305. LFTs showed AP of 214 otherwise WNL. Coags were WNL. CMP showed hypernatremia of 150, Cl of 112, BUN 33, with rest of BMP in normal range, Lactate was 2.1, and valproate level was 27. ABG was checked and pH was 7.51, pCO2 of 28, pO2 of 72. Given tachypnea and hypoxemia as well as high work of breathing, patient was intubated with fentanyl and midazolam for sedation. Noted was food in oropharynx/larynx per ED resident on intubation. His CXR showed a questionable aspiration pneumonia as well as possible LLL process. CT scan showed bilateral PE and likely pneumonia. He was empricially provided with levofloxacin, metronidazole, and vancomycin. His blood pressure dropped to 70/40 just before transfer to the ICU. After an 3 additional 3L NS SBP increased to 100's. Past Medical History: 1) Osteoarthritis 2) Schizophrenia 3) Tardive dyskinesia 4) Neurogenic bladder indwelling catheter with recurrent UTIs 5) BPH 6) CAD 7) Lumbar pain 8) TURP 9) Dysphagia with large hiatial hernia . Social History: Lives at [**Hospital1 **] 174 [**Location (un) 538**], MA Family History: Patient unable to elucidate. Physical Exam: ADMIT EXAM: Vitals: Temp: 36.8 ??????C, HR: 84, BP: 96/53(68)mmHg, RR: 26 insp/min, SpO2: 97% General: Sedated on vent, NAD, thin HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, 2mm pupils, poorly reactive Neck: supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: limited exam Clear to auscultation bilaterally on anterior exam Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: suprapubic foley Ext: warm, well perfused, 1+ pulses Neuro: moving all extremities DISCHARGE EXAM: AF 97.6/98 100-116/59-80 HR 84-100 RR 18 sat 96% on RA Gen: NAD. Sleeping comfortably HEENT: moist mucosa. Patient with upper airway wheezing. Nasal breather. Appears obstruction in nose. Tongue protruding while sleeping CV: tachycardic, regular rhythm, [**1-25**] holosystolic murmur Lungs: Tachypnic. Upper airway wheezing. CTAB but intermediate aeration Abd: NT, ND, soft Ext: no peripheral edema Skin: no rashes or lesions noted; area around suprapubic cath is c/d/i without erythema or discharge Pertinent Results: IMAGING: CT ANGIO CHEST [**2185-6-24**] - TECHNIQUE: CTA of the chest was performed per department protocol. Oblique sagittal and coronal reformats were available for review along with the axial images. CT OF THE CHEST: There are small pulmonary arterial filling defects in the subsegmental bronchi supplying the lingula (4:71) as well as additional filling defect in the subsegmental right lower lobe bronchi (4:87). An additional area of segmental pulmonary embolus is seen in the apical segment of the right upper lobe (4:33). There is no evidence of right heart strain. Within the right middle and upper lobe there are extensive nodular opacities as well as several more gound glass appearing areas of opacity (4:61 and 4:27). There is extensive atelectasis of the right lower lobe (4.83) with relative [**Name (NI) 71062**] peripheral area within the collapsed lung. No definitive arterial supply with embolus is seen in this area; however in the setting of other emboli and configuration of this finding, it is concerning for infarct. There is no pleural or pericardial effusion. In the left hemithorax, there is a large hiatal hernia with stomach and GE junction above the diaphragm. This causes compressive atelectasis (4:102) on the adjacent lung. The patient is intubated with endotracheal tube terminating approximately 4 cm from the carina. An nasogastric tube is seen in the esophagus but does not reach the GE junction or the stomach. Subdiaphgramatically, gallstones are seen. The aorta and the great vessels appear unremarkable. No suspicious lytic or sclerotic lesions are seen within the bones. IMPRESSION: 1. Right middle and upper lobe nodular opacities as well as several areas of ground-glass opacity consistent with infectious process. 2. Bilateral pulmonary emboli in the segmental and subsegmental levels with no evidence of right heart strain. There is an area of hypoenhancement within the atelctatic right lower lobe along the periphery concerning for infarction. 3. Complete right lower lobe atelectasis. 4. Large diaphgramatic hernia. 5. Cholelithasis. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND [**2185-6-24**] - Grayscale and Doppler son[**Name (NI) **] of the left common femoral, left superficial femoral, left popliteal vein show normal compressibility, flow and augmentation. Note is made of duplicated left superficial femoral veins. The left calf veins show normal flow. Grayscale, color, and spectral Doppler examination of the right common femoral vein shows normal compressibility and flow. Note is made of duplicated right superficial femoral veins. There is partially occlusive thrombus noted within one of the right proximal superficial femoral veins which is of unclear chronicity. The distal superficial femoral vein, the entire length of the other superficial femoral vein, popliteal vein appear patent. The right posterior tibial veins were patent. The right peroneal veins were not visualized. IMPRESSION: 1. Partially occlusive thrombus noted within one of the two right proximal superficial femoral veins which is of unclear chronicity. Right peroneal veins were not visualized. 2. No DVT in left lower extremity. ECHO [**2185-6-24**] - Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - ventilator. Conclusions Technically suboptimal study. 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 and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No definate aortic regurfgitation is seen. The mitral leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a very prominent fat pad. IMPRESSION: Very suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation. CXR [**2185-6-26**] Compared with [**2185-6-25**] at 5:46 a.m., an NG tube is again noted. It overlies the lower chest, but appears to overlie the gastric fundus, which is elevated due to a diaphragmatic herniation, as seen on [**2185-6-24**] CT scan. If clinically indicated, a lateral view could help to confirm this. Again noted is ET tube in satisfactory position above the carina. Prominence of right paratracheal soft tissues is noted, but may be accentuated due to patient rotation. There is focal opacity in the right upper zone and patchy opacity in the right lower zone medially. These findings are better depicted on [**2185-6-24**] CT scan. The lung apices are excluded from the film. Electronic battery pack is noted overlying left iliac crest. CXR [**2185-7-6**] FINDINGS: In comparison with the study of [**7-5**], the orogastric tube has been removed. Other monitoring and support devices remain in place. Persistent opacification at the left base with progressive clearing of opacification at the right base. No vascular congestion. CXR [**7-8**] Portable: IMPRESSION: Increased opacification in left base with some volume loss. CXR [**7-10**] Portable: IMPRESSION: Possible area of loculated fluid with trapped air verses pneumothorax verses atypical appearance of stomach bubble near the left CPA. Follow up upright chest radiograph with the patient swallowing 15 cc of barium just prior to imaging should help rule out these etiologies CXR [**7-11**] PA/Lat: CONCLUSION: There is no significant pneumothorax. ECG [**7-17**]: Sinus rhythm. Borderline low QRS voltage. Possible inferior wall myocardial infarction of indeterminate age. The lateral lead Q waves are likely not representative of a myocardial infarction but rather septal Q waves. Compared to the previous tracing of [**2185-7-8**] the sinus rate has decreased by 20 beats per minute with no other diagnostic change. MICRO/PATH: MRSA SCREEN (Final [**2185-6-26**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2185-6-25**] 2:00 pm BRONCHIAL WASHINGS BRONCHIAL WASH. Blood Culture, Routine (Final [**2185-7-1**]): NO GROWTH. GRAM STAIN (Final [**2185-6-25**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. GRAM STAIN (Final [**2185-6-28**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2185-6-30**]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 351-9662P ([**2185-6-24**]). YEAST. RARE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. GRAM STAIN (Final [**2185-7-4**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. Catheter tip Cx [**7-6**]: No growth BCx [**7-9**] and [**7-10**]: No growth Urine Cx ([**7-10**]) URINE CULTURE (Final [**2185-7-12**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ADMIT LABS: [**2185-6-24**] 08:40AM BLOOD WBC-10.1 RBC-4.41*# Hgb-13.6*# Hct-43.0# MCV-97# MCH-30.8 MCHC-31.6# RDW-14.1 Plt Ct-305 [**2185-6-24**] 08:40AM BLOOD Neuts-85.8* Lymphs-9.7* Monos-3.5 Eos-0.8 Baso-0.3 [**2185-6-24**] 08:40AM BLOOD PT-12.3 PTT-29.6 INR(PT)-1.1 [**2185-6-24**] 08:40AM BLOOD Glucose-91 UreaN-33* Creat-0.8 Na-150* K-3.5 Cl-112* HCO3-25 AnGap-17 [**2185-6-24**] 08:40AM BLOOD ALT-22 AST-31 AlkPhos-214* TotBili-0.6 [**2185-6-24**] 05:10PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8 [**2185-6-24**] 08:40AM BLOOD Albumin-3.4* [**2185-6-24**] 09:34AM BLOOD Type-ART pO2-72* pCO2-28* pH-7.51* calTCO2-23 Base XS-0 RELEVENT LABS: [**2185-6-24**] 05:10PM BLOOD WBC-11.6* RBC-3.43* Hgb-10.8* Hct-33.2* MCV-97 MCH-31.4 MCHC-32.4 RDW-14.3 Plt Ct-288 [**2185-6-25**] 03:11AM BLOOD WBC-12.6* RBC-3.39* Hgb-10.6* Hct-33.0* MCV-97 MCH-31.2 MCHC-32.1 RDW-14.3 Plt Ct-319 [**2185-6-26**] 03:46AM BLOOD WBC-14.4* RBC-3.57* Hgb-11.2* Hct-34.2* MCV-96 MCH-31.3 MCHC-32.6 RDW-14.7 Plt Ct-355 [**2185-6-25**] 03:11AM BLOOD Neuts-81.7* Lymphs-12.0* Monos-3.0 Eos-2.8 Baso-0.5 [**2185-6-25**] 03:11AM BLOOD PTT-58.7* [**2185-6-26**] 03:46AM BLOOD PT-14.2* PTT-88.5* INR(PT)-1.3* [**2185-6-26**] 10:04AM BLOOD PTT-128.0* [**2185-6-24**] 05:10PM BLOOD Glucose-93 UreaN-25* Creat-0.5 Na-149* K-2.8* Cl-119* HCO3-21* AnGap-12 [**2185-6-25**] 03:11AM BLOOD Glucose-100 UreaN-23* Creat-0.5 Na-148* K-3.7 Cl-120* HCO3-19* AnGap-13 [**2185-6-25**] 02:52PM BLOOD Glucose-85 UreaN-20 Creat-0.5 Na-150* K-3.4 Cl-120* HCO3-20* AnGap-13 [**2185-6-26**] 03:46AM BLOOD Glucose-148* UreaN-15 Creat-0.5 Na-144 K-2.8* Cl-115* HCO3-20* AnGap-12 [**2185-6-26**] 03:23PM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-115* HCO3-20* AnGap-9 [**2185-6-24**] 08:40AM BLOOD ALT-22 AST-31 AlkPhos-214* TotBili-0.6 [**2185-6-25**] 03:11AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.9 [**2185-6-25**] 02:52PM BLOOD Calcium-8.0* Phos-2.9 Mg-2.4 [**2185-6-26**] 03:46AM BLOOD Calcium-7.5* Phos-1.7* Mg-2.1 [**2185-6-26**] 03:23PM BLOOD Calcium-7.2* Phos-1.8* Mg-2.0 [**2185-6-24**] 05:50PM BLOOD Type-ART pO2-84* pCO2-27* pH-7.45 calTCO2-19* Base XS--2 [**2185-6-25**] 03:10PM BLOOD Type-ART Temp-37.2 pO2-114* pCO2-27* pH-7.47* calTCO2-20* Base XS--1 Intubat-INTUBATED [**2185-6-25**] 10:16PM BLOOD Type-ART pO2-91 pCO2-23* pH-7.49* calTCO2-18* Base XS--2 [**2185-6-26**] 04:01AM BLOOD Type-ART pO2-96 pCO2-26* pH-7.51* calTCO2-21 Base XS-0 [**2185-6-26**] 03:31PM BLOOD Type-ART Temp-36.8 pO2-85 pCO2-27* pH-7.50* calTCO2-22 Base XS-0 Intubat-INTUBATED [**2185-6-30**] 04:22AM BLOOD WBC-11.2* RBC-3.32* Hgb-10.4* Hct-31.5* MCV-95 MCH-31.4 MCHC-33.1 RDW-14.8 Plt Ct-450* [**2185-7-3**] 04:24AM BLOOD WBC-13.7* RBC-3.62* Hgb-11.3* Hct-34.2* MCV-95 MCH-31.3 MCHC-33.1 RDW-14.6 Plt Ct-615* [**2185-7-5**] 02:42AM BLOOD WBC-8.5 RBC-3.03* Hgb-9.3* Hct-28.9* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.6 Plt Ct-646* [**2185-7-7**] 03:49AM BLOOD WBC-8.6 RBC-2.97* Hgb-9.3* Hct-28.1* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.5 Plt Ct-596* [**2185-7-2**] 03:48AM BLOOD Neuts-62.4 Lymphs-28.4 Monos-6.7 Eos-2.0 Baso-0.6 [**2185-7-4**] 04:06AM BLOOD Neuts-64.0 Lymphs-25.8 Monos-6.5 Eos-2.9 Baso-0.9 [**2185-7-3**] 04:24AM BLOOD PT-25.9* PTT-116.3* INR(PT)-2.5* [**2185-7-4**] 04:06AM BLOOD PT-38.3* PTT-85.2* INR(PT)-3.7* [**2185-7-5**] 02:42AM BLOOD PT-27.3* PTT-42.7* INR(PT)-2.6* [**2185-7-6**] 03:39AM BLOOD PT-31.1* INR(PT)-3.0* [**2185-7-7**] 03:49AM BLOOD PT-50.0* PTT-46.7* INR(PT)-5.0* [**2185-7-6**] 03:39AM BLOOD ALT-11 AST-17 AlkPhos-125 TotBili-0.5 [**2185-7-7**] 03:49AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.0 [**2185-7-3**] 04:24AM BLOOD TSH-8.2* [**2185-7-3**] 04:30PM BLOOD T3-99 Free T4-0.78* [**2185-7-6**] 06:45AM BLOOD Cortsol-24.3* - 05:45AM BLOOD Cortsol-16.8 (STIM TEST) [**2185-7-4**] 04:06AM BLOOD Cortsol-6.0 DISCHARGE LABS: [**2185-7-20**] 06:55AM BLOOD WBC-5.4 RBC-3.25* Hgb-10.3* Hct-30.4* MCV-94 MCH-31.7 MCHC-33.8 RDW-14.2 Plt Ct-263 [**2185-7-20**] 06:55AM BLOOD PT-37.9* PTT-47.8* INR(PT)-3.7* [**2185-7-20**] 06:55AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-140 K-3.8 Cl-107 HCO3-25 AnGap-12 [**2185-7-20**] 06:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.4 Brief Hospital Course: Mr. [**Known lastname 71063**] is a 77 yo M transferred from MICU [**7-7**] with schizophrenia, neurogenic bladder, without guardianship, and found to have pneumonia and bilateral pulmonary emboli causing hypoxia/hypotension requiring pressors and intubation. He has been relatively stable on the floor while undergoing treatment for UTI. # UTI- Currently has suprapubic catheter in setting of neurogenic bladder and was found to have GNR's 10-100K in urine on [**2185-7-3**]. Species on [**7-3**] was Alcaligenes achromobacter. Patient complained of need to void urine on [**2185-7-11**] several times which was new for him. His suprapubic catheter was changed [**2185-7-13**] by urology. Levofloxacin was started on [**2185-7-11**] per [**2185-7-3**] sensitivities; for total 14 day course (last day is [**7-24**]). # Acute Pulmonary Emboli: Patient previously on Coumadin. [**2185-6-24**] CTA showed bilateral pulmonary emboli in the segmental and subsegmental levels without evidence of right heart strain. There was no clear cause for why he developed a PE. There was an area of hypoenhancement within the atelectatic right lower lobe along the periphery concerning for infarction. Increased coumadin from 1mg po to 2mg po daily on [**2185-7-13**]. Further increased coumadin from 2mg po to 4mg po daily on [**2185-7-16**]. His INR has been difficult to manage, likely in setting of antibiotics, malnutrition, Levothyroxine. On discharge, his Coumadin has just been restarted at 3mg after he has been supratherapeutic for the past 2 days. As an outpatient, he should have his INR followed (check in 48-72hrs). If his INR <2, he should be bridged with Lovenox 60mg q12h due to high risk for thromboembolism. On discharge, he is on room air, slightly tachypneic and tachycardic but has been stable. # Tachycardia/Hypotension: Related to above. Heart rates have been in 80-110's. SBP <80s in the ICU requiring pressors. Likely due to known pulmonary emboli with infection. Patient does not currently have sx of infection, so sepsis is less likely cause. It may be from pain, since patient is relatively unable to communicate. # Schizophrenia- Difficult to evaluate mental status. No evidence of responding to internal stimuli. Baseline over past few months [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] is that he is able to communicate pain/discomfort but does not have capacity. He is mostly lucid but answers questions in mumbles and broken statements. Patient had court date for guardianship on [**2185-7-19**] which was approved. He sometime says inappropriate comments but not frequently. Patient was ambulatory in [**Month (only) 205**] with assistance per previous [**Hospital1 1501**]. We continued his Depakote, Risperdal, and Remeron. # Pneumonia, MRSA: Treated with 8 day course of Vanc/Zosyn for bilateral patchy infiltrate and found to be MRSA positive on bronchial washings. Patient was hypotensive and hypoxic requiring intubation and pressors for 10 days in MICU. Extubated [**2185-7-6**]. [**2185-7-6**] CXR: Persistent opacification at the left base with progressive clearing of right base without vascular congestion. Later CXR cleared, he has finished treatment. # Hypothyroidism: Levothyroxine started this admission for TSH 8.6 in setting of acute septic shock. TSH 7.8 on [**2185-7-9**]. He should continue levothyroxine 25mcg po daily. He will need outpatient follow up of TSH in 1 month [**2185-8-8**] # FEN: IVF prn, replete electrolytes prn, ground solids, if ever needs tube feeds, needs post-pyloric b/c hiatal hernia TRANSITIONAL ISSUES - Continued on Levofloxacin until [**7-24**] - Guardianship obtained during admission. - Will need outpatient psych follow-up - He will need close management of coumadin with goal INR [**12-24**] indefinitely. He should have a bridge with Lovenox 60mg q12 if ever INR<2. Discharge Coumadin dose is 3mg. - please check TSH and free T4 on [**2185-8-8**]. Patient started on levothyroxine [**2185-7-3**] for low Triiodothyronine Thyroxine (T4), Free 0.78* and TSH 8.5. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Divalproex (DELayed Release) 250 mg PO QAM 2. Divalproex (DELayed Release) 375 mg PO QHS 3. Ranitidine (Liquid) 150 mg PO DAILY 4. Acetaminophen 650 mg PO BID 5. Milk of Magnesia 30 mL PO ONCE:PRN constipation 6. Bisacodyl 10 mg PO DAILY:PRN constipation 7. Loperamide 2 mg PO TID:PRN loose stools 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety 9. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6 hours wheezing 10. Megestrol Acetate 10 mg PO BID 11. Risperidone 7 mg PO HS 12. Mirtazapine 30 mg PO HS 13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain Monitor for sedation, RR < 8 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Divalproex (DELayed Release) 250 mg PO QAM 2. Divalproex (DELayed Release) 375 mg PO QHS 3. Risperidone 7 mg PO HS 4. Acetaminophen 650 mg PO BID 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Multivitamins 1 TAB PO DAILY 7. Megestrol Acetate 10 mg PO BID 8. Milk of Magnesia 30 mL PO ONCE:PRN constipation 9. Mirtazapine 30 mg PO HS 10. Ranitidine (Liquid) 150 mg PO DAILY 11. Loperamide 2 mg PO TID:PRN loose stools 12. Lorazepam 0.5 mg PO Q4H:PRN anxiety 13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain Monitor for sedation, RR < 8 14. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6 hours wheezing 15. Levothyroxine Sodium 25 mcg PO DAILY avoid taking around time of maalox, tums, simethicone RX *levothyroxine 25 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 16. Levofloxacin 500 mg PO Q24H Duration: 4 Days Please give until [**7-24**] for a total of 14 days RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 17. Warfarin 3 mg PO DAILY16 Goal INR [**12-24**] (bridge with lovenox if INR <2) RX *warfarin 3 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Pneumonia, Pulmonary Embolism Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Discharge Instructions: Mr. [**Known lastname 71063**], you were admitted to the [**Hospital1 827**] on [**2185-6-24**] for shortness of breath at your nursing facility. You were found to have pneumonia with MRSA in your lungs in addition to multiple blood clots in your lungs. This required you to be in the intensive care unit on a ventilator for over 1 week and requiring medicine to keep your blood pressure normal. After you had several days of antibiotics for your pneumonia, you were taken off the ventilator. Due to your lung clots, you will need to be on coumadin (a blood thinner) indefinitely. We have continued to change your dose depending on your INR (which needs to be between [**12-24**] to help prevent blood clots). You will be returning to your nursing home. Please follow up with your primary care physician. Followup Instructions: Please follow up with your Primary Care physician at [**Name9 (PRE) **] where you stay.

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icd9cm

[ [ [] ] ]

[ "96.6", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

21951, 22105

15856, 19963

312, 341

22179, 22294

3392, 10537

23184, 23275

2270, 2300

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22126, 22158

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22354, 23161

15502, 15833

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2866, 3373

265, 274

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397, 1957

22309, 22330

1979, 2179

2195, 2254

9,216

107,657

23777

Discharge summary

report

Admission Date: [**2199-4-5**] Discharge Date: [**2199-4-11**] Date of Birth: [**2170-4-19**] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 2932**] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 28 year old male with DM1 complicated by nephropathy, retinopathy, and severe gastroparesis requiring multiple admissions and gastric pacer placement, who presented to ER on [**2199-4-5**] with c/o nausea and vomiting x 3-4 days. He denied fevers, chills, hemetemesis, and reported that his symptoms were identical to prior flares of gastroparesis (last in 11/[**2198**]). He was admitted to the general medical floor. While on the floor, he continued to have marked nausea and vomiting, associated with labile blood sugars, ranging 300-400 (no anion gap to suggest DKA). He was evaluated by both gastroenterology and the [**Last Name (un) **] diabetes service, who recommended an insulin gtt to allow improved glucose control. For this reason, he was transferred to the ICU on [**2199-4-7**] Past Medical History: 1) Type 1 Diabetes Mellitus: Diagnosed at age 2, complicated by retinopathy (blind in left eye), nephropathy, and gastroparesis. Followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **]. 2) Chronic renal insufficency: baseline Cr ~ 1.6-2; + proteinuria 3) Gastroparesis: Since [**2194**]. Received Botox injection to the pylorus in 3/[**2197**]. Had Gastric stimulator placed on [**2197-11-10**] by Dr. [**Last Name (STitle) **]. Flare regimen includes reglan, Zelnorm, phenergan, compazine, and anzemet. Pacer last interrogated 06/[**2198**]. 4) History of hypoglycemic seizure 5) Hypertension 6) Migraines 7) Depression 8) Anemia 9) Gastritis/esophagitis Social History: Patient lives with his wife who is very dedicated to his care. Denies tobacco, alcohol, and illicit drug use. He is currently unemployed and on disability. Family History: Paternal grandfather with [**Name (NI) 59282**] Mother and sister with thyroid disease Physical Exam: VS: T 100.7 HR 130 BP 130/57 RR O2Sat 96% RA Gen: Patient nauseous, with rigors, looks uncomfortable Heent: PERRL, OP clear, MM dry Lungs: CTA B/L Cardiac: tachy, RRR S1/S2 no murmurs Abd: soft, NT, supressed bowel sounds Ext: no edema Neuro: AAOx3 Pertinent Results: Laboratory studies on admission: [**2199-4-5**] WBC-6.9 HGB-11.9 HCT-35.1 MCV-77 RDW-13.1 PLT COUNT-341 NEUTS-70.3* LYMPHS-20.6 MONOS-5.3 EOS-3.3 BASOS-0.6 LACTATE-1.8 GLUCOSE-266* UREA N-30* CREAT-2.3* SODIUM-139 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ALT(SGPT)-22 AST(SGOT)-22 ALK PHOS-101 AMYLASE-101* TOT BILI-0.3 CALCIUM-10.1 PHOSPHATE-1.9*# MAGNESIUM-2.4 U/A: URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Laboratory studies on discharge: [**2199-4-10**] WBC-9.6 Hgb-9.9 Hct-29.2 MCV-77 RDW-13.0 Plt Ct-295 Glucose-226* UreaN-14 Creat-1.7* Na-141 K-4.1 Cl-104 HCO3-26 [**4-5**] EKG: Sinus tachycardia. No significant change compared to the previous tracing of [**2198-11-11**]. There continues to show rapid heart rate and right axis deviation Radiology [**4-5**] CXR: Two views of the chest are markedly limited secondary to technique. Linear left retrocardiac opacities may represent atelectasis or may be secondary to poor technique. No definite airspace consolidation is present. No dilated bowel loops are identified within the visualized abdomen. Gastric stimulation device is unchanged in position. [**3-7**] KUB: Again visualized is a neurostimulating device projecting over the thoracolumbar spine. Gas is seen in the stomach and in the colon. Stool is seen throughout the colon. There is a paucity of small bowel gas, but no dilated loops are seen. There is no free air. Brief Hospital Course: 28 year old male with Type I diabetes and gastroparesis presents with exacerbation of gastroparesis. His course was complicated by acute renal failure and persistent hyperglycemia requiring transfer to the ICU for an insulin drip. 1) Gastroparesis: The patient's symptoms improved with improved glucose control in the ICU. He was initially NPO with IV anti-emetics, however, as his symptoms improved, his diet was gradually advanced. He was transferred to the general medical floor the evening of [**2199-4-10**], after which he remained asymptomatic off IV anti-emetics. At time of discharge, he was tolerating a regular diabetic diet without difficulty. 2) Type I diabetes, poorly controlled with complications: As mentioned above, the patient was transferred to the ICU for an insulin drip. He was subsequently transitioned to glargine and, at time of discharge, was on his home dose of glargine (although this was qAM rather than qhs). He will follow-up with Dr. [**Last Name (STitle) 3617**] as an outpatient. The precipitant of the patient's hyperglycemia is unclear; infectious work-up (urine culture, blood cultures, CXR) was unrevealing and EKG was without acute change. 3) Possible coffee ground emesis: Following the admission to the floor, the patient had an episode of emesis with possible coffee grounds. The gastroenterology service was consulted, who did not recommend EGD given his hematocrit was stable at 29. They felt that this was most likely related to gastritis (as visualized on prior EGD). He will continue PPI [**Hospital1 **] and will follow-up with gastroenterology as an outpatient. 4) Acute on chronic renal failure: The patient's creatinine was 2.3, which improved to his baseline 1.7 on discharge with hydration, indicating likely pre-renal etiology. 5) Hypertension: The patient was continued on his home doses of metoprolol and valsartan. 6) Iron deficiency anemia: At time of discharge the patient's hematocrit was stable at 29.2 (within baseline 27-31). His admission hematocrit of 35 likely represented hemoconcentration in the setting of nausea/vomiting. He will follow-up with gastroenterology as an outpatient for further work-up. Outpatient iron supplementation may be considered if his GI symptoms remain stable. Full Code. Medications on Admission: 1. Tegaserod Hydrogen Maleate 6 mg PO BID 2. Valsartan 80 mg PO BID 3. Metoprolol Tartrate 25 mg PO BID 4. Pantoprazole 40 mg PO Q12H 5. Metoclopramide 10 mg PO Q6H 6. Prochlorperazine 10 mg PO Q6H prn 7. Promethazine 25 mg PO Q6H prn 8. Insulin Glargine 30U qhs 9. Insulin Lispro per sliding scale 10. Clonidine patch QWednesday, unknown dose Discharge Medications: 1. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. 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* 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous QAM. 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding scale/carb counting Subcutaneous QAC and QHS. Discharge Disposition: Home Discharge Diagnosis: Primary: Type I diabetes, poorly controlled with complications Secondary: Gastroparesis, iron-deficiency anemia, hypertension, acute on chronic renal failure Discharge Condition: Tolerating food well, on oral medications Discharge Instructions: You were admitted with high blood sugars and a flare of gastroparesis. You were treated with an insulin drip and IV hydration/medications with improvement, and are now doing well on your home medication regimen. 1) Please follow-up as indicated below. 2) Please take all medications as prescribed. 3) Please see your primary care physician or come to the emergency room if you develop worsening nausea/vomiting, unable to tolerate oral medications, fevers, chills, abdominal pain, or other symptoms that concern you. Followup Instructions: 1) Primary Care: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) Thursday [**2202-5-3**]:10 a.m. 2) [**Last Name (un) **]: Dr. [**Last Name (STitle) 3617**] ([**Telephone/Fax (1) 2378**]) [**5-17**] at 3:30 p.m. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2199-4-11**]

[ "536.3", "362.01", "584.9", "250.41", "250.61", "583.81", "535.51", "276.51", "585.9", "403.90", "285.21", "250.51" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7376, 7382

3874, 6149

293, 318

7584, 7628

2398, 2417

8193, 8632

2025, 2114

6544, 7353

7403, 7563

6175, 6521

7652, 8170

2129, 2379

2905, 3851

238, 255

346, 1140

2431, 2891

1162, 1834

1850, 2009

58,515

125,506

3738

Discharge summary

report

Admission Date: [**2122-12-19**] Discharge Date: [**2123-1-4**] Date of Birth: [**2039-1-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Cholangitis/Pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is an 83 year-old congenitally deaf, Russian sign only Male with a history of systolic dysfunction, DM II, HTN, who presented initially in the ED with pancreatitis [**12-21**] CBD stone s/p ERCP. Via translator pt stated he started experiencing a constant [**2124-5-25**] sharp pain in his RLQ yesterday afternoon after eating dinner, pain did not improve which was why he came into the ED. Since the pain started he has had no appetite. He also experienced an episode of emesis, non-bloody yesterday. He denies any fevers, chills, changes in bowel movements, melena, hematochezia, hematemesis, chest pain, difficulty breathing. In the ED, had BP 115-140/70-92, HR 100-116, RR 16-20, Sat 96-100%. He underwent a CT abd which showed a small CBD stone with some inflammation of the pancreas head. Labs were also notable for Lipase of 2650, AST/ALT 413/402, Alk Phos 203. An EKG obtained in the ED was also notable for ST depressions with T wave incersions, cardiology was consulted and assessed pt having likely demand ischemia from his infectious state. Pt was started on Zosyn for cholangitis broad coverage as well as 2L NS. Pt underwent ERCP which resulted in visualization of two irregular stones in the common bile duct, one in the ampulla and one in the common hepatic duct with mild dilation of the biliary tree. Pt noted to be hypotensive with a SBP in the 70s following induction and during procedure was started Neosenephrine and transferred back to ICU still intubated. Past Medical History: HTN DM II Congenital Deafness (Russian sign) CAD (fixed apical myocardial defect with EF 40% [**5-/2121**]) Osteoarthritis Bifasicular block L subclavian steal syndrome Social History: Pt denies any Etoh, tobacco or recreational drug history. He currently lives at home with his wife. Family History: Family lives in [**Country 532**] and pt does not know. Physical Exam: GEN: Well-nourished elderly Caucasian Male intubated able to open eyes and follow simple commands with visual prompting (pt is deaf) HEENT: EOMI, PERRL, sclera anicteric NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, facial grimacing on palpation of RUQ, ND, +BS EXT: No C/C/E, no palpable cords Pertinent Results: [**2122-12-19**] 08:00AM GLUCOSE-364* UREA N-42* CREAT-2.2* SODIUM-135 POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-19* ANION GAP-20 [**2122-12-19**] 08:00AM ALT(SGPT)-413* AST(SGOT)-402* CK(CPK)-119 ALK PHOS-203* TOT BILI-3.9* [**2122-12-19**] 08:00AM LIPASE-2650* [**2122-12-19**] 08:00AM cTropnT-0.89* [**2122-12-19**] 08:00AM CK-MB-6 [**2122-12-19**] 08:00AM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-1.4* [**2122-12-19**] 08:00AM WBC-18.4*# RBC-4.46* HGB-14.1 HCT-42.2 MCV-95 MCH-31.6 MCHC-33.5 RDW-13.2 [**2122-12-19**] 08:00AM NEUTS-94.3* LYMPHS-3.2* MONOS-2.3 EOS-0.1 BASOS-0.1 [**2122-12-19**] 08:00AM PLT COUNT-237 [**2122-12-19**] 09:45AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-12-19**] 09:45AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2122-12-19**] 07:30PM TYPE-ART PO2-116* PCO2-36 PH-7.33* TOTAL CO2-20* BASE XS--6 [**2122-12-19**] 04:00PM PT-13.5* PTT-31.1 INR(PT)-1.2* [**2122-12-19**] 01:32PM GLUCOSE-323* LACTATE-2.0 K+-5.1 [**2122-12-19**] 12:26PM LACTATE-2.3* Imaging: CXR: No evidence of free air. Stable appearance of the right proximal humerus osteochondroma. CT ABD and PELVIS w/o Contrast: 1. Marked peripancreatic inflammatory stranding, most consistent with acute pancreatitis. Evaluation for complications related to acute pancreatitis is limited without intravenous contrast. Presumably, given the presence of multiple small gallstones, and likely stone in the region of the distal CBD,these findings represent gallstone pancreatitis. 2. Cholelithiasis. 3. Bilateral incompletely characterized hyperdense renal cysts. Followup renal ultrasound is recommended for further evaluation. ERCP: Bulging of the major papilla, due to impacted stone. Two irregular stones in the common bile duct ( one impacted in the ampulla) and common hepatic duct. Mild dilation of the biliary tree. Successful sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Successful extraction of two stones and sludge successfully using a 9 mm balloon. Infected black bile was seen draining from the bile duct. CT ABDOMEN [**2122-12-26**]: FINDINGS: There is atelectasis and/or consolidation at both bases, with bilateral small pleural effusions, left worse than right. There is extensive stranding surrounding the pancreas, with stranding also throughout the retroperitoneum, in keeping with pancreatitis. Overall, the extent of inflammation is unchanged. Please note that the lack of intravenous contrast limits the evaluation for pancreatic necrosis. Within the common bile duct as well as the cystic duct, there is hyperattenuating material. There is also hyperattenuating material layering within the gallbladder. The density of the material within the gallbladder appears somewhat higher when compared with the gallstones seen on the recent examination. Therefore, while some of this material may represent gallstones, contrast material retained within the gallbladder lumen is a possibility. Likewise, the hyperattenuating material within the common bile duct and within the cystic duct may also represent small stones vs. small amount of refluxed contrast. There is no evidence of common bile duct dilatation. The stomach is somewhat distended, and there is reflux of oral contrast into the esophagus. However, there is no evidence of bowel obstruction. Oral contrast passes to at least the distal ascending colon. Small bowel loops are normal in caliber throughout. Note is made of mild wall thickening of the ascending colon distally. The transverse colon and descending colon demonstrate no evidence of wall thickening. The findings in the right colon may be secondary to the pancreatic/retroperitoneal inflammation. Alternatively, it may reflect edema. It should be noted that there is evidence of diffuse subcutaneous edema as well as a small amount of ascites. Less likely, the findings could represent a focal infectious or inflammatory process. Allowing for lack of intravenous contrast administration, there is no gross contour abnormality associated with the liver, spleen, adrenals, or kidneys. There is no abdominal lymphadenopathy by size criteria. PELVIS: There is trace free fluid within the pelvis. The bladder is decompressed by a Foley catheter. OSSEOUS STRUCTURES: There are no suspicious osseous lesions. IMPRESSION: 1. Persistent inflammatory changes consistent with pancreatitis. Please note that non-contrast technique precludes the evaluation for pancreatic necrosis. Overall, the extent of inflammatory change is stable. 2. Hyperdensity within a non-dilated common bile duct extending over a fairly long segment. Differential considerations include small stones vs. refluxed oral contrast, vs. retained contrast material from the patients ERCP. ECHO [**2122-12-28**]: The left atrium is mildly 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 and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 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. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No pathologic flow identified. Compared with the prior study (images reviewed) of [**2122-12-21**], the findings are similar. Brief Hospital Course: 83 year-old congenitally deaf, Russian sign only Male with a history of systolic dysfunction, DM II, HTN, who presented initially in the ED with pancreatitis [**12-21**] CBD stone s/p ERCP. # Pancreatitis/Cholangitis: Pt noted to have cholangitis on and pancreatitis on ERCP examination on [**2122-12-19**] and two stones were extracted from the ampulla and common hepatic duct; a sphincterotomy was also performed. The patient was empirically treated with vanc and zosyn for gram positive and enteric coverage. His LFTs and pancreatic enzymes began trending down shortly after his procedure, but his hospital course became complicated by renal failure, subsequent metabolic acidosis, and inadequate respiratory complication requiring intubation secondary to respiratory fatigue. This is described further in the sections below. Regarding his pancreatitis, a KUB was attained on [**2122-12-20**] and was read as likely ileus with distended air-filled loops of small and large bowel. This gradually resolved, however, and was not present on a KUB on [**2122-12-24**], which was essentially normal. An abdominal CT obtained on [**2122-12-26**] to evaluate for a possible abscess or other etiology for infection (see the "?C. Diff" section below) in the setting of luekocytosis confirmed that there was persistent pancreatitis but no evidence of ileus or abscess. He was continued on Zosyn and vancomycin and called out to the floor. There, he developed an ileus and aspirated, subsequently entering septic shock. He was transferred to the [**Hospital Unit Name 153**] and was maintained on pressors and IVF but progressively became acidotic, with a rising lactic acidosis of unclear etiology. Ultimately, his family agreed that he should be CMO and he expired on [**2123-1-4**]. # Resp failure: Initial respiratory failure presumed due to volume overload and metabolic acidosis secondary to ARF and anuria, with fatigue [**12-21**] respiratory compensation. A LIJ was placed on [**2122-12-22**] and the patient was intubated on [**2122-12-23**] for worsening respiratory distress. Extubation was attempted on [**2122-12-25**] but the patient had to be reintubated shortly afterward because of profound wheezing secondary to pulmonary edema and peribronchial cuffing. He was successfully extubated on [**2122-12-28**] after significant volume removal with CVVH. His re-intubation on [**12-25**] was complicated by an esophogeal intubation in which he aspirated. His antibiotic coverage was not changed, however, because of its broad coverage. He was also treated with budesonide/atrovent/albuterol nebs. Was called out to floor as above and developed Acute lung injury/ARDS after aspirating. He expired on [**2123-1-4**] as described above. # [**Last Name (un) **] on CKD: Pt has history of CKD with a baseline Creatinine of 1.7-1.9. Pt's creatinine peaked at 6.0 prior to starting CVVH on [**12-22**] . Still unclear etiology of ARF; thought to be ATN initially but there was an absence of muddy brown casts on microscopic urine exam. A R subclav was placed for HD, and a tunneled HD line was planned in IR on [**2122-12-31**]. #?C difficile colitis: Patient developed a leukocytosis with a WBC count that peaked at approximately 40. Cultures were negative and CT showed no abcess or drainable fluid collection but did show persistent pancreatitis. The presumed was C. diff and his white count did indeed begin to follow after the initiation of therapy. He was started on flagyl and PO vanco empirically for c. diff (anticipate 14 day course). # Shock: After ERCP on [**12-19**] pt was noted to be hypotensive to SBP in the 70s and required pressors on arrival to the [**Hospital Unit Name 153**]. Septic shock was considered to be a contributing factor, along with possible PE. His antibiotics were continued as above and he was given IVF and placed on vasopressors as needed to maintain MAP>65. He last required pressors on [**2122-12-23**] before being called out to the floor. After returning to the [**Hospital Unit Name 153**], he was again restarted on pressors but ultimately expired on [**2123-1-4**] as described above. # ?Pulmonary embolism: On [**2122-12-21**], the patient had an acute episode of hypoxia and hypotension. There was high suspicion for acute PE and he was empirically anticogulated. Chest CTA could not be performed because of his renal failure, and LENIs were negative. Our decision was to empirically treat him with 9 months of anticoagulation. This was d/c'd when he returned to the [**Hospital Unit Name 153**], however. # DM II: Continued on ISS. # Chronic systolic CHF: Patient on prior echo noted to have a reduced EF of 40% with a fixed Apical defect. Pt on afterload therapy with Lisinopril and Valsartan per OMR. His lisinopril and valsartan were held given his ARF and hypotension. # Code: FULL CODE # Comm: (Son) [**Name (NI) 751**] [**Telephone/Fax (1) 16839**] Medications on Admission: Medications:(Per OMR and confirmed with Pharmacy pt could not recall medications) Glyburide 5MG once a day Lipitor 40 mg once a day Lisinopril 10 mg Tablet Metoprolol Succinate 25 mg once a day Aspirin 81 mg once a day Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: Expired Discharge Instructions: None Followup Instructions: N/A Completed by:[**2123-1-4**]

[ "576.1", "038.9", "584.9", "008.45", "250.00", "560.1", "995.92", "785.52", "577.0", "410.71", "414.01", "428.22", "389.8", "276.2", "403.90", "518.81", "574.51", "585.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "51.85", "51.88", "38.95", "51.87", "96.04", "38.91", "39.95", "99.15", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

13729, 13738

8486, 13431

340, 346

13786, 13796

2711, 8463

13850, 13884

2189, 2246

13701, 13706

13759, 13765

13457, 13678

13820, 13827

2261, 2692

276, 302

374, 1862

1884, 2055

2071, 2173

55,337

118,009

37829

Discharge summary

report

Admission Date: [**2170-2-6**] Discharge Date: [**2170-3-9**] Date of Birth: [**2118-7-8**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1384**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2170-2-6**]: Exploratory laparotomy with lysis of adhesions and resolution of small bowel obstruction. [**2170-2-6**]: EGD [**2170-2-6**]: Reopening of recent laparotomy with control of intra-abdominal hemorrhage. [**2170-2-15**]: Replacement of [**Last Name (un) **]-intestinal feeding tube (line cracked) [**2170-2-13**]: Angiogram [**2170-3-2**]: Attempted PTC placement: no ducts identified, no drain left in place History of Present Illness: 51y F s/p OLT/kidney txp [**12-3**], well-known to transplant surgery service presents w/acute onset of abdominal pain, nausea/vomiting beginning 12 hours earlier. The pain is constant, initially epigastric and becoming more diffuse. The was described as coffee ground in appearance, it is non-bilious. She has had normal bowel movements, and has been passing flatus. The patient denies fever/chills, change in bowel/urinary habits. She had been tolerating tube feeds as well as PO intake prior to this episode. Of note her post-transplant course was complicated by breakdown of the jeju-jejunosotomy requiring revision, as well as hepatic artery stenosis requiring stenting, resp failure requiring tracheostomy, atrial fibrillation/flutter which resolved prior to discharge. Details of her post-operative course are listed below [**2169-11-28**] DCD Liver transplantation with portal vein to portal vein, roux-n-y hepaticojejunostomy, common hepatic artery (donor) to proper hepatic artery (recipient) [**2169-11-28**] DCD kidney tranplantation, left kidney to right iliac fossa [**2169-11-28**] splenectomy [**2169-12-7**] exploratory laparotomy, small bowel resection, enteroenterostomy x 2 [**2169-12-21**] open tracheostomy [**2169-12-24**] CT guided drainage of splenic bed fluid collection and aspiration of anterior abdominal wall collection [**2169-12-25**] right hepatic artery stent placement Past Medical History: - ESLD [**12-26**] EtOH cirrhosis - hisory of alcohol hepatitis refractory to steroids. Diagnosed [**2169-6-24**], followed by Dr. [**Last Name (STitle) 696**] since [**2169-8-24**]. - HRS requiring HD - s/p liver/kdney transplant and splenectomy [**2169-11-29**] Social History: Heavy EtOH use w/ last drink [**5-/2169**], actively involved in EtOH relapse prevention counseling. Patient was drinking 1 L of hard alcohol over 3 days for the past year (up until [**Month (only) 205**]). She denies any history of tobacco use or other substance use. She is not currently working, but was previously a human resources director. She lives at home with her husband and [**Name2 (NI) **] when not at [**Name (NI) **]. She has two children ages 21 and 18, who live near her. Family History: Her [**Name (NI) **] are alive at ages 79 and 80 and in good health. She has four siblings, none of whom have any chronic illnesses. Physical Exam: Physical exam 98.1 111 127 91 20 100 RA Gen: appears uncofortable Cardio: NSR, converted to Afib w/RVR while awaiting CT Resp: ctab abd: soft, bruised, diffusedly tender,+ guarding, + rebound ext: mild LE edema Pertinent Results: On Admission: [**2170-2-6**] WBC-7.4 RBC-2.77* Hgb-8.9* Hct-27.0* MCV-98 MCH-32.2* MCHC-33.0 RDW-16.7* Plt Ct-656*# PT-12.5 PTT-23.2 INR(PT)-1.1 Glucose-123* UreaN-25* Creat-0.9 Na-138 K-5.0 Cl-99 HCO3-28 AnGap-16 ALT-22 AST-27 AlkPhos-384* TotBili-0.3 Lipase-16 Albumin-3.3* Calcium-9.2 Phos-4.8* Mg-2.7* Triglyc-315* HDL-20 [**2170-2-12**] TSH-9.5* [**2170-2-20**] PTH-17 At Discharge: [**2170-2-21**] WBC-14.1* RBC-3.13* Hgb-9.2* Hct-28.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-14.9 Plt Ct-760* Glucose-117* UreaN-12 Creat-0.5 Na-131* K-5.2* Cl-94* HCO3-28 AnGap-14 Calcium-8.7 Phos-2.8 Mg-1.5* ALT-27 AST-28 AlkPhos-258* TotBili-0.3 Brief Hospital Course: 51 y/o female s/p combined liver and kidney transplant with splenectomy in [**2169-11-24**] and protracted post op course who now presents with abdominal pain and coffee ground emesis. On admission she underwent CT exam of the abdomen which showed massive dilation of the distal Roux limb, just proximal to the anastamosis, and moderate dilatation of the proximal Roux limb concerning for obstruction at the Roux- en- Y anastomosis. Small amount of free fluid in the leaves of the mesentery. She was taken emergently to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] for exploratory laparotomy with lysis of adhesions and resolution of small bowel obstruction. Upon entering the abdomen they found dilated and matted bowel down to the terminal ileum and she required extensive lysis of adhesions. There was also some thick contents in the bowel, and it seemd there was fecalization of the small bowel and that this material was quite hard. This was broken up manually and pushed through to the ileocecal valve to make sure that she could pass them. The Roux tube was no longer in the bowel and this was removed. She tolerated the surgery without complication and was transferred to the SICU. That same day she underwent an EGD due to the coffee ground emesis and was noted to have a small amount of altered blood in the fundus with no active bleeding source. there were no gastric varices or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear seen on retroflexion. Mucosa normal without evidence of congestive gastropathy or ulceration. Small amount of blood seen refluxing from the pylorus. Later the same day she dropped her hematocrit to 17%. Of note she had been on aspirin and plavix as an outpatient which had been stopped on admission. She was taken back to the OR again with Dr [**Last Name (STitle) 816**] for reopening of recent laparotomy with control of intra-abdominal hemorrhage. Upon reopening, they immediately met with approximately 2 units of blood in the abdomen. The blood was evacuated and seemed to be coming from a Prolene suture which was in the abdominal wall fascia. No other sites could be found. She was transferred back to the ICU. Over the course of these events she received 7 units RBCs, 1 u platelets and FFP and her hematocrit stabilized. She was transferred to [**Hospital Ward Name 121**] 10 and then on [**2-12**] developed melenotic stool and she was transferred back to the ICU. On the same day she had a positive GI bleeding study with tracer uptake on the first image. There was concern this could be from the Roux limb. She underwent CTA showing new intraperitoneal fluid seen in the abdomen and pelvis, not present on the prior scan. Higher attenuation material within this fluid is suspicious for hemorrhage. No obvious source of bleeding is identified on this examination. Hematocrits continued to be monitored, she had another EGD, this time not showing evidence of any active bleeding. Hematocrit had dropped to 22%. She received an additional 4 units RBCs over the 22nd and 23rd and 1 unit platelets and has remained stable since. Stools have become normal brown again. Aspirin and then plavix have been added back in to the medication regimen (for the hepatic artery stent) A Dobhoff was placed on [**2-13**] and tube feeds were resumed with reasonable tolerance. The feeds were adjusted to Isosource with less diarrhea. Due to increasing alk phos a transjugular liver biopsy was performed on [**2-23**]. Results showing one fragment with zonal necrosis involving periportal zone and zone 2 hepatocytes with mixed inflammation including plasma cells, liver parenchyma with bile ductular proliferation with associated neutrophils, focal mild lobular inflammation with plasma cells and NO features of rejection seen. Due to the necrosis picture, a liver ultrasound was obtained. Resistive indices were low and an abnormal waveform in the hepatic arteries was reported. An angiogram was performed based on the ultrasound findings showing patent celiac artery, common hepatic artery, right hepatic artery and left hepatic artery. There is mild narrowing of the distal common hepatic artery, presumably at the level of the anastomotic site, with no significant change in comparison with exam performed on [**2169-12-25**]. There is good flow through the previously placed stent at the origin of the right hepatic artery. The patient is continued on aspirin and plavix. As the alk phos continued to be elevated, a PTC was attempted on [**3-2**]. Percutaneous transhepatic passes made in an attempt to perform PTC which was not possible as no ducts are opacified. Note that simultaneous ultrasound shows evidence of passes throughout the left lobe but does not show any visible ducts. No drain was left in place. The alk phos very slowly has trended to about 200. WBC was elevated to 17 for a few days. The central line was removed, cath tip not showing significant growth, Urien culture was negative and blood cultures are negative to date but not finalized. She has remained afebrile and the WBC has slowly trended back down to 15 at discharge. The patient remains on tubes feeds which she is tolerating without problems. She is ambulatory with a walker and needs major assistance with rehab for home. Medications on Admission: Plavix 75 mg p.o. daily famotidine 20 mg p.o. twice daily fluconazole 400 mg p.o. daily levothyroxine 112 mcg p.o. daily lorazepam 0.5 mg p.r.n. anxiety metoprolol sustained release 100 mg p.o. daily, mirtazapine 7.5 mg p.o. q.h.s. p.r.n. insomnia mycophenolate mofetil 500 mg p.o. twice daily ondansetron 4 mg every eight hours p.r.n. nausea, oxycodone 5 mg every four hours p.r.n. pain, pentamidine monthly prednisone 5 mg p.o. daily tacrolimus 1.5 mg p.o. twice daily ursodiol 600 mg p.o. twice daily Valcyte 900 mg p.o. daily aspirin 325 mg p.o. daily calcium carbonate two tablets p.o. twice daily [**Doctor First Name **] sulfate one tablet p.o. twice daily Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Small bowel obstruction Upper GI bleed Abdominal wall hematoma UTI Moderate malnutrition Hypothyroidism s/p liver transplant [**2169-11-24**] Discharge Condition: Stable/fair A+Ox3 Minimal ambulation, needs extensive PT Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, inability to take or keep down food fluids or medications, abdominal pain. Monitor for any evidence of bleeding such as nosebleed, rectal bleeding, easy bruising. Monitor the incision for redness, drainage or bleeding. Call if there are problems with the post pyloric feeding tube or the patient is not tolerating tube feeds Labs to be drawn q Monday and Thursday with results faxed to the transplant clinic at [**Telephone/Fax (1) 697**]. Labs include CBC, Chem 10, AST, ALT, T bili, alk phos, trough prograf and U/A TSH, Free T4 should be rechecked week of [**3-26**] for dosage increase end of [**Month (only) 958**] Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2170-3-21**] 10:40 Completed by:[**2170-3-9**]

[ "V42.7", "996.59", "E878.1", "V42.0", "560.81", "E878.8", "535.50", "276.6", "998.11", "263.0", "244.9", "427.31", "578.1", "535.60", "287.5", "275.3", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "87.54", "45.13", "99.05", "50.13", "96.07", "88.47", "54.59", "54.12" ]

icd9pcs

[ [ [] ] ]

10027, 10098

4008, 9313

303, 728

10284, 10343

3355, 3355

11124, 11316

2973, 3107

10119, 10263

9339, 10004

10367, 11101

3122, 3336

3743, 3985

249, 265

756, 2163

3369, 3729

2185, 2450

2466, 2957

1,616

177,269

22304

Discharge summary

report

Admission Date: [**2118-11-14**] Discharge Date: [**2118-11-20**] Date of Birth: [**2075-8-18**] Sex: M Service: HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 47 year old male underwent coronary bypass grafting times three in [**2118-6-9**], and now has onset of shortness of breath and increasing fatigue since [**2118-8-10**]. He had an echocardiogram which showed three to four plus mitral regurgitation and he is now admitted, was seen preoperatively by Dr. [**Last Name (Prefixes) **] for mitral valve replacement. Cardiac catheterization showed venous left anterior descending coronary artery with 70 to 80 percent stenosis, vein graft to the obtuse marginal two with 80 percent stenosis, patent vein graft to the posterior descending coronary artery, ejection fraction 25 to 30 percent, occluded left coronary artery, global hypokinesis, three to four plus mitral regurgitation, 100 percent native left anterior descending coronary artery, 70 to 80 percent native circumflex and obtuse marginal one 99 percent lesion. Echocardiogram showed global hypokinesis, inferior akinesis, ejection fraction 30 percent, three to four plus mitral regurgitation and trace tricuspid regurgitation. PAST MEDICAL HISTORY: Status post coronary artery bypass graft times three in [**2118-6-9**]. Elevated lipids. Hypertension. Ankle surgery. ICD placement 11/[**2117**]. Percutaneous transluminal coronary angioplasty with stents times three in [**2118-8-10**]. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. daily. 2. Lisinopril 10 mg p.o. daily. 3. Toprol 25 mg p.o. daily. 4. Lipitor 40 mg p.o. daily. 5. Plavix 75 mg p.o. daily. 6. Bupropion SR 150 mg p.o. twice a day for smoking cessation. 7. Vitamin B1 10 mg p.o. daily. ALLERGIES: He had no known allergies. SOCIAL HISTORY: The patient is currently unemployed. He had a thirty pack year history of smoking four to five cigarettes a day right at this time although the patient admits that he is cutting down. He also admits to a couple of beers per week. Cardiac MR performed [**2118-10-13**], showed a left ventricular ejection fraction of 55 percent, a forward left ventricular ejection fraction of 30 percent, right ventricular ejection fraction of 59 percent, moderate to severe mitral regurgitation, mild to moderate tricuspid regurgitation and descending thoracic aorta diameter was 29 with global hypokinesis. Preoperative laboratories were as follows: Urinalysis was negative. ALT 24, AST 23, alkaline phosphatase 112, total bilirubin 0.5, total protein 8.5, albumin 4.9, globulin 3.6, hemoglobin A1C 5.7 percent. Prothrombin time 12.8, partial thromboplastin time 28.2 and INR 1.0. Sodium 137, potassium 4.5, chloride 99, bicarbonate 25, blood urea nitrogen 22, creatinine 1.1 with a blood sugar of 78. White blood cell count 8.9, hematocrit 43.8. Electrocardiogram showed sinus bradycardia at 59 beats per minute. Chest x-ray showed interval placement of right ventricular ICD lead, as well as decreasing left base lung atelectasis. PHYSICAL EXAMINATION: On examination, the patient is five feet nine inches tall, 190 pounds, oxygen saturation 96 percent in room air, in sinus rhythm at 67 beats per minute with a blood pressure of 133/86. He came into the office in no apparent distress. His skin was warm and dry with normal skin tone. Extraocular movements were intact. No jugular venous distention or carotid bruits. Lungs were clear bilaterally. His heart was regular rate and rhythm with S1 and S2 tones and grade II/VI systolic ejection murmur heard best at the apex. His abdomen was soft, round, nontender, nondistended, with positive bowel sounds. Extremities were warm and well perfused with no edema. He had no varicosities apparent. He was alert and oriented times three and appropriate and grossly neurologically intact. He had bilateral two plus dorsalis pedis, posterior tibial and radial pulses. No carotid bruit was heard. HO[**Last Name (STitle) **] COURSE: The patient was seen preoperatively on [**2118-11-11**], in the office and was admitted for his surgery on [**2118-11-14**]. Dr. [**Last Name (Prefixes) **] performed a redo sternotomy with mitral valve replacement with 27 millimeter [**Last Name (un) 3843**]- [**Doctor Last Name **] bioprosthesis. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a Lidocaine drip of 2 mg a minute, Neo-Synephrine drip at 0.3 mcg/kg/minute, Epinephrine drip at 0.01 mcg/kg/minute and titrated Propofol drip. On postoperative day number one, the patient had a blood pressure of 109/65, remained ventilated in sinus rhythm at 73 beats per minute on an Epinephrine drip at 0.01, Neo-Synephrine drip at 0.6 and insulin drip at 2 units per hour and Lidocaine drip at 2.0. Epinephrine was discontinued during the day. Swan remained in and the patient remained intubated and sedated. When he was off sedation, he was moving all extremities. He had coarse breath sounds bilaterally with the plan to extubate him and try and cut back on his drips in preparation for extubation. He was also seen by electrophysiology service. His ICD detectors were turned off. The patient was left on VVI. They evaluated his pacer and then did postoperative interrogation. Detection was turned on and VVI was set at 40 and it was determined that the ICD single chamber was normally functioning. On postoperative day number two, the patient had been extubated and an ejection fraction of approximately 40 percent. Blood pressure 103/60 and sinus rhythm in the 70s, oxygen saturation 97 percent on nasal cannula. Started Aspirin and his oral Plavix as well as Lasix diuresis. Neo-Synephrine was weaned to off. He started on low dose beta blockers. Chest tubes and Swan-Ganz were discontinued and his Precedex was discontinued. The patient ask for a pain service consultation. This was determined by the team to be placed on the back burner at the time. The patient was making adequate urine. His postoperative hematocrit was 26, and a chest x-ray was ordered. On postoperative day number three, he continued Plavix, Lopressor and Lasix and he was off all drips. He was changed over to Toprol. His chest tubes were discontinued and his pacing wires were discontinued. The patient continued to have a slight oxygen requirement and he was transferred out to the floor. He was also started on Flomax. Foley was replaced for retention and was left in. Repeat chest x-ray showed a right lung base effusion. The patient had an oxygen requirement. Beta blocker was changed over to Toprol. The patient was transferred out to the floor later in the day. The patient was transferred out to the floor and began to work with physical therapy. He was also seen by case management in an effort to get him to improve his pulmonary toilet and start increasing his activity level. His creatinine remained stable at 0.9. He was on Toprol XL at 25 and continued with his Plavix. His p.o. intake was limited. The patient was managed with p.o. pain medications on the floor, continued to work with physical therapy, made excellent progress on postoperative day number five. He continued with Flomax and he was encouraged to ambulate and increase his p.o. intake. His pacing wires were discontinued without any incident and discharge planning was begun. The patient was also started on Thiamine and was receiving some Dilaudid p.r.n. for pain, as well as starting on some Flovent and Combivent to aid in his pulmonary status. The patient also was given a little bit of Ativan to help him with his Dilaudid, to decrease his anxiety and increase his pain relief. He had some right basilar crackles and was getting nebulizer treatments as previously stated. He continued to improve on the floor. On postoperative day number six, his weight was down to 87.2 kilograms and he was hemodynamically stable. He was doing very well and was discharged to home with VNA services. He was noted to have a small ridge noted on his incision but this was not deemed to be necessary to hold up his discharge and he was discharged to home on [**2118-11-20**]. DISCHARGE DIAGNOSES: Status post redo sternotomy and mitral valve replacement. Status post coronary artery disease [**2118-6-9**]. Elevated lipids. Hypertension. Ankle surgery. ICD placed 11/[**2117**]. Percutaneous transluminal coronary angioplasty with three stents 09/[**2117**]. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to follow- up with Dr. [**Last Name (Prefixes) **] and see him in the office at approximately four weeks postoperatively for his postoperative surgical visit. He was also instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12300**] for his postoperative visit in one to two weeks, [**Telephone/Fax (1) 58104**]. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. twice a day for seven days. 2. Potassium Chloride 20 mEq p.o. twice a day for seven days. 3. Colace 100 mg p.o. twice a day. 4. Enteric Coated Aspirin 81 mg p.o. one daily. 5. Plavix 75 mg p.o. daily. 6. Dilaudid 2 mg tablets, dispense one to two tablets p.o. p.r.n. q4-6hours for pain as needed. 7. Albuterol/Ipratropium 103/118 mcg aerosol two puffs inhalation q6hours. 8. Fluticasone Propionate 110 mcg aerosol two puffs twice a day inhalation. 9. Ibuprofen 600 mg p.o. q6hours as needed for pain. 10. Metoprolol 50 mg p.o. sustained release one daily. 11. Tamsulosin Hydrochloride 0.4 mg sustained release p.o. daily at bedtime. 12. Bupropion 150 mg sustained release p.o. twice a day for smoking cessation. CONDITION ON DISCHARGE: Again, the patient was discharged home in stable condition on [**2118-11-20**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2119-1-31**] 16:47:43 T: [**2119-1-31**] 20:25:44 Job#: [**Job Number 58105**]

[ "V45.82", "424.0", "788.20", "997.5", "V45.81", "V53.32", "786.05", "412" ]

icd9cm

[ [ [] ] ]

[ "35.23", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

8194, 8894

8920, 9684

1518, 1805

3075, 8172

1248, 1492

1822, 3052

9709, 10042

21,306

137,814

52213+59409

Discharge summary

report+addendum

Admission Date: [**2134-5-30**] Discharge Date: Date of Birth: [**2065-5-24**] Sex: M Service: CCU Please note that this is an initial discharge summary that will have an associated addendum dictated at a later time. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with dilated cardiomyopathy with an ejection fraction of approximately 10%, who presented with worsening orthopnea and dyspnea. He has had multiple recent admissions to the Cardiovascular service. In [**2134-4-14**], he was admitted with complete heart block and a DDD pacemaker was placed. Earlier this month, in [**2134-5-15**], he was readmitted with acute renal failure, hyperkalemia, and hypotension. He was transiently in the Coronary Care Unit on dopamine for one day before being transferred to the floor when his heart failure medications were gradually added back on. He was just discharged on [**2134-5-19**]. He has been followed closely by his cardiologist, Dr. [**First Name (STitle) 2031**], who had been able to increase his lasix back to his previous outpatient dose of 80 mg by mouth twice a day. Enalapril had been continued at 10 mg by mouth once daily and Toprol XL had been held. Today he complains of dyspnea on exertion and progressive orthopnea for the last three to five days. He has had increasing peripheral edema but, over the last two or three days, he thinks this has improved. His weight was 191 pounds yesterday, although he claims his dry weight is approximately 180 pounds. He felt extremely fatigued. No fevers, chills, nausea, vomiting or diarrhea. No recent antibiotic use. No dysuria, no chest pain. He did have paroxysmal nocturnal dyspnea and a mild cough. He admitted to a decreased appetite. Because of his feeling generally unwell, he called his niece to bring him into the Emergency Room. PAST MEDICAL HISTORY: 1. Dilated cardiomyopathy, likely ethanol-induced; ejection fraction of approximately 10%. An echocardiogram in [**2134-5-15**] showed an ejection fraction of less than 20%, superior left ventricular dilation, severe global right ventricular and left ventricular hypokinesis, 3+ mitral regurgitation, and 2+ tricuspid regurgitation. 2. Coronary artery disease, although he had a normal cardiac catheterization in [**2128**] 3. Noninsulin dependent diabetes mellitus 4. Asthma 5. Complete heart block status post DDD pacemaker in [**2134-5-15**] 6. Tophaceous gout, recently in the fourth toe on the left foot 7. Chronic renal insufficiency progressing to acute renal failure in [**2134-5-15**], now resolved. His baseline creatinine is approximately 1.5 to 2.0. MEDICATIONS ON ADMISSION: K-Dur 20 mEq by mouth once daily, Vasotec 10 mg by mouth once daily, Coumadin 3 mg by mouth once daily, Colace 100 mg by mouth once daily, lasix 80 mg by mouth twice a day, aspirin 325 mg by mouth once daily, Atrovent inhaler two puffs inhaled four times a day, amiodarone 400 mg by mouth once daily, Toprol XL 12.5 mg by mouth once daily that was on hold, Glyburide 10 mg by mouth twice a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a former iron worker, now retired. He lives next door to his niece, who is his closest relative. [**Name (NI) **] denies smoking or current drinking. The niece's phone number is [**Telephone/Fax (1) 108018**], name [**First Name4 (NamePattern1) **] [**Known lastname 11752**]. PHYSICAL EXAMINATION: Afebrile, heart rate 80, blood pressure 90/54 (this is his baseline blood pressure), respirations 14, oxygen saturation 98% on room air. In general, an elderly male, lying in bed, comfortably, speaking in full sentences, in no acute distress. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, extraocular movements intact, normocephalic, atraumatic, oropharynx clear, jugular venous distention approximately 10 cm. Chest: Bilateral basilar rales that he is known to have at baseline, otherwise clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2, and S3 are heard. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: 2+ pitting edema bilaterally. LABORATORY DATA: White count 7.2, with a normal differential. Hematocrit 33.8 with a mean cell volume of 79. Platelets 235, INR 2.4, PTT 36.4. Chem 7: Sodium 134, potassium 5.3, chloride 99, bicarbonate 20, BUN 53, creatinine 2.3, glucose 182. Initial CK was 73. Electrocardiogram: He was AV paced at 80 beats per minute with a left bundle branch block. There were no changes compared to previous electrocardiogram. Chest x-ray showed cardiomegaly with mild upper zone redistribution. IMPRESSION: This is a 69-year-old man with dilated cardiomyopathy, who presents with increasing dyspnea, paroxysmal nocturnal dyspnea, and orthopnea, consistent with fluid overload. HOSPITAL COURSE BY SYSTEM: 1. Cardiac: Because of the patient's acute decompensated congestive heart failure, the patient was ruled out for myocardial infarction by enzymes. Aspirin was continued. In order to more accurately assess the patient's fluid status in light of his surprisingly clear lung examination, the patient was taken to cardiac catheterization for a right heart catheterization. This showed marked increased pulmonary capillary wedge pressure up to 30 mm Hg, with a mean right atrial pressure of 25, consistent with marked fluid overload. The cardiac index was depressed at 1.82. Milrinone intravenous was given, and the wedge pressure decreased to 22, with an increase in the cardiac output to 2.62. He was transferred to the Coronary Care Unit with his Swan-Ganz catheter in place, for further management and aggressive diuresis. Initially this was attained with a milrinone drip to improve cardiac output, and intravenous lasix to reduce pre-load. However, the patient's blood pressure did not tolerate this regimen, so dopamine was added for pressor support. The lasix drip was increased to 40 mg/hour, and Zaroxolyn was added, with good effect. The patient diuresed approximately 2 liters over two days on this regimen. With hopes of weaning the dopamine, Natrecor was added as an augmentation to the lasix. The patient continued to diurese, however, the dopamine was continued for low blood pressure. It should be noted that we maintained the dopamine dose at 3 mcg/kg/minute because, at higher doses, the patient experienced considerable ectopy. By hospital day seven, the lasix drip had been converted to twice a day lasix, the milrinone was turned off, Aldactone was added, and Zaroxolyn was continued. The patient was given Enalapril 2.5 mg by mouth twice a day intermittently, but this was often held for low blood pressure. It was felt that, by hospital day seven, the patient had returned to his normal dry weight. The patient's electrocardiogram showed evidence of ventricular dyssynchrony. Specifically, the QRS duration was prolonged. Therefore, the Electrophysiology service was consulted to consider conversion to biventricular leads provide biventricular synchronization. It was decided that this would be performed once the patient was euvolemic. As of this dictation, the plan is to perform this procedure on [**6-7**]. The patient's amiodarone was continued for his history of atrial fibrillation. The dose was decreased to 200 mg by mouth once daily. The patient was also anticoagulated both for the history of atrial fibrillation as well as the low ejection fraction. 2. Pulmonary: The patient had few pulmonary symptoms after he was adequately diuresed. Supplemental oxygen was provided, and he had excellent oxygen saturation. 3. Infectious Disease: The patient had a temperature spike to 102 on hospital day number seven. Blood cultures and urine cultures were taken, and the results were still pending at the time of this dictation. Empiric vancomycin, levofloxacin and Flagyl were started. The patient's central line was discontinued to account for the possibility of line sepsis. These antibiotics should be continued until the culture results are known, with tailoring of the antibiotic regimen for the appropriate pathogen or, in the event of a negative culture workup, the antibiotics should be discontinued. 4. Gastrointestinal: The patient had a history of constipation, and this was a problem for him during this hospitalization. He required an aggressive bowel regimen. We also continued Protonix. 5. Prophylaxis: The patient received heparin subcutaneously for deep venous thrombosis prophylaxis, as well as Protonix as mentioned above. 6. Code status: The patient is full code. DISPOSITION: As of this dictation, the plan is for transfer back to [**Hospital Unit Name 196**] after stabilization of the patient's blood pressure and conversion of DDD pacer to biventricular mode. The remainder of the hospital course will be dictated in a separate dictation summary addendum. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2134-6-6**] 00:02 T: [**2134-6-6**] 04:02 JOB#: [**Job Number 108019**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 17653**] Admission Date: [**2134-5-30**] Discharge Date: [**2134-6-16**] Date of Birth: [**2065-5-24**] Sex: M Service: ADDENDUM: HOSPITAL COURSE: This is a 69 year old Caucasian male with a history of dilated cardiomyopathy with ejection fraction of approximately 10% who was transferred from the CCU to the [**Hospital Unit Name **] Service for further observation biventricular lead placement and discharge. HOSPITAL COURSE BY SYSTEM: 1. Cardiac. An echocardiogram was performed on the [**11-11**] which showed the following; the left atrium was moderately dilated approximate 5.3 cm. the left ventricular cavity was severely dilated (7.8 cm). There is severe global left ventricular hypokinesis. The right ventricular cavity is moderately dilated. There was moderate to severe global right ventricular free wall hypokinesis. The aortic root was mildly dilated. The aortic mitral leaflets are also mildly dilated. Mild +1 (aortic regurgitation was seen). The mitral valve leaflets are mildly thickened. Moderate to severe +3 (mitral regurgitation) was seen. The interval between the R-wave to the aortic valve opening was measured at 245 milliseconds, 250 milliseconds and 250 milliseconds in serial recordings, a pericardial short access view. The interval between the R-wave to aortic valve opening was measured as 260 milliseconds in the parasternal long access view. The interval between the R-wave to pulmonic valve opening was measured at 170 milliseconds, 185 milliseconds, 190 milliseconds and 185 in serial recordings in the parasternal views. In the parasternal RVOT view the interval between the R-wave to the pulmonic valve opening was measured at 190 milliseconds. It was determined that it would be beneficial to the patient to have a placement of a third pacemaker lead wire to provide biventricular synchronization. This procedure was successfully performed. The patient claimed that his symptoms were dramatically improved shortly following the procedure. While he was on the service, we continued to restrict his fluids to a liter/day. He was continued to diurese on Lasix, Metolazone and Spirnalactone. In addition, due to his congestive heart failure he was placed on Enalapril and he remained on his Digoxin home level. Beta-blocker was held due to his low blood pressure. The patient had a history of atrial fibrillation and he remained on Amiodarone 200 mg p.o. q.d. 2. Pulmonary. The patient had no pulmonary symptoms after he is adequately diuresed. Occasionally the patient required supplemental oxygen. 3. Infectious Disease. The patient completed his course of treatment of Vancomycin, Levofloxacin and Flagyl. The patient's blood cultures 1/6 came back positive for a coag negative Staph may be due to possible contamination. The patient, during his stay on [**Hospital Unit Name **] demonstrated no signs of infection or sepsis. 4. Diabetes. The patient remained on his Glyburide and sliding scale insulin regimen. Glucophage was discontinued due to his chronic renal insufficiency. 5. Tophaceous gout. The patient's gout was treated superficially by joint aspiration. The patient's improved dramatically and the patient showed no symptoms of infection. 6. Chronic renal insufficiency. The patient's creatinine remained around his baseline, approximately 1.5 to 2.0 during his entire stay with [**Hospital Unit Name **]. It should be reminded that the patient on presentation had a creatinine of 3.3 along with hyperkalemia and hypertension. He was aggressively treated for that by the Coronary Care Unit Team in their dictation summary. DISCHARGE DIAGNOSIS: 1. Dilated cardiomyopathy, likely ethanol induced, ejection fraction less than 20%. 2. Coronary artery disease. 3. Noninsulin dependent diabetes mellitus. 4. Asthma. 5. Complete heart block status post DDD placement in [**2134-4-14**]. 6. Tophaceous gout. 7. Chronic renal failure, baseline creatinine 1.5 to 2.0. 8. Benign prostatic hypertrophy. DISCHARGE MEDICATIONS: 1. Lasix 60 mg p.o. b.i.d. 2. Enalapril 2.5 mg p.o. q.d. 3. Digoxin 0.125 mg p.o. q.d. 4. Oxybutynin 5 mg p.o. t.i.d. 5. Spirnalactone 6.25 mg p.o. q.d. 6. Atrovent two puffs b.i.d. 7. Amiodarone 200 mg p.o. q.d. 8. Pantoprazole 40 mg p.o. q.d. 9. Aspirin 325 mg q.d. 10. Lactulose 30 ml p.o. t.i.d. 11. Multi-vitamin. 12. Aluminum, magnesium, hydroxide 15 ml p.o. q.i.d. as needed. 13. Glyburide 10 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: A follow-up with Dr. [**First Name (STitle) 1313**] in the Congestive Heart Failure Clinic on the [**2134-7-5**] at 12 o'clock. He was also to follow at the [**Hospital 8325**] Clinic on the [**2134-6-28**] at 1:30 on the [**Location (un) **] of the [**Hospital **] Clinic. Finally, he was to follow-up with Dr. [**Last Name (STitle) 17654**] in the next 2-3 weeks. He was to discuss restarting Coumadin and increasing his Enalapril with Dr. [**First Name (STitle) 1313**] at his next visit. He was told to continue to restrict his fluids to approximately one liter/day and avoid foods containing sodium. He was to be followed closely by a VNA Nurse on a regular basis to follow his medications, his weight. The patient was to return to the Emergency Room or contact EMS if he develops any further chest pain, shortness of breath, heart palpitations or other cardiac related symptoms along with gaining a significant amount of weight. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1600**], M.D. [**MD Number(1) 1601**] Dictated By:[**First Name3 (LF) 17655**] MEDQUIST36 D: [**2134-7-11**] 12:40 T: [**2134-7-19**] 20:11 JOB#: [**Job Number 17656**]

[ "250.00", "593.9", "996.62", "425.5", "414.01", "038.19", "428.0", "274.82", "493.90" ]

icd9cm

[ [ [] ] ]

[ "37.74", "89.64", "81.91" ]

icd9pcs

[ [ [] ] ]

13325, 13750

12946, 13302

2673, 3107

9461, 9726

13775, 14987

9753, 12925

3433, 4853

267, 1852

1874, 2646

3125, 3410

29,493

187,350

31919

Discharge summary

report

Admission Date: [**2165-9-27**] Discharge Date: [**2165-10-6**] Date of Birth: [**2107-10-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: abdominal pain, volume depletion Major Surgical or Invasive Procedure: ERCP with sphincterotomy, stent placement, stone removal History of Present Illness: 57M history of gallstone pancreatitis, hospitalized in [**8-13**], transfer from OSH after second admission with severe abdominal pain, mental status changes and dehydration. Past Medical History: Diabetes, non-insulin dependent Hypertension Lumbar disk bulge (L4) Gallstone pancreatitis as above Social History: Married, non-drinker Physical Exam: T 99.0, P 74, BP 119/80, RR 24 94% on RA NAD, alert & oriented x3 CN 2-12 intact Neck supple Chest clear, no wheezes or rhonchi Heart regular, no murmurs Abdomen soft, round, non-tender, minimally distended, no rebound/guarding, normal bowel sounds Extremities without edema, 2+ dorsalis pedis pulses Pertinent Results: Admission Labs: [**2165-9-27**] 10:39PM LACTATE-2.8* K+-5.4* [**2165-9-27**] 02:17PM LIPASE-[**2087**]* [**2165-9-27**] 02:17PM ALT(SGPT)-115* AST(SGOT)-62* LD(LDH)-325* ALK PHOS-63 AMYLASE-1113* TOT BILI-0.7 [**2165-9-27**] 02:17PM GLUCOSE-256* UREA N-29* CREAT-1.4* SODIUM-138 POTASSIUM-6.4* CHLORIDE-108 TOTAL CO2-19* ANION GAP-17 Discharge labs: [**2165-10-6**] WBC 22.2 HCT 36.4 Plts 294 Brief Hospital Course: GI: Pt was admitted with gallstone pancreatitis based on clinical presentation, known history and laboratory analysis. He was severely dehydrated and sent to the ICU for monitoring. He was made NPO and put on IVF and resuscitiated. Transferred to the floor after being resuscitated. On HD5 he had an ERCP with sphincterotomy, stent placement, and extraction of multiple stones. On PPD1 he was given sips and advanced to regular diet by PPD3, which he tolerated well. During this hospitalization, he developed profuse watery diarrhea, having more than 5 bowel movements on multiple days, and C.diff toxin studies were sent off and returned negative. ID: On PPD1, the pt developed watery diarrhea and was empirically begun on flagyl for C.difficile. By discharge he had completed 4 days of PO flagyl and the diarrhea had improved to loose solid bowel movements. His WBC count rose to 22 during this hospitalization, but clinically he was improving on discharge, remaining afebrile throughout his course. Endo: Known to be NIDDM, during his hospitalization, pt required more than a standard regular insulin sliding scale to cover his elevated blood glucose values. On HD9, he recorded a value of 375, but remained asymptomatic. Upon discharge, he should follow up with his primary care physician for evaluation. Medications on Admission: toprol xl 100 qd lisinopril 20 qd aspirin 81 qd Discharge Medications: 1. 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* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: [**1-10**] Caps PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*120 Cap(s)* Refills:*2* 7. Glucose Meter, Disp & Strips Kit Sig: One (1) Miscellaneous three times a day. Disp:*1 1* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: pancreatitis, diabetes Discharge Condition: Good Discharge Instructions: If you experience fever >101.5, abdominal pain, nausea/vomiting, shortness of breath, chest pain, bloody diarrhea, or any other symptom concerning to you please call [**Hospital1 18**]. Take all medications as prescribed by your doctor. You should follow up after discharge from the hospital with visits to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**], [**10-7**], and Dr. [**Last Name (STitle) **] in 3 weeks. Please call to arrange an appointment with Dr. [**Last Name (STitle) **] and tell the staff that you need a CT scheduled before this appointment. You have had slightly elevated blood sugars during this hospitalization. You should follow up with your primary care physician for diabetic evaluation. You may also develop loose, fatty stools. If this happens, begin taking the new prescription medication, creon, as prescribed with all meals. Followup Instructions: Dr. [**Last Name (STitle) **] in 3 weeks. Be sure to get a CT of your abdomen before this appointment. Dr. [**First Name (STitle) **] on [**First Name (STitle) 20212**], [**2165-10-7**].

[ "008.45", "577.0", "574.50", "276.51", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "51.87", "51.85", "38.93" ]

icd9pcs

[ [ [] ] ]

3856, 3862

1536, 2855

347, 406

3929, 3936

1107, 1107

4881, 5074

2953, 3833

3883, 3908

2881, 2930

3960, 4858

1466, 1513

786, 1088

275, 309

434, 610

1123, 1450

632, 733

749, 771

22,386

104,626

2197

Discharge summary

report

Admission Date: [**2131-11-6**] Discharge Date: [**2131-11-20**] Date of Birth: [**2051-11-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 158**] Chief Complaint: 1. Colon Cancer 2. Recurrent Ventral Hernia Major Surgical or Invasive Procedure: [**2131-11-6**]: 1. Exploratory laparotomy. 2. Removal of mesh. 3. Left colectomy. 4. Ventral hernia repair with component separation. History of Present Illness: 79M w multiple medical problems who on screening colonoscopy [**8-7**] was found to have a descending colon adenocarcinoma. Preoperatively, patient denies any symptoms that could be related to his diagnosed cancer, including bleeding, abdominal pain, nausea, vomiting, change in bowel movements, change in size of bowel movements, constipation or any other problems. [**Name (NI) **] does have a large lump on his belly, which looks like an incarcerated hernia and occasionally causes him some discomfort; however, he never had any obstruction symptoms from this. At this point, he is feeling well and does not have any concerns. Past Medical History: # Colon adenocarcinoma # Diabetes type 2 # CAD status post stent # Hypertension # SVT (AVNRT) status post ablation # Hypercholesterolemia # Rib fracture # Dislocated right shoulder # Reactive airway disease during the winter months, # Epigastric hernia that was repaired in [**2116**] under general anesthesia # Cataract surgery of his left eye. Social History: - Spanish speaking - Lives alone in a senior housing apartment - Has 3 sons in the area - Tobacco: 20 pack year smoking history. Quit 15 years ago. - Alcohol: None. Quit many years ago - Illicits: None Family History: Mother died of unknown causes. Father died of heart disease at the age of 86, had heart disease starting in his 50s. Sister has diabetes. Physical Exam: Physical Exam on Discharge Tmax: 99.3 ??????F, Tcurrent: 97.5??????F, HR: 75-108bpm, BP (126-150)/(57-84)mmHg, RR 22 insp/min, SpO2 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Reduced BS on left, + wheeze CV: Tachy, PMI not displaced, no murmors appreciated Abdomen: soft, non-distended, non-tender; GU: + foley Ext: palpable pulses, 1+ lower extremity edema, +[**Male First Name (un) **] stockings Pertinent Results: ================= LABS ================= [**2131-11-6**] - CBC with differentials: WBC-7.2 RBC-3.62* Hgb-10.0* Hct-30.7* MCV-89 MCH-27.7 MCHC-31.1 RDW-16.3* Plt Ct-276 Neuts-79* Bands-0 Lymphs-14* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 - CHEM 6: UreaN-27* Creat-1.4* Na-143 K-4.5 Cl-110* HCO3-21* - Cardiac enzymes @ 1:52PM: CK(CPK)-453* CK-MB-4 cTropnT-0.04* - Cardiac enzymes @ 10:22PM: CK(CPK)-699* CK-MB-4 cTropnT-0.05* [**2131-11-7**] - CHEM 7: Glucose-139* UreaN-38* Creat-2.2* Na-142 K-5.0 Cl-109* HCO3-20* - Cardiac enzymes @ 06:36AM: CK(CPK)-1124* CK-MB-4 cTropnT-0.04* - CK (CPK) @ 02:22PM: 1268* - Lactate: 2.7* - UA: Coloer-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM RBC-16* WBC-7* Bacteri-FEW Yeast-NONE Epi-<1 CastHy-5* AmorphX-RARE Mucous-RARE Eos-NEGATIVE - Urine lytes: UreaN-470 Creat-162 Na-15 K-90 Cl-44 Calcium-0.6 Uric Ac-18.3 Osmolal-440 [**2131-11-8**] - LFTs: ALT-16 AST-31 AlkPhos-79 TotBili-0.3 - CK (CPK) @ 5:35AM: 1171* [**2131-11-9**] - CBC: WBC-9.1 RBC-2.25* Hgb-6.5* Hct-19.8* MCV-88 MCH-28.7 MCHC-32.6 RDW-17.0* Plt Ct-247 - Cardiac enzymes @ 08:30PM: CK (CPK) 688* CK-MB-3 cTropnT-0.03* [**2131-11-10**] - Lactate: 1.3 [**2131-11-11**] - CBC: WBC-6.1 RBC-3.08* Hgb-9.0* Hct-27.2* MCV-88 MCH-29.1 MCHC-33.0 RDW-16.6* Plt Ct-272 - CHEM 7: Glucose-181* UreaN-47* Creat-1.7* Na-142 K-3.6 Cl-102 HCO3-28 =================== MICROBIOLOGY =================== [**2131-11-6**] - abdominal wound swab: 1+ Polymorphonuclear leukocytes, wound culture negative, NGTD anaerobics [**2131-11-7**] - Urine cx- negative [**2131-11-8**] - Blood cx 1x- NGTD [**2131-11-12**]: C. diff: POSITIVE ================== IMAGING ================== [**2131-11-6**] - CXR: Left lower lobar collapse with small pleural effusion. Diaphragmatic injury from procedure is possible, but unlikely. [**2131-11-9**] - CXR: Increased moderate biventricular congestive heart failure. - Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is mild anterior leaflet mitral valve prolapse. An eccentric, inferolaterally directed jet of mild-moderate ([**12-30**]+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mitral valve prolapse with at least mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2131-7-6**], the estimated pulmonary artery systolic pressure is now higher. The other findings are similar. PATH [**2131-11-6**]: 1.7cm colonic adenocarcinoma T1N1aMx; [**1-9**] lymph nodes positive Brief Hospital Course: 79 yo Spanish speaking M w/ colon adenocarcinoma (dx in [**8-7**]), DM, CAD s/p stent LAD/first diag ([**2123**]), SVT s/p ablation, HTN, DLP, CRI (Cr 1.4) s/p left colectomy with component separation/ventral hernia repair, drainage of abcess related to old abdominal mesh. Immediate postoperative course c/b hypertension, tachycardia, and hypoxia transferred to [**Hospital Unit Name 153**] for further care. Consults were obtained from the [**Hospital Ward Name 332**] ICU, cardiology and geriatrics for assistance with this patient's care. Neuro: Pre-operatively, an epidural was placed for pain control. Post-operatively, the patient continued with epidural anesthesia with good effect and adequate pain control. Epidural was removed on POD4 and pain control managed with intermittent morphine IV. When tolerating oral intake, the patient was transitioned to oral pain medications. Per recommendations from geriatrics, narcotic pain medications were discontinued on POD9 secondary to increased risk delirium in geriatric population. Pain control then managed with non-narcotic po medication. CV: The patient was initially hypertensive postoperatively but then became hypotensive likely secondary to CHF. Cardiac enzymes were drawn times three to rule out myocardial infarction and they were negative. A cardiology consult was sought on POD3, there assessment was that underlying mitral regurgitation, continued hypertension, and overall positive fluid balance since surgery were contributing to his CHF picture. A TTE was obtained on POD3 and results are above. Patient was found to be intermittently in atrial fibrillation and recommendations per cardiology were followed-beta blocker, amlodipine were titrated to appropriate heart rate and blood pressure. Patient's fluid balance was carefully monitored and he intermittently received lasix vs fluid to achieve euvolemia such that he was adequately supported from a cardiovascular standpoint without fluid overload compromising his pulmonary status. Patient also was transfused packed RBCs when appropriate to maintain adequate volume status without fluid overload. Patient's vital signs were routinely monitored. Pulmonary: Postoperatively, patient required non-rebreather in ICU setting to maintain oxygenation. As patient was diuresed oxygen requirement diminished and patient was transferred to floor on POD6 on supplemental oxygen via nasal canula and intermittent nebulizer treatments for shortness of breath/wheezing. The patient's fluid balance was balanced as per above. Patient with baseline COPD and patient received intermittent CXR's in addition to monitoring of vital signs to achieve adequate oxygen saturation. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. He was found to have elevated creatinine postoperatively consistent with ATN per his FeNa. He was hydrated judiciously and his renal function eventually returned to baseline. Patient's ACE inhibitor was held during admission secondary to increased creatinine. It may be restarted per his PMD after assessment of renal function one week postoperatively. His diet was advanced when appropriate, which was tolerated well. Foley was maintained throughout admission and will be continued following discharge given sensitive fluid balance issues and need for urine output monitoring. Intake and output were closely monitored. ID: The patient was given appropriate preoperative antibiotics. These were continued postoperatively (cipro/flagyl) as empiric coverage for possible infection. On POD4, patient was found to be positive for C diff and started on po vancomycin and IV flagyl. Patient's number of bowel movements decreased on antibiotic therapy and he will be discharged to complete a 10 day course. The patient's temperature was closely watched for signs of infection. Endocrine: Patient was maintained on an insulin sliding scale and diabetic appropriate diet secondary to his DM2. Geriatrics assisted in management of his blood sugars which Hem/Onc: Patient transfused as per above to maintain adequate cardiopulmonary function. Pathology showed T1N1aMx colonic adenocarcinoma. He will be followed by medical oncology and surgery for management of this issue. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#14, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating with assistance, with a foley in place, and pain was well controlled. Medications on Admission: Home Medications: AMLODIPINE 5 mg daily ATORVASTATIN 40 mg daily LISINOPRIL-HYDROCHLOROTHIAZIDE 20 mg-25 mg daily METOPROLOL TARTRATE 50 mg daily NITROGLYCERIN 0.4 mg Tablet, Sublingual prn RANITIDINE HCL 150 mg Tablet [**Hospital1 **] SITAGLIPTIN [JANUVIA] 50 mg daily ASPIRIN 325 mg Tablet daily Medications upon transfer to [**Hospital Unit Name 153**]: Heparin 5000 UNIT SC BID 1000 ml LR Continuous at 85 ml/hr Hydromorphone 10 mcg/ml + Bupivacaine 0.1% 1 mg/ml ED Insulin SC (per Insulin Flowsheet) Acetaminophen 1000 mg PO TID Ipratropium Bromide Neb 1 NEB IH Q6H Ciprofloxacin 200 mg IV Q12H Metoclopramide 10 mg IV Q6H MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: [**11-6**] @ 1243 DiphenhydrAMINE 12.5-25 mg PO/IV Q6H:PRN Itching Metoprolol Tartrate 10 mg IV Q6H Droperidol 0.625 mg IV Q6H:PRN Nausea Nitroglycerin SL 0.4 mg SL PRN chest pain Enalaprilat 0.625 mg IV Q6H Ondansetron 4 mg IV Q6H:PRN nausea Famotidine 20 mg IV Q24H Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 ml PO Q6H (every 6 hours) as needed for pain. 2. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for C diff for 4 days. Disp:*40 Capsule(s)* Refills:*0* 3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for pruritis. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. ipratropium bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 4 days. Disp:*30 Tablet(s)* Refills:*0* 10. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day) for 10 days: Please give no sooner than three hours prior to vancomycin dosing. Thank you. . 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 12. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Colon Cancer 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 Colorectal Surgery service for Open Left Colectomy and Ventral Hernia Repair. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in three weeks. Call ([**Telephone/Fax (1) 3378**] for an appointment. Thank you. Completed by:[**2131-11-20**]

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icd9cm

[ [ [] ] ]

[ "38.97", "53.51", "45.75" ]

icd9pcs

[ [ [] ] ]

12866, 12937

5719, 10331

359, 496

12994, 12994

2441, 5696

15476, 15666

1765, 1904

11329, 12843

12958, 12973

10357, 10357

13177, 14170

14964, 15453

1919, 2422

10375, 11306

14202, 14949

276, 321

524, 1158

13009, 13153

1180, 1527

1543, 1749

12,690

104,647

7837

Discharge summary

report

Admission Date: [**2157-10-4**] Discharge Date: [**2157-10-8**] Service: CARDIOTHORACIC Allergies: Gluten Attending:[**First Name3 (LF) 2969**] Chief Complaint: Referral for resection of mediastinal mass Major Surgical or Invasive Procedure: Left VATS converted to left hemi- clamshell thoracotomy with dissection of mediastinal mass. Flexible bronchoscopy with therapeutic aspiration of secretion at the end of the procedure. Placement of fiducial seed implants. Past Medical History: Bilateral L > R glaucoma, celiac spure, hx colitis, hiatal hernia, Aortic Stenosis (noncritical 1.1 cm^2 valve area), Mitral Regurgitation, OA, nephrolithiasis, hyponatremia, GERD, hx UGIB secondary to to Dieulafoy ulcer [**4-2**], hypertension PSx: ORIF R hip, hiatal hernia Social History: Married, lives with wife. Children close by and closely involved. Drinks 1 drink per day, 10 pack year smoking history, quit 30 years ago. Remote exposure to asbestos in shipyard. No radiation exposure. Family History: No family history of cancer. Physical Exam: T 96.8, HR 69, BP 144/66, RR 18, 97% RA Gen: No apparent distress, alert and oriented x 3 CV: Regular rate and rhythm with systolic murmur Resp: Lungs clear to auscultation bilaterally Chest: Hemi-clamshell incision dressed with Steri-strips, no erythema, induration, or fluctuance Abd: Soft/non-tender/non-distended Ext: No clubbing, cyanosis, or edema Pertinent Results: [**2157-10-4**] 09:15AM freeCa-1.16 [**2157-10-4**] 09:15AM HGB-14.5 calcHCT-44 [**2157-10-4**] 09:15AM GLUCOSE-124* LACTATE-1.3 NA+-129* K+-4.0 CL--93* [**2157-10-4**] 09:15AM TYPE-ART PO2-146* PCO2-40 PH-7.43 TOTAL CO2-27 BASE XS-2 [**2157-10-4**] 12:23PM PT-12.8 PTT-25.1 INR(PT)-1.1 [**2157-10-4**] 12:23PM PLT COUNT-262 [**2157-10-4**] 12:23PM NEUTS-88.8* LYMPHS-6.6* MONOS-4.1 EOS-0.3 BASOS-0.1 [**2157-10-4**] 12:23PM WBC-10.4# RBC-3.95* HGB-12.4* HCT-35.0* MCV-89 MCH-31.5 MCHC-35.5* RDW-13.6 Brief Hospital Course: After undergoing his Left VATS converted to left hemi-clamshell thoracotomy with dissection of mediastinal mass and flexible bronchoscopy with therapeutic aspiration of secretion with placement of fiducial seed implants on [**2157-10-4**], Mr. [**Known lastname 20793**] was admitted to the SICU still intubated. He was successfully extubated later that same night without difficulty or complications. He was given IV medication for pain control and was initially kept NPO. He was given Lactated Ringers solution for hydration, and was bolused for hypotension upon admission to the SICU. His blood pressure responded appropriately. He had a L chest [**Doctor Last Name **] drain to suction. A chest xray showed no pneumothorax. Post-operative lab work revealed a sodium that was low at 126. His fluids were then switched from LR to normal saline for correction of hyponatremia. The patient was asymptomatic and had no EKG changes, and also has a reported history of hyponatremia. On POD1, his diet was advanced to clears with free water restrictions because of the hyponatremia. His [**Doctor Last Name **] drain was placed to water seal and a repeat chest xray again showed no pneumothorax. Oral pain medications and home medications were provided. On POD2, his chest [**Doctor Last Name **] was removed and the chest xray again showed no pneumothorax. His diet was advanced to regular, gluten free for his celiac disease. His foley catheter was removed and he voided without difficulty. He was transferred out of the SICU to the floor. He remained stable and had no issues on the floor. On POD 3, he ambulated with nursing staff with a walker. On POD 4, physical therapy saw him and cleared him for discharge to a rehabilition facility. A rehab bed was identified at the facility where he lives and he was discharged there in good condition with instructions to follow up with Dr. [**Last Name (STitle) **] in [**12-1**] weeks with a chest xray prior to the appointment. Code status was full code. Final pathological analysis was still pending at the time of discharge. A frozen section from the mediastinal mass sent intra-operatively came back with possible chondrosarcoma. Medications on Admission: Atenolol 12.5 QD, Asacol 400mg 2 tabs TID, Multivitamins, Omeprazole 20 QD, Travoprost 0.004% OU QD, Aspirin 81 mg QD, Ca-D3 500/200 QD, Citrucel 500 mg QD Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Tablet(s) 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Travoprost 0.004 % Drops Sig: [**12-1**] Ophthalmic qPM (). 4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] Discharge Diagnosis: Mediastinal mass status post resection and fiducial seed placement. Discharge Condition: Good, meeting discharge criteria. Discharge Instructions: Call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 28276**] if experiencing: -Fever > 101 or chills -Increased cough, shortness of breath or chest pain -Sternal incision develops drainage or increased redness Follow sternal precaution instructions reviewed by physical therapy. No lifting greater than 10 pounds for 4 weeks. No driving for 4 weeks You may shower. No tub bathing or swimming for 6 weeks Take stool softners with narcotics. Followup Instructions: Call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 28276**] to schedule a follow up appointment 1-2 weeks after discharge. Let them know that you need to have a chest x-ray done 45 minutes before your appointment with Dr. [**Last Name (STitle) **].

[ "164.3", "579.0", "458.9", "V64.42", "V15.82", "276.1", "396.2" ]

icd9cm

[ [ [] ] ]

[ "34.3", "96.05" ]

icd9pcs

[ [ [] ] ]

5379, 5494

1983, 4168

263, 487

5606, 5642

1442, 1960

6137, 6395

1023, 1053

4374, 5356

5515, 5585

4194, 4351

5666, 6114

1068, 1423

181, 225

509, 787

803, 1007

14,768

119,197

50249

Discharge summary

report

Admission Date: [**2151-10-23**] Discharge Date: [**2151-10-30**] Date of Birth: [**2080-5-6**] Sex: M Service: MEDICINE Allergies: Mevacor / Pravachol / Bactrim / Adhesive Tape / Linezolid / Clindamycin Attending:[**First Name3 (LF) 800**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Right IJ central venous line Hemodialysis History of Present Illness: This is a 71 year old male with MMP including CAD s/p CABG '[**38**], s/p failed renal transplant(HD MWF), s/p recent admission for febrile illness though to be due to C.diff colitis discharged [**2151-10-23**] who returns for fever to 102 and persistent diarrhea. He was discharged one day PTA on multiple antibiotics and per report, he felt well for 24 hours at home. However, he describes an episode of depressed MS where he notes that he recalls was his wife yelling at him that he was hanging his head down while sitting on the couch and not responding to her. He then notes that he does not recall the reason for his re-presentation to the hospital but reports that his wife told him that he had fever to 102 at home and persistent diarrhea, no melena/brbpr. He notes that he has had a good appetite and good PO intake. He continues to have [**Month/Day/Year **] which he reports is unchanged over the past several months, denies CP/SOB. He feels that his energy has been good. He does note that his granddaughter who lives with him has had a recent febrile illness thought to be viral in etiology. He notes that he's had persistent LLE erythema, but feels that the area has improved. He has been using 1 toilet and wiping down with bleach wipes as he was told to do. He has been compliant with his medications. In the ED, Tm 101.8 HR 91-113 RR 16 O2sat98%RA. He had hypotension to 74/38 which responded to fluid boluses, stabilized in 100s systolic after 2L NS. CVP 20. Right IJ was placed and he received Levofloxacin 500mg, IV Vancomycin 1g, and Vancomycin Oral Liquid 250mg x 1, as well as 1gm tylenol. U/A was negative. ROS: The patient denies any nausea, vomiting, abdominal pain, constipation, orthopnea, PND, lower extremity edema, weight change, urinary frequency, urgency, dysuria, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: # Atrial fibrillation s/p cardioversion [**2147**] # Atrial flutter s/p ablation [**2144**] with resultant atrial fibrillation - on coumadin # CAD s/p MI x2, CABG [**2138**] # Chronic systolic CHF # DM2 c/b neuropathy on insulin ([**Name (NI) **] pt) # ESRD [**1-2**] autoimmune glomerulonephritis s/p cadaveric renal transplant [**2145**] c/b delayed graft rejection, CRI # Pseudogout # R adrenal lesion (stable) # Depression # h/o pulmonary nocardiosis [**2143**] # h/o bladder CA s/p surgery, BCG treatment [**2136**] # h/o GI bleed on heparin # h/o L1 compression fracture ([**2-6**]) Social History: Married and lives with his wife, daughter and grand-daughter. Retired illustrator. Quit smoking but smoked 1.5 packs per day for 25 years. Denies alcohol and IVDU. Family History: Father, died at age 56 of MI Mother, died at age 65 of CHF also had DM Physical Exam: Vitals: T: 97.9 BP: 126/94 HR: 84 RR: 15 O2Sat:98%RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: flat JV, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, soft systolic murmur, no G/R, normal S1 S2, radial pulses +2 PULM: inspiratory/expiratory wheezes BL, crackles at left base, no rhonchi ABD: obese, Soft, NT, ND, +BS, no HSM, no masses EXT: AV fistulas noted in RUE, left LE erythema demarcated, stable per demarcations from prior hospitliazation, No edema noted, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: Ulcer on plantar aspect of left foot, multiple areas of skin breakdown between Left toes. No jaundice, cyanosis, or gross dermatitis. multiple ecchymoses in UE BL. Pertinent Results: [**2151-10-22**] 06:35AM BLOOD WBC-10.4 RBC-4.68 Hgb-11.0* Hct-36.9* MCV-79* MCH-23.4* MCHC-29.7* RDW-18.7* Plt Ct-358 [**2151-10-26**] 04:40AM BLOOD WBC-14.3* RBC-4.30* Hgb-10.4* Hct-32.9* MCV-76* MCH-24.1* MCHC-31.6 RDW-19.3* Plt Ct-256 [**2151-10-30**] 08:00AM BLOOD WBC-13.0* RBC-4.31* Hgb-10.0* Hct-32.6* MCV-76* MCH-23.3* MCHC-30.8* RDW-20.0* Plt Ct-274 [**2151-10-23**] 04:00PM BLOOD PT-23.2* PTT-29.0 INR(PT)-2.2* [**2151-10-29**] 06:45AM BLOOD PT-33.2* PTT-37.4* INR(PT)-3.5* [**2151-10-30**] 08:00AM BLOOD PT-29.6* INR(PT)-3.0* [**2151-10-22**] 06:35AM BLOOD Glucose-102 UreaN-31* Creat-4.5* Na-138 K-3.4 Cl-98 HCO3-26 AnGap-17 [**2151-10-30**] 08:00AM BLOOD Glucose-171* UreaN-54* Creat-5.3*# Na-139 K-4.0 Cl-102 HCO3-25 AnGap-16 [**2151-10-30**] 08:00AM BLOOD Calcium-7.5* Phos-4.3# Mg-1.9 [**2151-10-23**] 04:00PM BLOOD CK-MB-3 cTropnT-0.13* [**2151-10-23**] 11:27PM BLOOD CK-MB-3 cTropnT-0.09* [**2151-10-26**] 09:54AM BLOOD CK-MB-3 cTropnT-0.12* [**2151-10-26**] 06:28PM BLOOD CK-MB-3 cTropnT-0.10* [**2151-10-25**] 05:47AM BLOOD TSH-2.9 [**2151-10-27**] 04:38AM BLOOD Cyclspr-80* [**2151-10-29**] 06:45AM BLOOD Cortsol-24.9* [**2151-10-23**] 04:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2151-10-23**] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CMV Viral Load (Final [**2151-10-27**]): CMV DNA not detected. EBV Viral Load: pending Blood culture ([**10-24**] x2): negative Blood culture ([**10-26**], [**10-27**]): NGTD Stool O+P ([**10-24**], [**10-25**]): negative x3 Stool culture (Final [**2151-10-27**]): negative CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2151-10-21**]): positive CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2151-10-25**]): negative MRSA screen ([**10-27**]): negative Urine culture (Final [**2151-10-26**]): NO GROWTH. Sputum culture ([**10-27**]): <10 PMNs and >10 epithelial cells/100X field. PCP immunoflourescent test negative. No AFB on direct or concentrated smear. No nocardia isolated (prelim). CXR ([**10-23**]): Stable cardiomegaly with elevated pulmonary venous pressure, as evidenced by increased interstitial markings. Followup is recommended post-diuresis. There is a patchy infiltrate at the left hilum. CXR ([**10-27**]): Small region of focal opacification in the infrahilar left lung could be pneumonia, but could also be atelectasis. Mild pulmonary edema is worsened in the interim accompanied by increasing mediastinal vascular engorgement. Borderline cardiomegaly is stable since [**3-24**], increased slightly since [**3-23**]. Pleural effusion if any is minimal. No pneumothorax. RUE AV fistula U/S ([**10-25**]): Findings compatible with an evolving hematoma. However, superinfection cannot be completely excluded by ultrasound. CT C/A/P ([**10-25**]): 1. Since the prior exam from [**2151-6-25**], there is interval development of patchy opacity within the lung bases, worrisome for aspiration/pneumonia. Small left pleural effusion. 2. Cardiomegaly and diffuse atherosclerotic calcification involving the aorta and coronary arteries. 3. Bowel wall thickening involving the cecum, which may relate to cecitis or possibly in an immunocompromised patient, typhlitis. 4. Low-attenuation fluid collection in the right pelvis adjacent to the right iliac vein, slightly increased in size from prior exam and may represent a lymphocele. 5. High-grade compression deformity of the L1 vertebral body, unchanged from [**2151-3-18**]. 6. Multiple mildly enlarged lymph nodes in the mediastinum, retroperitoneum, pelvis and inguinal region. 7. Multiple healing right sided rib fractures. 8. Stable small right adrenal nodule. 9. Pulmonary arterial hypertension. TTE ([**10-27**]): The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferior and inferolateral segments, LVEF 40-45%. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Brief Hospital Course: 1) Fevers/hypotension: CVL was placed in the ED for BP 70s/30s, and fluid resuscitation brought SBP back to 100s. He was started on levofloxacin, IV and PO vancomycin, and IV metronidazole. By day 2 his CVL was pulled as he did well for ~18 hrs, but then spiked fevers and became hypotension again. He responded to fluids and did not require pressors. CT torso showed consolidation concerning for PNA. Other possible sources were C. diff and LLE cellulitis. US of his AVF was done to rule out abscess, and was most consistent with hematoma. ID was consulted. His levofloxacin was changed to ceftriaxone and then broadened to cefepime. He was called out to the floor as he remained hemodynamically stable, and his metronidazole was stopped. Given clinical improvement, the cefepime was briefly stopped for PO azithromycin, but per ID recs was restarted as ceftazidime, which can be dosed at HD. He will complete a 10 day course of cefepime/ceftazidime and will continue on PO vancomycin for 2 additional weeks for C diff coverage. Finally, his 2 week IV vancomycin course for cellulitis was completed prior to discharge. Bronchoscopy was considered due to his history of nocardia, but a pulmonary consult felt this was unnecessary given negative interim BALs. He had no further fevers (and actually was mildly hypothermic), tachycardia, or hypotension during admission. All blood cultures were negative or no growth. 2) COPD: Patient received a 3d steroid burst (switched between methylprednisolone, dexamethasone, and prednisone) due to concern for both COPD flare and adrenal insufficiency. His pulmonary status was stable, so he was started on a rapid prednisone taper. Note the dexamethasone was for a planned ACTH stim test, although the cosyntropin dose was accidentally not administered. As his am cortisol was normal, this test was deferred. 3) A-fib with RVR: Had multiple episodes of RVR requiring lopressor. Due to concern that albuterol nebs were contributing, he was switched to levalbuterol. However, given no data suggesting a difference between these formulations, he was deemed stable to be discharged on his prior albuterol. He had no episodes of RVR on the medical floor. For a supratherapeutic INR, his warfarin was held. His discharge INR was 3.0 and warfarin will be resumed one day after discharge. 4) ESRD: Patient is status post failed renal transplant on HD, chronic prednisone and cyclosporine. He was started on calcium acetate for hyperphosphatemia. Biopsy was considered due to initial concern for rejection, but this was deferred. EBV viral load was sent for concern for post transplant lymphoproliferative disorder, and was pending at discharge. 5) Diabetes: [**Month/Year (2) **] was consulted for a left foot ulcer, debrided the wound, and recommended daily dressing changes. His gabapentin was renally dosed. He was initially started on ~ half his outpatient NPH dose. His sliding scale was tightened due to concurrent steroid use. At discharge, his NPH dose was increased, although still less than his admission dose to prevent hypoglycemia. This can be titrated at outpatient follow up. 6) Scrotal pain: Apparent yeast infection. Treated with miconazole powder. 7) RUE swelling: Noted just prior to discharge. US prelim read showed no DVT. Medications on Admission: Vancomycin in Dextrose 1 gram/200 mL Intravenous HD PROTOCOL for 8 doses Vancomycin Oral Liquid 125 mg PO Q6H times 21 days(started [**2151-10-19**]) Levofloxacin 500 mg PO Q48H (every 48 hours) for 8 days Folic Acid 1 mg PO DAILY Aspirin 81 mg PO DAILY Atorvastatin 10 mg PO EVERY 3 DAYS Gabapentin 100 mg PO TID Pantoprazole 40 mg PO Q24H Tiotropium Bromide 18 mcg [**12-2**] Caps Inhalation DAILY Metoprolol Tartrate 50 mg PO DAILY Allopurinol 100 mg PO EVERY OTHER DAY Prednisone 5 mg PO DAILY Amiodarone 200 mg PO DAILY Cyclosporine Modified 25 mg PO Q12H Fluticasone 110 mcg/Actuation Aerosol One Puff Inhalation [**Hospital1 **] Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID as needed. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup 5 ML PO Q6H as needed for [**Hospital1 **]. Warfarin 2 mg PO Once Daily at 4 PM. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-2**] Inhalation every six 6 hours as needed for wheezing. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO once a day. Tylenol Oral Insulin Lispro 100 unit/mL Insulin Pen Subcutaneous once a day: and NPH as before. Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 19 days: Only take one pill on [**10-30**]. Disp:*73 Capsule(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO EVERY 3 DAYS (Every 3 Days). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). Disp:*15 Capsule(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [**12-2**] Inhalation once a day. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: On Sunday [**10-31**] only. Can take two 5mg pills. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Starting [**Month/Year (2) 766**] [**11-1**]. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 14. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Start on Sunday [**10-31**]. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed. 19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*1 bottle* Refills:*0* 21. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*0* 22. Ceftazidime 2 gram Recon Soln Sig: One (1) Intravenous with hemodialysis for 2 doses: Last day [**11-3**]. Disp:*2 doses of 2 gram Recon Soln* Refills:*0* 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Take Subcutaneous twice a day: 30 units NPH in the am and 12 units NPH in the pm. Continue your prior 4 times daily sliding scale. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary: Clostridium difficile colitis Hospital acquired pneumonia Cellulitis Secondary: Chronic obstructive pulmonary disease Chronic systolic and diastolic heart failure Atrial fibrillation Discharge Condition: hemodynamically stable, afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] with fevers and low blood pressure. We treated you for pneumonia, cellulitis, and an intestinal bug called C. diff. You have improved with these antibiotics. We also gave you a short course of steroids for your lung disease. Please take all medications as prescribed and go to all follow up appointments. We have made the following medication changes: - Changed your antibiotics to ceftazidime, given at dialysis, and oral vancomycin. - Changed you gabapentin dose due to your kidney disease. - You will take an extra prednisone 5mg pill tomorrow as part of a taper from a higher dose. After that, resume 5mg daily. - Do not take your warfarin on Saturday [**10-30**] due to a slightly high INR. - Use miconazole powder for your scrotal rash. - Take calcium acetate to help your electrolytes. - Note slightly lower insulin doses, since you were not on you full dose in the hospital. Ask your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 104791**]g your prior doses. If you experience fevers, chills, shortness of breath, worsening coughing or wheezing, diarrhea, abdominal pain, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Please call your primary care doctor, [**Doctor First Name **] [**Doctor Last Name **], at [**Telephone/Fax (1) 1144**] to set up a follow up appointment. [**Telephone/Fax (1) **]: Please follow up with Dr. [**First Name (STitle) 3209**] in 2 weeks. Please call [**Telephone/Fax (1) 543**] for an appointment Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2151-11-16**] 10:30 Please follow up at your coumadin clinic to have your INR measured. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2151-10-30**]

[ "428.42", "428.0", "491.21", "V10.51", "357.2", "250.60", "996.73", "E878.0", "112.2", "E878.2", "682.6", "V58.61", "V45.81", "996.81", "427.32", "585.6", "285.21", "486", "008.45", "V58.67", "427.31" ]

icd9cm

[ [ [] ] ]

[ "86.22", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

15334, 15409

8409, 11692

338, 382

15646, 15681

4248, 8386

17071, 17775

3103, 3176

12861, 15311

15430, 15625

11718, 12838

15705, 16078

3191, 4229

16098, 17048

293, 300

410, 2294

2316, 2906

2922, 3087

25,655

106,240

16938+16939

Discharge summary

report+report

Admission Date: [**2177-5-15**] Discharge Date: [**2177-5-16**] Date of Birth: [**2135-1-14**] Sex: M Service: . CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a 42 year old man with an anterior myocardial infarction on [**4-30**], status post left anterior descending PCI at [**Hospital6 **], who presented to his primary care physician's office on the morning of admission with complaints of left substernal chest pain. The symptoms began at 9 a.m. with chest pain, diaphoresis, nausea and some dizziness. The pain was slow in onset. It radiated to the left shoulder; no shortness of breath. Similar in location and character to anginal pain but less severe, seven out of ten as opposed to ten out of ten with myocardial infarction, not relieved by sublingual Nitroglycerin. The pain was also different in that it was exacerbated by motion, pleuritic in nature. The patient denies shortness of breath, has two to three pillow orthopnea which is stable. No paroxysmal nocturnal dyspnea. The patient reports loosing weight since discharge from hospitalization on [**5-5**]. He has mild intermittent lower extremity edema but no progressive edema. The patient was transferred to [**Hospital1 69**] and underwent cardiac catheterization. The cardiac catheterization demonstrated a patent left anterior descending stent, serial 40% lesions in obtuse marginal 2, 80% right coronary artery lesion with left to right collaterals from the left anterior descending, PAP pressures 43/20. The patient was transferred to the cardiac care unit for concerns of elevated pulmonary capillary wedge pressures post procedure. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Gastroesophageal reflux disease. 5. History of alcohol. 6. Status post right knee surgery. 7. Status post tummy tuck in [**2173**]. MEDICATIONS: 1. Aspirin. 2. Plavix. 3. Lipitor 80. 4. Warfarin 5. 5. Lisinopril 10. 6. Atenolol 50 p.o. q. day. 7. Mirtazapine 30 p.o. q. day. 8. Zoloft 100 mg q. day. 9. Neurontin 1500 mg p.o. q. day. 10. Protonix 40 mg p.o. q. day. 11. Lorazepam 0.5 mg p.o. three times a day. 12. Azolitmin nasal spray. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Attends [**State 1558**] as a student. Works at [**Doctor First Name 47672**] Pantry. Quit tobacco one week; prior one pack per day times 35 years. History of heavy alcohol use; quit eleven months ago. No illicit drug use. No intravenous drug use. FAMILY HISTORY: No early coronary disease in the family; father with alcohol abuse. PHYSICAL EXAMINATION: Blood pressure 121/66; pulse 56; respirations 15, O2 saturation 98%. PA-pressure 36/16 with mean of 23. In general, a middle aged man in no acute distress. HEENT: Extraocular muscles are intact. Moist mucous membranes. Neck supple. No jugular venous distention. Cardiovascular is regular rate and rhythm, positive S3. Pulmonary clear to auscultation bilaterally. Abdomen soft, notable for ecchymosis across the lower abdomen. Mildly tender around area surrounding bruise. No hematomas, not distended. Positive obesity. Extremities with no edema. Two plus dorsalis pedis pulses bilaterally. Neurological: Alert and oriented, appropriate, non-focal. LABORATORY: White blood cell count 10.8, normal differential. Hematocrit 40.8, platelets 372. Sodium 137, potassium hemolyzed, chloride 100, bicarbonate 25, BUN 21, creatinine 0.6, glucose 88. CK 159, troponin less than 0.3, MB 2.0. Coagulation studies were INR 2.1. EKG normal sinus rhythm at 70, normal axis and intervals. ST elevation in V1 through V4 with Q waves V1 through V3 consistent with evolving old infarction. HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Cardiac Care Unit for monitoring overnight. His hemodynamics remained stable. He was negative approximately two liters post cardiac catheterization and his wedge pressure returned to [**Location 213**]. His arterial and Swan-Ganz catheter were removed by morning. The patient underwent echocardiogram which demonstrated no pericardial effusion. Ejection fraction 30 to 35% on early depressed overall left ventricular systolic function. The patient was started on aspirin 650 mg four times a day times seven days for treatment of post myocardial infarction pericarditis. The patient's Telemetry monitoring demonstrated no arrhythmia and the patient will continue to follow-up for further electrophysiology studies as planned through [**Hospital6 **]. DISCHARGE MEDICATIONS: 1. Aspirin 650 mg p.o. four times a day times seven days, then return to aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. 3. Lipitor 80 mg p.o. q. day. 4. Warfarin 5 mg p.o. q. h.s.; INR measured at 2.6 on [**2177-5-16**]. 5. Lisinopril 10 mg p.o. q. day. 6. Atenolol 50 mg p.o. q. day. 7. Mirtazapine 30 mg p.o. q. day. 8. Zoloft 100 mg p.o. q. a.m. 9. Neurontin 1500 mg p.o. q. day. 10. Protonix 40 mg p.o. q. day. 11. Lorazepam 0.5 mg p.o. three times a day p.r.n. 12. Azolitmin spray 137 micrograms, two sprays q. nostril h.s. 13. Percocet one to two tablets q. six hours p.r.n., dispense twenty. 14. Nicotine transdermal 21 patch q. day. DISCHARGE INSTRUCTIONS: 1. Follow-up as previously planned with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1617**]. 2. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**]. 3. Appointment with Dr. [**Last Name (STitle) **] on [**6-25**] at 03:00 p.m. with appointment with Dr. [**Last Name (STitle) 1617**] to follow. PLEASE SEND CARDIAC CATHETERIZATION REPORT AND ECHOCARDIOGRAM REPORT WITH CARBON COPIES. DISCHARGE DIAGNOSES: Pericarditis. CONDITION ON DISCHARGE: Good. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2177-5-16**] 16:27 T: [**2177-5-16**] 22:20 JOB#: [**Job Number 47673**] CC.: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 **], [**Location **], TELEPHONE NUMBER [**Telephone/Fax (1) 47674**]. DR. [**Last Name (STitle) **], [**Hospital1 2177**] CARDIOLOGY, TELEPHONE NUMBER [**Telephone/Fax (1) 47675**] Admission Date: Discharge Date: Date of Birth: Sex: Service: CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old man with anterior MI on [**4-30**]. The patient had been recovering without incident and on [**5-15**], he presented to his PCP's office with complaints of left substernal chest pain. The patient states symptoms began approximately 9 a.m. with slow onset of chest pain radiating to his left shoulder associated with diaphoresis, nausea, some dizziness. The patient denies shortness of breath. The patient reports the pain is similar in location and character to his anginal pain, but less severe. The pain was 10 out of 10. The patient took two sublingual nitroglycerins without relief. The patient's pain is exacerbated by motion, cough and reproducible on palpation. The patient denies shortness of breath, he notes two to three pillow orthopnea, which is stable, no paroxysmal nocturnal dyspnea. The patient reports having loss weight since discharge from the hospital, followed by home VNA and had intermittent, but not progressive lower extremity edema. The patient was transferred to [**Hospital1 188**]. The patient underwent cardiac catheterization, which demonstrated patent stent, serial 40% lesions in OM2 and 80% RCA lesion with left to right collaterals in the LAD. Hemodynamics in the catheterization lab were suggestive of fluid overload. The patient was transferred to cardiac care unit for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. GERD. 5. History of alcohol. 6. Status post right knee surgery. 7. Status post tummy tuck. MEDICATIONS: 1. Aspirin. 2. Plavix. 3. Lipitor. 4. Warfarin. 5. Lisinopril. 6. Atenolol 50 mg p.o. q.day. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2177-5-16**] 15:03 T: [**2177-5-20**] 20:16 JOB#: [**Job Number 47676**]

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Discharge summary

report

Admission Date: [**2116-7-30**] Discharge Date: [**2116-8-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3016**] Chief Complaint: N/V, fever Major Surgical or Invasive Procedure: ERCP with external stent placement Percutaneous biliary drainage History of Present Illness: 89 year old female with terminal metastatic colon cancer with plans for hospice complicated by biliary stricture s/p stenting who was recently admitted for possible cholangitis and pseudomonas bacteremia. She now presents with fevers and N/V. She denies abdominal pain, cough, SOB, dysuria. Past Medical History: Metastatic colon CA Biliary stricture Pseudomonas bacteremia Anemia Breast CA s/p L mastectomy h/o lower extremity DVT, s/p IVC filter in [**2-8**] HTN Hyperlipidemia CAD, h/o NSTEMI . MEDS: Omeprazole 40 [**Hospital1 **] (2 times a day). Meclizine 12.5 mg [**Hospital1 **] Atorvastatin 80 mg DAILY Aspirin 325 Docusate Sodium 100 mg [**Hospital1 **] Magnesium Oxide 400 mg DAILY Isosorbide Mononitrate SR 60 mg [**Hospital1 **] Atenolol 25 mg [**Hospital1 **] Nifedical XL 30 mg once a day . NKDA Social History: Denies any tobacco or alcohol use. Lives with daughter. Immigrated from [**Location (un) 3156**] 10 years ago. Family History: NC Physical Exam: VITAL SIGNS: Temperature: 98.3 Blood pressure: 96/45 Heart rate: 74 Resp rate: 20, 96%2L GENERAL: elderly woman in no acute distress. HEENT: Sclerae icteric. Pupils equal, round, reactive to light. LUNGS: Bibasilar rales. HEART: Normal S1, S2. Regular rate and rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, nontender, nondistended, normal bowel sounds. EXTREMITIES: No edema. SKIN: No rash Pertinent Results: Trop-T: <0.01 . 137 / 102 / 22 gluc 90 ------------------- 3.7 / 25 / 1.1 . MB: 2 . ALT: 49 AP: 1693 Tbili: 8.0 Alb: 2.5 AST: 109 LDH: 218 Lip: 21 . WBC 24.3 HCT 25.0 PLT 252 N:95.8 L:2.5 M:1.5 E:0.1 Bas:0.1 . UA: Lg Bili, Tr Ketone . BC pending . Ucx pending . CXR: no signficant change from [**7-20**]. . [**7-21**] ERCP: Successful removal of previous palstic stent seen at major papilla. Evidence of previous metal stent seen within the CBD. A single irregular stricture that was 10mm long was seen at the upper third of the common bile duct. There was mild post-obstructive dilation. These findings are compatible with known CBD tumor. Some sludge and tissue debris was extracted successfully using a 15 mm RX balloon. A 6cm by 10mm uncovered metal stent biliary stent was placed successfully. . [**8-5**] Percutaneous Transhepatic Biliary Drainage: 1. Percutaneous cholangiogram demonstrating dilated left biliary ducts with some filling of the right-sided ducts. 2. Placement of 8.5 French left-sided external biliary drain. 3. 60 cc of purulent bile was aspirated and sent for culture and sensitivity. 4. Unable to cross previously endoscopically placed biliary stents. . [**2116-8-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING INPATIENT [**2116-8-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-8-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-5**] BILE GRAM STAIN-FINAL; FLUID CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} INPATIENT [**2116-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2116-8-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-7-30**] BLOOD CULTURE Blood Culture, Routine-FINAL {PSEUDOMONAS AERUGINOSA}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2116-7-30**] BLOOD CULTURE Blood Culture, Routine-FINAL {PSEUDOMONAS AERUGINOSA, ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2116-7-30**] URINE URINE CULTURE-FINAL . [**2116-7-30**] 06:00PM BLOOD pO2-71* pCO2-36 pH-7.47* calTCO2-27 Base XS-2 Comment-GREEN TOP [**2116-7-30**] 05:55PM BLOOD Albumin-2.5* [**2116-7-31**] 05:55AM BLOOD Iron-12* [**2116-8-1**] 08:45AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.4 Mg-2.0 [**2116-8-2**] 05:25AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.0 [**2116-8-2**] 05:25AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.0 [**2116-8-3**] 05:35AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.0 [**2116-8-4**] 06:40AM BLOOD Calcium-7.8* Phos-1.0* Mg-2.0 [**2116-8-4**] 11:00AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.2 [**2116-8-5**] 06:25AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0 [**2116-8-6**] 04:41AM BLOOD Albumin-1.0* Calcium-6.5* Phos-2.0* Mg-1.3* [**2116-8-6**] 08:35AM BLOOD Albumin-2.0* Calcium-7.5* Phos-3.9# Mg-2.3 [**2116-8-7**] 10:50AM BLOOD Albumin-1.9* Calcium-7.3* Phos-3.3 Mg-2.6 [**2116-8-8**] 01:15PM BLOOD Calcium-7.3* Phos-3.5 Mg-2.3 [**2116-8-9**] 06:10AM BLOOD Calcium-7.5* Phos-4.1 Mg-2.1 [**2116-8-10**] 06:15AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.0 [**2116-8-11**] 06:50AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.8 [**2116-8-12**] 06:45AM BLOOD Albumin-1.9* Calcium-7.7* Phos-2.9 Mg-1.8 [**2116-7-30**] 05:55PM BLOOD Lipase-21 [**2116-8-6**] 04:41AM BLOOD Lipase-7 [**2116-8-6**] 08:35AM BLOOD Lipase-11 [**2116-7-30**] 05:55PM BLOOD ALT-49* AST-109* LD(LDH)-218 AlkPhos-1693* TotBili-8.0* [**2116-7-31**] 05:55AM BLOOD ALT-40 AST-96* AlkPhos-1423* TotBili-6.2* DirBili-5.0* IndBili-1.2 [**2116-8-1**] 08:45AM BLOOD ALT-38 AST-93* AlkPhos-1570* TotBili-5.9* [**2116-8-2**] 05:25AM BLOOD ALT-37 AST-109* AlkPhos-1642* TotBili-5.5* [**2116-8-6**] 04:41AM BLOOD ALT-19 AST-72* LD(LDH)-216 AlkPhos-656* Amylase-16 TotBili-2.7* [**2116-8-6**] 08:35AM BLOOD ALT-39 AST-136* LD(LDH)-254* AlkPhos-1405* Amylase-38 TotBili-5.4* [**2116-8-7**] 10:50AM BLOOD ALT-38 AST-125* LD(LDH)-273* AlkPhos-1316* TotBili-3.9* [**2116-8-8**] 01:15PM BLOOD ALT-36 AST-108* LD(LDH)-273* AlkPhos-1386* TotBili-3.2* [**2116-8-9**] 06:10AM BLOOD ALT-27 AST-88* AlkPhos-1363* TotBili-3.0* [**2116-8-10**] 06:15AM BLOOD ALT-22 AST-60* AlkPhos-1127* TotBili-2.9* [**2116-7-30**] 05:55PM BLOOD WBC-24.3*# RBC-3.07* Hgb-8.5* Hct-25.0* MCV-82 MCH-27.6 MCHC-33.8 RDW-17.6* Plt Ct-252 [**2116-7-31**] 05:55AM BLOOD WBC-19.8* RBC-2.95* Hgb-8.6* Hct-24.5* MCV-83 MCH-29.0 MCHC-35.0 RDW-17.7* Plt Ct-234 [**2116-8-1**] 08:45AM BLOOD WBC-14.4* RBC-3.23* Hgb-8.8* Hct-27.2* MCV-84 MCH-27.2 MCHC-32.2 RDW-17.7* Plt Ct-294 [**2116-8-2**] 05:25AM BLOOD WBC-11.9* RBC-2.85* Hgb-8.0* Hct-23.6* MCV-83 MCH-28.0 MCHC-33.8 RDW-17.9* Plt Ct-309 [**2116-8-3**] 05:35AM BLOOD WBC-10.3 RBC-2.93* Hgb-8.0* Hct-24.8* MCV-84 MCH-27.3 MCHC-32.4 RDW-17.7* Plt Ct-339 [**2116-8-4**] 06:40AM BLOOD WBC-14.6* RBC-3.09* Hgb-8.5* Hct-25.5* MCV-83 MCH-27.4 MCHC-33.2 RDW-17.9* Plt Ct-379 [**2116-8-5**] 06:25AM BLOOD WBC-22.6*# RBC-2.81* Hgb-7.8* Hct-23.2* MCV-83 MCH-27.8 MCHC-33.6 RDW-18.1* Plt Ct-359 [**2116-8-5**] 09:45PM BLOOD WBC-17.1* RBC-2.66* Hgb-7.3* Hct-21.9* MCV-82 MCH-27.6 MCHC-33.5 RDW-17.4* Plt Ct-377 [**2116-8-6**] 04:41AM BLOOD WBC-12.5* RBC-1.65*# Hgb-4.7*# Hct-14.4*# MCV-87 MCH-28.6 MCHC-32.9 RDW-17.9* Plt Ct-170# [**2116-8-6**] 06:06AM BLOOD Hct-24.2*# [**2116-8-6**] 08:35AM BLOOD WBC-22.6*# RBC-3.00*# Hgb-8.5*# Hct-25.0* MCV-83 MCH-28.4 MCHC-34.0 RDW-17.9* Plt Ct-315# [**2116-8-7**] 10:50AM BLOOD WBC-19.4* RBC-3.14* Hgb-8.9* Hct-26.6* MCV-85 MCH-28.2 MCHC-33.3 RDW-18.1* Plt Ct-341 [**2116-8-8**] 01:15PM BLOOD WBC-17.9* RBC-3.22* Hgb-9.0* Hct-27.6* MCV-86 MCH-28.0 MCHC-32.8 RDW-18.0* Plt Ct-355 [**2116-8-9**] 06:10AM BLOOD WBC-14.7* RBC-3.09* Hgb-8.6* Hct-26.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-18.3* Plt Ct-337 [**2116-8-10**] 06:15AM BLOOD WBC-10.5 RBC-3.12* Hgb-8.7* Hct-26.3* MCV-84 MCH-27.7 MCHC-32.9 RDW-18.0* Plt Ct-286 [**2116-8-11**] 06:50AM BLOOD WBC-6.8 RBC-2.95* Hgb-8.0* Hct-24.9* MCV-84 MCH-27.2 MCHC-32.2 RDW-18.1* Plt Ct-266 [**2116-8-12**] 06:45AM BLOOD WBC-6.4 RBC-2.82* Hgb-7.8* Hct-24.0* MCV-85 MCH-27.6 MCHC-32.4 RDW-18.1* Plt Ct-253 [**2116-7-30**] 05:55PM BLOOD Neuts-95.8* Lymphs-2.5* Monos-1.5* Eos-0.1 Baso-0.1 [**2116-8-6**] 04:41AM BLOOD Neuts-90* Bands-4 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2116-8-6**] 08:35AM BLOOD Neuts-93.5* Lymphs-3.6* Monos-2.4 Eos-0.5 Baso-0.1 [**2116-8-8**] 01:15PM BLOOD Neuts-85.0* Bands-0 Lymphs-10.7* Monos-3.8 Eos-0.4 Baso-0.1 Brief Hospital Course: In the ICU patient was resusitated with 6L of fluid and then required 2 RBC packs overnight. Patient was stable for the rest of the night. Early morning patient pulled by herself the foley catheter out. Patient was able to urinate (non-quantified) afterwards. A/P: 89 year old female with metastatic colon cancer c/b biliary stricture requiring stenting and recent admit for cholangitis and bacteremia who now presents with fever, leukocytosis, and worsened LFTS. . #) Cholangitis: The patient was taken for ERCP and found to have an obstructed bile duct. Purulent material was drained and a new stent was placed. She was started on ciprofloxacin after the procedure per recommendations of the ERCP team but blood cultures grew out two strains of Pseudomonas and E. coli, at which time she was placed on zosyn. She remained afebrile and was discharged on cephalexin and cipro based on sensitivities. Dr. [**Last Name (STitle) **], her attending gastroenterologist that supervised the ERCP, was contact[**Name (NI) **] regarding additional stenting measures that would prevent restenosis of the CBD. He stated, however, that additional procedures were not indicated at this time, and that he was hopeful that the patient would not again experience re-obstruction and subsequent cholangitis. Note that the patient has a history of chronic intrahepatic bile duct obstruction which is thought to potentially represent a cholangiocarcinoma versus colon cancer metastasis with bile duct obstruction. However, this has not been further evaluated because the patient has metastatic colon cancer and the goals of care at this time are comfort based, per the patient's discussion with her outpatient oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (see OMR notes). When the patient was once again found to have signs of sepsis a CT scan was performed that noted the presence of multiple biliary lakes. IR was consulted and they placed an exnternal drain because an internal drain could not be placed after the ERCP placed stent became clogged. The external drain was functioning well. Culture of the biliary fluid grew pansensitve pseudomonas. Zosyn and Cipro were started for double coverage with a plan to continue for a total of 14 days. . #) Metastatic colon cancer: The patient was seen by Dr. [**Last Name (STitle) **] a few weeks prior to admission and at that time, she made the decision to pursue hospice care and not to pursue further treatment for her colon cancer, as she would be unlikely to tolerate chemo well. A frank discussion was had with Dr. [**Last Name (STitle) **], patient and her daughter, and the decision was made not to pursue further chemotherapy. . #) Anemia: The patient had a low serum iron, a borderline low MCV, and normal ferritin levels. She required 3 U PRBC on [**2116-8-6**] and 2U PRBC on [**2116-8-16**] This combination is not diagnostic for any common type of anemia. Though she is at risk for anemia of chronic disease, she does have a history of rectal bleeding secondary to her colonic mass. She likely has some component of iron deficiency anemia and was therefore started on iron supplementation. Note that patient also has a history of NSTEMI in the setting of rapid blood loss. . #) Hypertension: Antihypertensives were held because the patient's blood pressure was low to normotensive, and because she was bacteremic. Isosorbide was continued, however, to prevent anginal pain. . #)Oral Candidiasis: Patient was found to have thrush and started on nystatin swish and swallow with significant improvement. She was discharged on nystatin. . #) Code: Code status is DNR/DNI. Please see outpatient note from Dr. [**Last Name (STitle) **] for confirmation. Medications on Admission: Omeprazole 40 [**Hospital1 **] (2 times a day). Meclizine 12.5 mg [**Hospital1 **] Atorvastatin 80 mg DAILY Aspirin 325 Docusate Sodium 100 mg [**Hospital1 **] Magnesium Oxide 400 mg DAILY Isosorbide Mononitrate SR 60 mg [**Hospital1 **] Atenolol 25 mg [**Hospital1 **] Nifedical XL 30 mg once a day Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed. Disp:*30 Capsule(s)* Refills:*2* 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days Disp:*14 Tablet(s)* Refills:*0* 14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 2 days: Please take through [**8-20**] and then stop. Disp:*21 * Refills:*0* 15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day) as needed for thrush. Disp:*50 ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Cholangitis . Secondary: Metastatic colon CA Biliary stricture Pseudomonas bacteremia Anemia Breast CA s/p L mastectomy h/o lower extremity DVT, s/p IVC filter in [**2-8**] HTN Hyperlipidemia CAD, h/o NSTEMI Discharge Condition: Stable, tolerating food Discharge Instructions: You were admitted because of nausea, vomiting, and fever. We determined that you had an infection in your common bile duct. To treat you for this, we performed an endoscopic procedure and drained your bile duct. You now have an external biliary drain to prevent bile from collecting in your liver and hopefully to prevent you from getting another infection. We also gave you antibiotics. You will need to continue these antibiotics for several days after you leave the hospital. We also found that you have an iron deficiency anemia. To treat you for this, we gave you iron supplements. . Please take all of your medications as prescribed. Please keep all of your follow-up appointments. . Please call your doctor or return to the hospital if you experience fevers, chills, sweats, chest pain, shortness of breath or anything else of concern. Followup Instructions: DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], HER OUTPATIENT ONCOLOGIST on [**2116-9-2**] at 3 pm. Please contact the interventional radiology PA [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) 12528**] with any qustions regarding the external biliary drain. Her office number is [**Telephone/Fax (1) 12529**]. She should be contact[**Name (NI) **] in [**Name (NI) 1096**] regarding replacement of drain. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**] Completed by:[**2116-8-19**]

[ "576.1", "785.52", "995.92", "276.50", "153.7", "V12.51", "038.42", "401.9", "576.2", "038.43", "272.4", "V10.3", "112.0", "197.7", "280.0" ]

icd9cm

[ [ [] ] ]

[ "51.98", "99.04", "97.05", "51.10" ]

icd9pcs

[ [ [] ] ]

14099, 14165

8431, 12172

273, 339

14426, 14452

1775, 8408

15346, 15930

1331, 1335

12523, 14076

14186, 14405

12198, 12500

14476, 15323

1350, 1756

223, 235

367, 660

682, 1185

1201, 1315

1,171

171,475

14660

Discharge summary

report

Admission Date: [**2131-6-2**] Discharge Date: [**2131-6-12**] Date of Birth: Sex: M Service: NEUROLOGY CHIEF COMPLAINT: Left hand clumsiness. HISTORY OF PRESENT ILLNESS: This is a 55 year old man with a history of diabetes mellitus, hypertension and hypercholesterolemia, who presents after experiencing left morning of [**2131-6-2**], while playing golf when he noticed that the golf ball suddenly became blurry and appeared as though it was moving. He experienced light-headedness. He decided to play on when he realized that his left arm was wobbling all over; he took his right hand to steady the left. Although the blurry vision resolved quickly, the left arm weakness persisted until he went to an outside hospital. the time did not reveal any acute bleed. He was transferred to the [**Hospital1 69**] for further evaluation. PAST MEDICAL HISTORY: 1. Diabetes mellitus since [**2122**], noninsulin requiring. 2. Hypertension since [**2122**]. 3. Hyperlipidemia for four years. 4. Right hip degenerative joint disease. ALLERGIES: Penicillin causes hives. Strawberries cause rash. MEDICATIONS ON ADMISSION: 1. Lipitor 40 mg p.o. once daily. 2. Glucovan 2.5-500 two pills p.o. twice a day. 3. Accupril 20 mg p.o. once daily. 4. Aspirin 325 mg p.o. two pills once daily. SOCIAL HISTORY: Dr. [**Known lastname 32495**] is a dentist who is married with two children. He does not drink or smoke. FAMILY HISTORY: Father died at age 58 from myocardial infarction. Mother died from a stroke at age 68. He has two siblings who are healthy. PHYSICAL EXAMINATION: Vital signs revealed temperature 98.6, blood pressure 120/80, heart rate 74, respiratory rate 20, oxygen saturation 94% in room air. General- a middle age man in no acute distress. Head and neck - normocephalic, supple. No lymphadenopathy, no bruits. Cardiovascular - regular rate and rhythm. Pulmonary clear to auscultation bilaterally. Abdomen - positive bowel sounds, soft, nontender, nondistended. Extremities - positive pulses, no cyanosis, clubbing or edema. Neurologic - awake, alert and oriented times three. Speech and comprehension are intact. Attention is intact as well as memory recalling four out of four objects at five minutes. There was some minor word finding slowness but no apraxia. Cranial nerves - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are full. Funduscopic examination is normal. Visual fields are full. Face moves symmetrically as well as palatal elevation. Tongue protrudes midline. Facial sensation is intact. Motor - bulk, tone and power are normal throughout. There is minimal left drift though unclear. Reflexes are 2+ and symmetric. Plantar reflexes are flexor. Sensation is intact to touch, pin prick, temperature and proprioception throughout. Coordination - finger to nose is sloppy on the left. Finger tap is slow on the left. Rapid alternating movement is also slow. Heel to shin is difficult to ascertain for old hip injury on the right. LABORATORY DATA: MR imaging - There is a diffusion restriction in the right parietal lobe in apparent relenting fashion. MRA reveals an occluded left carotid artery with some collateralization in the left MCA distribution. The right carotid appears to be diseased but no appreciable flow compromise. HOSPITAL COURSE: The patient presents with what is most consistent with an acute ischemic insult leaving some weakness on the right arm. Formal strength testing was unremarkable though coordination reveals some weakness. Taking together the presentation is very concerning for symptomatic right carotid disease. Further evaluation reveals 60 to 70% stenosis of the right internal carotid. Transesophageal echocardiography was also performed to evaluate for possible cardiac source of emboli. This did not reveal evidence of thrombus, however, there is a small patent foramen ovale appreciated. Based upon these findings, the patient was started on more aggressive antiplatelet regimen including Aspirin and Plavix. However, the patient's course deteriorated while in house and he experienced another episode of left arm weakness and on examination he had severe weakness of the finger extensors and interossei of the left hand. His triceps and deltoids were also weak on the left. He was started on Heparin drip. Transcortical Doppler revealed intermittent emboli arising from the right carotid stenotic atherosclerosis. Therefore, consultants further evaluated and recommended right carotid stenting which was done. He underwent stenting of the right internal carotid with good results. He initially required some pressor support in the Intensive Care Unit but was quickly weaned successfully. His left arm weakness improved dramatically. He was started on a regimen of Warfarin, Plavix and Aspirin. At the time of discharge, the patient was clinically markedly improved with better control of his left hand and arm. He continued to work with occupational therapy to help increase his manual dexterity on the left. We would anticipate that he will continue to make clinical improvement. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: The patient was discharged home with follow-up and services. DISCHARGE DIAGNOSES: 1. Right parietal ischemic infarction. 2. Symptomatic right internal carotid artery disease, status post successful stenting. SECONDARY DIAGNOSES: 1. Hyperlipidemia. 2. Diabetes mellitus. 3. Hypertension. MEDICATIONS ON DISCHARGE: 1. Warfarin 2.5 mg p.o. once daily with an INR goal of 2.0 to 3.0> 2. Glucovan 2.5/500 two tablets p.o. once daily. 3. Plavix 75 mg p.o. once daily. 4. Aspirin 325 mg p.o. once daily. 5. Atorvastatin 40 mg p.o. once daily. FOLLOW-UP: 1. The patient will follow-up with Dr. [**Last Name (STitle) **] in Stroke/[**Hospital 878**] Clinic [**2131-7-6**]. 2, He will also follow-up with me in [**Hospital 878**] Clinic [**2131-8-31**]. 3. He will follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 43168**]. 4. We have written a prescription for outpatient occupational therapy. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**] Attending in Neurology Dictated By:[**Last Name (NamePattern4) 43169**] MEDQUIST36 D: [**2131-12-2**] 10:43 T: [**2131-12-2**] 12:24 JOB#: [**Job Number 43170**]

[ "433.11", "342.90", "E878.8", "458.2", "250.00", "998.12", "272.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "42.23", "39.50", "88.41", "39.90" ]

icd9pcs

[ [ [] ] ]

1463, 1590

5310, 5439

5548, 6474

1154, 1321

3386, 5172

5460, 5522

1613, 3368

149, 172

201, 867

889, 1128

1338, 1446

5197, 5289

11,144

103,602

17808

Discharge summary

report

Admission Date: [**2118-4-8**] Discharge Date: [**2118-4-19**] Date of Birth: [**2046-1-13**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old woman with a history of myelodysplastic syndrome and hypertension, who presented to [**Hospital 8**] Hospital on [**2118-4-8**] with complaint of epigastric and right upper quadrant pain radiating to her back for several days. She had several episodes of emesis that day and was also complaining of malaise. No documented fevers at that time. She had a prior episodes of occasional epigastric pain, but not as severe as this. She was also noted to be jaundiced, but afebrile. Workup at outside hospital revealed white blood cell count of 11.6, amylase 2,164, lipase 5,997, total bilirubin of 6, and direct bilirubin of 4.2 with decreased transaminases. Ultrasound showed gallstones with 1.1 common bile duct and a prominent pancreatic duct. She was transferred to [**Hospital1 1444**] for emergent ERCP. This showed an impacted stone in the major papilla which was extracted, however, the procedure was aborted secondary to patient desating to O2 saturations in the 50s. She received Narcan and flumazinol with improvements in sats, and was transferred to the MICU for further management. General Surgery was called to evaluate the patient for worsening abdominal pain and for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Myelodysplasia. PAST SURGICAL HISTORY: None. MEDICATIONS AT HOME: 1. Norvasc 5 mg q day. 2. Hydrochlorothiazide 25 mg q day. 3. Amitriptyline 25 mg q hs. 4. Hydroxyurea 500 mg q day. MICU MEDICATIONS: 1. Meropenem 1 gram IV q12. 2. Pepcid 20 mg IV q12. 3. Lopressor 5 mg IV q6h. 4. Hydroxyurea. 5. Tylenol prn. 6. Compazine prn. 7. Morphine prn. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She denied tobacco or alcohol use. FAMILY HISTORY: Diabetes. PHYSICAL EXAMINATION: On examination, the patient had a temperature of 99.9, pulse of 108, blood pressure 147/59, respiratory rate 13, and sating 94% on 3 liters nasal cannula. Urine output was approximately 50 cc an hour. The patient was somnolent, but arousable, mild scleral icterus. Chest was clear to auscultation bilaterally. Cardiovascular: Regular, rate, and rhythm. Abdominal examination: She is slightly distended, soft, tender in the epigastric region without rebound or guarding. Rectal had normal tone, stool was guaiac negative. Extremities: Warm, no edema, and 2+ dorsalis pedis pulses bilaterally. LABORATORIES: White count of 27.5, hematocrit of 45.2, and platelets of 954. Chemistries: Sodium 141, potassium 3.4, chloride 104, bicarb 26, BUN 21, creatinine 0.9, glucose 141, calcium 6.9, magnesium 2.2, phosphorus 2.6, ALT 296, AST 247, alkaline phosphatase 508, total bilirubin 4.9 down from 6.0 at the outside hospital. Albumin 3.3, amylase 946 which is down from [**2115**] at the outside hospital and lipase 2200 down from 6,000 at the outside hospital. Chest x-ray showed no acute infiltrates. ERCP showed the impacted stone in the major papilla which was extracted. CT scan of the abdomen showed pericholecystic fluid, pancreatic inflammation with dilated ducts. This is a 72-year-old woman with gallstone pancreatitis and question of cholangitis, was admitted to the Medical Team in the Intensive Care Unit, and was made NPO, given IV fluids, aggressive hydration. Patient was given Morphine for pain and urine output was followed closely. Foley catheter was in place. Meropenem was continued empirically, and General Surgery followed along as a consult service at this time. On the evening of first day of hospitalization, the total bilirubin was actually noted to increase of again after the initial decrease after the stone extraction. the white blood cell count on repeat was noted to be 28 with the increasing bilirubin and increasing abdominal pain. GI was again asked to evaluate the patient's biliary ducts. On hospital day four, the patient was noted to have improved epigastric pain. She had a temperature of 100.4 and her white blood cell count was 24.7 down from 29. Also her amylase was down to 131 and her lipase down to 100. At this time, she was continued on meropenem and she was continued NPO with IV fluids, and at this time, plan was for continued medical management of her pancreatitis and cholangitis, and surgically, the patient would need a cholecystectomy once the pancreatitis resolved. On hospital day #5, the patient clinically appeared to be improving with bilirubin, LFTs, amylase, lipase trending down. The patient was continued NPO and white blood cell count also continued to trend downward. Patient continued to do well, clinically improved, and was taken to the operating room on [**2118-4-15**], where a laparoscopic cholecystectomy was performed. Patient did well postoperatively. Was immediately postoperative was tolerating po, was HEP locked. Kefzol was given for two days, and the patient was clinically feeling very well. She was also continued on meropenem and by postoperative day #3, was tolerating a regular diet was put on all po medications, and continued to have adequate urine output, and the patient's abdominal examination was benign. Her LFTs were normal and white blood cell count was still elevated, however, it was trending downward. On postoperative day #4, the patient felt good, had no complaints, was tolerating regular diet, was moving her bowels, normal bladder function. Her maximum temperature over the past 24 hours had been 98.6. However, her white blood cell count was elevated to 30 without any obvious source of infection. Chest x-ray and urinalysis were performed, and were negative, and Dr. [**Last Name (STitle) **] discussed with Dr. [**Last Name (STitle) 724**], and the medical attending, as well as patient's PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11461**], who thought it could be secondary to her myelodysplastic syndrome, and patient was discharged home with followup with Dr. [**Last Name (STitle) **] as well as her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11461**] on no medications and to continue her previous medications, and patient was to return or call Dr.[**Name (NI) 6218**] office if there is any increase in abdominal pain or complaints of any fever or chills. DISCHARGE DIAGNOSES: 1. Gallstone pancreatitis. 2. Cholangitis. 3. Hypertension. 4. Myelodysplastic syndrome. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 7241**] MEDQUIST36 D: [**2118-5-22**] 15:41 T: [**2118-5-26**] 13:11 JOB#: [**Job Number 49435**]

[ "997.4", "560.1", "238.7", "576.1", "574.61", "238.4", "577.0", "578.0", "789.5" ]

icd9cm

[ [ [] ] ]

[ "51.88", "38.93", "51.85", "51.23", "99.15" ]

icd9pcs

[ [ [] ] ]

1900, 1911

6489, 6854

1502, 1830

1474, 1481

1934, 6468

155, 1391

1413, 1450

1847, 1883

10,843

149,226

9548

Discharge summary

report

Admission Date: [**2162-4-23**] Discharge Date: [**2162-5-3**] Date of Birth: [**2096-6-25**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: HERE FOR ERCP History of Present Illness: Mrs [**Known lastname **] has a previous history of a Whipple ([**9-/2157**]) and was transferred to the hospital with a bowel obstruction which caused her to have elevated amylase and elevated liver function tests. She was thought to have an afferent loop syndrome. She came in with a cc/o abdominal pain x 2 days. No N/V. +Subjective fevers. Last BM on Monday, loose. No dysuria. Initially came to OSH on Monday with abdominal pain. Now, at [**Hospital1 18**] evaluation, pain is markedly decreased. Past Medical History: -MS [**Name13 (STitle) 32418**] Physical Exam: VS: 96.4, 100, 110/60, 16, 95(RA) GEN: NAD CV: RRR RESP: CTAB ABD: mild distended, +tympany, NT, NABS EXT: good peripheral pulses, no c/c/e NEURO: AxOx3 Pertinent Results: [**2162-4-23**] 05:50AM PT-16.7* PTT-28.1 INR(PT)-1.8 [**2162-4-23**] 05:50AM PLT SMR-VERY LOW PLT COUNT-21*# LPLT-3+ [**2162-4-23**] 05:50AM WBC-13.4* RBC-4.12* HGB-12.1 HCT-34.6* MCV-84 MCH-29.5 MCHC-35.1* RDW-13.5 [**2162-4-23**] 05:50AM NEUTS-92.2* BANDS-0 LYMPHS-5.0* MONOS-2.2 EOS-0.5 BASOS-0.1 [**2162-4-23**] 05:50AM GLUCOSE-161* UREA N-23* CREAT-0.5 SODIUM-137 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13 [**2162-4-23**] 05:50AM CALCIUM-7.7* PHOSPHATE-0.5* MAGNESIUM-2.0 [**2162-4-23**] 05:50AM ALT(SGPT)-86* AST(SGOT)-50* ALK PHOS-206* AMYLASE-47 TOT BILI-7.1* [**2162-4-23**] 05:50AM LIPASE-24 Brief Hospital Course: She underwent an exploratory-laparotomy on [**4-23**]. She tolerated the procedure well and was transferred to the floor. Post-operatively, she was transferred to ICU for pulmonary toilet while experiencing increased respiratory difficulty/effort on POD#2. Tube feeds were started in the ICU. She experienced some loose stool; C. diff cultures were sent and negative. Patient remained in SICU till [**4-29**], POD#6. Upon reaching floor, chest PT was administered. On POD#7, regular diet was begun. By discharge, she had Tube Feeds cut to [**1-10**] and cycled overnight with POs. She remained in the hospital over the weekend due to difficulty finding rehabilitation placement. On POD#10, she was deemed suitable and stable for discharge. On discharge, she had received 6 days of a 10 day course of Levofloxacin. Medications on Admission: Ranitidine 150' Fosamax 70 qwk Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 6 days. 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**1-10**] teaspoons PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Small bowel obstruction s/p Whipple ([**9-/2157**]) Discharge Condition: Good. Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. You may remove your dressings 2 days after your surgery if they were not removed in the hospital. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise contraindicated and follow up with PCP. Followup Instructions: F/U with [**Doctor Last Name **]. Call for appt. Completed by:[**2162-5-3**]

[ "V10.09", "733.00", "340", "577.0", "552.8" ]

icd9cm

[ [ [] ] ]

[ "46.41", "53.59", "54.59" ]

icd9pcs

[ [ [] ] ]

3174, 3246

1772, 2587

327, 342

3342, 3349

1117, 1749

4556, 4635

2668, 3151

3267, 3321

2613, 2645

3373, 4533

944, 1098

273, 289

370, 874

896, 929

54,958

169,549

32852

Discharge summary

report

Admission Date: [**2188-4-30**] Discharge Date: [**2188-5-7**] Date of Birth: [**2111-3-11**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Biaxin / Tetracycline / Albuterol / Succinylcholine Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia. Major Surgical or Invasive Procedure: [**2188-4-30**] Right thoracotomy and thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, left main stem bronchoplasty with mesh, bronchoscopy with aspiration. History of Present Illness: Sister [**Name (NI) 60965**] is a 77-year-old woman who has had dyspnea and was found to have severe tracheobronchomalacia. She did not tolerate a Y-stent but after placement of a left main stem self-expanding metal stent she had marked improvement of her symptomatology. Past Medical History: COPD/Asthma Atrial Fibrillation s/p ablation [**2184**] Hypertension GERD Degenerative disc disease Arthritis Small hiatal hernia Status post-cholecystectomy [**2160**] Social History: Single. Works part-time. ETOH none Family History: Father - A Fib, cataracts Siblings - brother died from MI, 1 sister with breast cancer. All siblings have a "familial tremor" Physical Exam: VS: T; 98.3 HR: 81 SR BP: 116/70 Sats: 94% RA General: 77 year-old female who appears well HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: faint bibasilar crackles otherwise clear GI: benign Extr: warm no edema Incison: Right thorocotomy site clean dry intact Neuro: non-focal Pertinent Results: [**2188-5-5**] WBC-5.4 RBC-3.81* Hgb-11.3* Hct-32.9* Plt Ct-257 [**2188-5-4**] WBC-5.6 RBC-3.50* Hgb-10.6* Hct-30.0* Plt Ct-216 [**2188-5-1**] WBC-8.7 RBC-4.00* Hgb-12.2 Hct-33.9* Plt Ct-231 [**2188-4-30**] WBC-11.5*# RBC-4.30 Hgb-13.0 Hct-36.1 Plt Ct-231 [**2188-4-29**] WBC-4.7 RBC-4.85 Hgb-14.4 Hct-41.1 Plt Ct-281 [**2188-5-5**] Glucose-88 UreaN-9 Creat-0.6 Na-138 K-4.3 Cl-98 HCO3-33* AnGap-11 [**2188-5-4**] Glucose-95 UreaN-11 Creat-0.5 Na-137 K-4.1 Cl-101 HCO3-31 AnGap-9 [**2188-5-3**] Glucose-105 UreaN-10 Creat-0.6 Na-137 K-3.8 Cl-102 HCO3-27 [**2188-4-29**] UreaN-18 Creat-0.8 Na-139 K-3.5 Cl-98 HCO3-30 AnGap-15 [**2188-5-1**] CK(CPK)-1271* [**2188-5-1**] CK(CPK)-1413* [**2188-5-1**] CK(CPK)-1087* [**2188-5-1**] CK-MB-13* MB Indx-1.0 [**2188-4-30**] MRSA SCREEN (Final [**2188-5-3**]): No MRSA isolated. CXR: [**2188-5-6**] PA and lateral chest views were obtained with patient in upright the right-sided chest tube has been removed. There is no further collapse of the right lung however the small apical pneumothorax remains rather unchanged in size. A left sided small amount of pleural effusion blunts the left lateral and posterior pleural sinus mildly. No new abnormalities are identified. [**2188-5-5**] Left pleural effusion and lower lobe atelectasis are not significantly changed. Linear opacity at the right lung base remains most consistent with atelectasis. There is new superimposed opacity in the right lower lobe, the rapid interval development of which suggests asymmetric mild pulmonary edema. Small right pleural effusion is also increased, likely with a loculated component adjacent to the thoracotomy site. The right chest tube remains in place, and tiny right apical pneumothorax has decreased. [**2188-5-2**] Right apical pneumothorax increased, still small. A right chest tube is in unchanged position. Lung volumes are lower and right basilar opacities, likely atelectasis increased, now moderate-to-severe. Small left pleural effusion is new. Right basilar opacities also increased, likely atelectasis. Perihilar opacities are also likely due to atelectasis. [**2188-4-30**] Newly inserted right-sided chest tube. Moderate air collections in the soft tissues, no visible right-sided pneumothorax. Surgical material projecting over the right main bronchus. Left-sided line in situ. Left basal atelectasis. Normal size of the cardiac silhouette. Brief Hospital Course: Mrs. [**Known lastname 60965**] was admitted on [**2188-4-30**] for Right thoracotomy and thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, left main stem bronchoplasty with mesh, bronchoscopy with aspiration. She was She was extubated in the operating room, monitored in the PACU prior to transfer to the SICU. The chest-tube on suction draining moderate amounts of serosanguinous fluid and was subsequently removed POD6. She was followed by serial chest films which showed a stable right apical pneumothorax, left lower lobe effusion and atelectasis. She had good pain control via Bupivacaine/Hydromorphone Epidural managed by the acute pain service. This was removed on POD5. She converted to PO pain medications and NSAIDS with good pain control. On POD1 she was seen by ENT for hoarseness which showed bilateral true vocal folds mobile and WNL. Overall she has very dry mucosa in the upper airway. They recommended humidified air and PPI [**Hospital1 **]. Aggressive pulmonary toilet and nebs were continued. Her respiratory status improved with oxygen saturations in the high 90's on room air. She was gently diuresised. Tolerated a clear liquid diet. She was seen by physical therapy who recommended rehab. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Aspirin 325mg daily, HCTZ 12.5 mg daily, Toprol 50 mg daily Discharge Medications: 1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation every eight (8) hours as needed for shortness of breath or wheezing. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) PO BID (2 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SQ Injection TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain: give with food and water. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Tracheomalacia COPD/asthma Atrial fibrillation (s/p ablation in [**2184**]) GERD/Hiatal Hernia Hypertension Degenerative disc disease Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Sleep with the Head of the BED elevated 30-45 degrees Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**2190-5-20**]:30am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center, [**Location (un) **]. Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[**2188-5-13**]

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icd9cm

[ [ [] ] ]

[ "33.48", "33.23", "31.79" ]

icd9pcs

[ [ [] ] ]

6533, 6622

4043, 5400

355, 574

6800, 6816

1626, 4020

7093, 7453

1138, 1266

5510, 6510

6643, 6779

5426, 5487

6840, 7070

1281, 1607

292, 317

602, 876

898, 1069

1085, 1122

2,662

109,631

29709

Discharge summary

report

Admission Date: [**2131-12-4**] Discharge Date: [**2131-12-8**] Date of Birth: [**2103-9-8**] Sex: M Service: MEDICINE Allergies: Cephalosporins / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 5755**] Chief Complaint: headache, fever Major Surgical or Invasive Procedure: none History of Present Illness: 28 yo M w/ no significant [**Hospital 3262**] transferred from [**Hospital3 25148**] Center with headache, fever, neck pain, and vomiting for continued management of likely meningitis. Patient's history dates back to [**Month (only) **] when he was experiencing cough and low grade temperatures, for which he was treated with azithromycin. He continued to have on/off fevers and on [**2131-11-26**] presented to [**Hospital3 25148**] Center ED with complaints of ? headache, photophobia, nausea, and vomiting. Tests were sent inlcuding: monospot neg, strep neg, infleunza negative, CXR negative, urine cx negative, blood cx negative, and throat cx negative. He had a normal CBC. He received IVF and no antibx and was discharged home. He returned the following day and that time was treated with ceftriaxone and again sent home pending cultures (lyme negative, hep B ?, ESR 30, bcx x 2, wbc 6.8). He then went to see his PCP the following day for a F 101.4 and non-petechial macular rash. At that time he was started on levofloxacin and instructed to present to the hospital for admission if he continued to have fevers on this antibiotic. He represented to [**Hospital3 25148**] Center ED the following day and underwent an LP which showed: wbc 724, rbc 69, glu 53, TP 97, gram stain: 4+ PMNs, no organisms. Other tests done: MRI: mild left mastoiditis. Mycoplasma IgM negative, IgG positive. CXR: LLL atelectasis vs PNA. He was admitted to the ICU, ID was consulted and he was started on vanc/doxy/rifampin. Given continued fevers, decision was made to transfer the patient to [**Hospital1 18**] for continued care. Past Medical History: # hypercholesterolemia # s/p T&A # s/p recent URI tx with azithromycin [**9-30**] Social History: Denies tobacco, Etoh, illicits. Married and his wife is currently pregnant. Works as a music teacher at [**Location (un) **]. He is active outdoors and was last outside in early/mid [**Month (only) **]. He denies history of tick bites. He is sexually active with 1 partner (his wife). No history of STDs. No recent travel. No unusual foods. Family History: Mother has epilepsy, dx age 15 Physical Exam: T 100.1 bp 127/66 hr 85 rr 23 O2 96% RA genrl: appears fatigued but not toxic heent: anicteric, eomi, perrla, mild pharyngeal erythema and petechiae neck: supple, no LAD cv: rrr, normal S1/S2 Lungs: CTA bilaterally Abd: nabs, soft, nt/nd, no HSM Extr: no [**Location (un) **] Neuro: A, Ox3, CN 2-12 grossly intact, sensation and strength normal throughout Pertinent Results: [**2131-12-4**] 09:28PM GLUCOSE-97 UREA N-10 CREAT-0.6 SODIUM-130* POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-25 ANION GAP-12 [**2131-12-4**] 09:28PM ALT(SGPT)-57* AST(SGOT)-52* LD(LDH)-322* ALK PHOS-122* TOT BILI-0.6 [**2131-12-4**] 09:28PM ALBUMIN-3.0* CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.4 [**2131-12-4**] 09:28PM WBC-13.5* RBC-3.90* HGB-11.5* HCT-33.4* MCV-86 MCH-29.5 MCHC-34.6 RDW-13.6 [**2131-12-4**] 09:28PM NEUTS-83.2* LYMPHS-10.1* MONOS-4.6 EOS-1.9 BASOS-0.1 [**2131-12-4**] 09:28PM PLT COUNT-477* [**2131-12-4**] 09:28PM PT-19.1* PTT-32.1 INR(PT)-1.8* FDP 0-10, FIBRINOGEN 442 RETIC 1.2%, IRON 38, TIBC 172, FERRITIN 610, FOLATE 10.4, B12 1203, TSH 0.96 ALBUMIN 3.0, VANCO TROUGH 16.1 . HEPATITIS B S AG: NEGATIVE, S AB: POSITIVE, C AB: NEGATIVE HEPATITIS C AB: NEGATIVE HIV ANTIBODY: NEGATIVE . PA and lateral upright chest radiograph was reviewed. The heart size is normal. Mediastinum has normal position, contour and _____. The left lower lobe consolidation in the posterior basal segment of the lobe is demonstrated accompanied by small pleural effusion. The rest of the lung is unremarkable. IMPRESSION: Left lower lobe pneumonia. Small amount of pleural effusion. . Anaplasma Phagocytophilum and Ehrlichia Chaffeensis Ab panel Ehrlichia Chaffeensis Antibody, IFA E. Chaffeensis IgG Titer 1:64 (H) E. Chaffeensis IgM Titer <1:20 Interpretation: PAST INFECTION . Anaplasma Phagocytophilum (HGE [**Doctor Last Name **]) IgG/IgM Ab, IFA A. Phagocytophilum IgG Titer <1:64 A. Phagocytophilum IgM Titer <1:20 Interpretation: Antibody Not Detected . RMSF IGG NEGATIVE NEGATIVE RMSF IGM NEGATIVE NEGATIVE RMSF IGG TITER TNP-SCREENING TEST <1:64 NEGATIVE. TITER NOT PERFORMED. RMSF IGM TITER SEE BELOW <1:64 TNP-SCREENING TEST NEGATIVE. TITER NOT PERFORMED. Brief Hospital Course: # Meningitis: Initial DDX included most likely bacterial, perhaps due to invasive strep pneumo given concurrent lobar pneumonia; possibly viral given enteroviruses and adenoviruses still prevalent due to the unusual winter; and less likely zoonotics such as Rickettsia or ehrlichia (unlikely given relatively short incubation periods with a rather distant outdoor exposure). CSF culture was negative, likely due to pretreatment with antibiotics. Rickettsial and ehrichia antibodies do not suggest current, active infection. Lyme antibodies at the outside hospital were negative. Patient had significantly improved on the vanco/rifampin/doxy started at the OSH. ID recommended completing a 14 day course of meropenem (reportedly covers Listeria; NO similar data for erbapenem), vancomycin (q8h, vanco trough 16.1), and doxycycline. A PICC was placed for IV access for long term antibiotics. . # Rash/joint pain: Suspect serum sickness vs secondary to above infection. Patient's symptoms steadily improved with above treatment. . # Transaminitis: Suspect this is due to serum sickness vs above infection. Hepatitis B serologies consistent with prior immunization and hepatitis C antibody negative. HIV antibody was negative. Statin was held. On the day of discharge: ALT 104, AST 73. Consider outpatient imaging for possible NASH if abnormalties persist. . # Coagulopathy: Likely nutritional. INR improved from 1.8->1.4 with vitamin K supplementation. [**Month (only) 116**] be secondary to hepatic dysfunction. DIC panel was otherwise normal. . # Thrombophlebitis: Patient developed multiple sites of thrombophlebitis related to peripheral IVs. With hot packs and elevation, the redness and swelling improved. He was instructed to continue hot packs and elevation and to notify his PCP or to go to the local ER if swelling or erythema worsened to rule out a subsequent DVT. . # Normocytic anemia: Hematocrit remained stable at 31-33. Low retic may be suggestive of BM suppression from active infection. High ferritin suggestive of anemia of chronic disease. Folate, B12 normal. Recommend PCP [**Name9 (PRE) 702**] for continued monitoring. . # Hypercholesterolemia: Statin held. Patient will follow-up with his PCP to restart this medication once his LFTs normalize. . # PPX: SQ heparin . # FEN: Given low albumin and poor po intake, patient was advised to take boost supplements [**Hospital1 **] until his po intake improves back to normal . # Dispo: Patient discharged home with services for IV antibiotics Medications on Admission: (on transfer): doxycycline 200 mg IV q12h cefotaxime 2 g IV q6h dilaudid PCA albuterol nebs guiafenesin prn toradol zofran hydroxazine tylenol benadryl promethazine reglan (home): simvastatin 40 levofloxacin 750 mg po qd Discharge Medications: 1. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days: through [**2131-12-13**]. Disp:*16 Recon Soln(s)* Refills:*0* 2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 8H (Every 8 Hours) for 5 days: through [**2131-12-13**]. Disp:*16 gram* Refills:*0* 3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 5 days. Disp:*10 Capsule(s)* Refills:*0* 4. PICC LINE CARE, PER PROTOCOL Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: meningitis, organsim unknown left lower lobe pneumonia, organism unknown thrombophlebitis transaminitis with negative hepatitis panel and negative HIV normocytic anemia drug rash Discharge Condition: good: afebrile, symptomatically much improved, taking good po Discharge Instructions: Please call your doctor or go to the emergency room for temperature > 101, worsening headache, light sensitivity, neck stiffness, diarrhea, rash, worsening swelling/pain/redness in your arms, or other concerning symptoms. Please follow-up with your primary care doctor to monitor for diarrhea, to follow-up your anemia (low blood count), and to discuss further tests for your abnormal liver enzymes. Please follow a low cholesterol diet. Please note the following changes in your home medications: 1. You have been started on 3 antibiotics: vancomycin, meropenem, and doxycycline. Please take these, as prescribed. 2. Please do not take your simvastatin until you have your liver enzymes rechecked by your primary care doctor. Followup Instructions: Please call to schedule follow-up with Dr. [**Last Name (STitle) 71166**] within 1 week of discharge. Phone: [**Telephone/Fax (1) 63696**]

[ "486", "280.9", "276.1", "E930.5", "272.0", "451.82", "693.0", "320.9", "999.2" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8245, 8297

4930, 7466

327, 334

8520, 8584

2902, 4907

9364, 9507

2475, 2507

7738, 8222

8318, 8499

7492, 7715

8608, 9091

2522, 2883

9109, 9341

272, 289

362, 1989

2011, 2094

2110, 2459

16,990

103,468

12103

Discharge summary

report

Admission Date: [**2149-1-17**] Discharge Date: [**2149-2-22**] Date of Birth: [**2081-11-28**] Sex: M Service: Cardiothor DATE OF EXPIRATION: [**2149-2-22**]. REASON FOR ADMISSION: A 67 year-old known vascular path who has history of coronary artery disease, peripheral vascular disease and carotid stenosis. The patient presented to [**Hospital6 3622**] on [**2149-1-12**] status post MVA. He had been watching the Patriot's game, went for a couple of beers and then on his drive home sustained crushing chest pain accompanied by visual changes and shortness of breath, right leg numbness, nausea, diarrhea, diaphoresis. He had a blood alcohol level of 0.170 and was arrested for DWI. He was brought to the [**Hospital6 33**] where he had an extensive work up revealing critical stenosis of his left internal carotid artery, total occlusion of his right carotid artery and RCI in his right internal carotid artery. Given his known cardiac history he was transferred to the [**Hospital1 1444**] for diagnostic catheterization which showed 80% PLAD, 90% PRCA right CIH was stented. Cardiac surgery was consulted. Vascular surgery was consulted. The patient was then seen by Drs. [**Last Name (STitle) 1537**] and [**Name5 (PTitle) **] who felt the patient would undergo a combined procedure of coronary artery bypass graft and a left CEA. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Carotid stenosis. 90% left internal carotid artery, 80% right internal carotid artery. Patent right vertebral, left vertebral no visualization. 3. History of coronary artery disease. 4. Chronic obstructive pulmonary disease. 5. Alcohol abuse. 6. ASAI. 7. Hypertension. MEDICATIONS: 1. Lopressor. 2. Cardizem. 3. Isordil. 4. Folate. 5. Thiamin. 6. Multi vitamins. 7. Zocor. 8. Inderal. 9. Trental 400 milligrams po four times a day. PHYSICAL EXAMINATION: He is a well appearing white male in no apparent distress. Neck - 1+ carotids. There is a III/VI systolic ejection murmur heard. Lungs are clear. COR - rate, regular rhythm, III/VI systolic ejection murmur at the right upper sternal border. Abdomen is benign. Extremities - no cyanosis, clubbing or edema. Neuro is nonfocal. HOSPITAL COURSE: Preoperatively the patient underwent a stent on [**2149-1-17**] to his RCIA. The patient was on the Cardiac [**Hospital Unit Name 196**] service. At this time the work up between cardiac and vascular continues. Dr. [**Last Name (STitle) **] saw the patient and discussed it with Dr. [**Last Name (STitle) 1537**] and the patient agreed to combined carotid coronary artery bypass graft procedure. On [**2149-1-21**] the patient went to the operating room and underwent a left carotid artery endarterectomy by Dr. [**Last Name (STitle) **] and a coronary artery bypass graft surgery times three; LIMA to LAD, saphenous vein to OM, saphenous vein to RPL by Dr. [**Last Name (STitle) 1537**]. The patient tolerated the procedure well and was transferred to the CSIU in satisfactory, hemodynamically stable condition. The patient was extubated that night and was doing well. Vascular Surgery saw him and felt he was doing well. From cardiac surgery point of view he was doing excellent. He was then transferred to the .................... floor. He had his large chest tube discontinued as scheduled. However on [**2149-1-22**] the patient developed respiratory insufficiency at the same time the patient was being worked up for an ischemic leg. Because the patient was acidotic the patient was intubated by anesthesia. At this point though Vascular Surgery turned their attention to his ischemic right leg. The patient was taken to the operating room and underwent fem fem bypass operation. The patient also had a head CT scan which showed a large right .................... infarct with a small left para .................... infarct. At this point GI was involved because they thought he had some infarct of his bowel due to persistent acidosis. CT scan of his abdomen showed some little contrast and hepatic artery but no defects to the [**Female First Name (un) 899**] or the SMA of bowel infarcts could be determined. The patient continued to do poorly. He had developed acute renal failure, ARF. He was seen by Renal. He was also seen by Hematology for what was thought to be possibly a platelet dysfunction. Hematology felt that giving him platelets and fresh frozen plasma for any bleeding would be appropriate. At this point he continued to be intubated. He was seen daily by Renal and had not yet at this point started on dialysis. At this point the patient was consulted to the SICU service for long term care. Infectious Disease was consulted and felt at the present time his abdominal exam was benign. However it would be possible that gram negative rods may end up being an enteric organism and they felt that starting him on Cipro Ceftazidine today and Vancomycin would be okay and also continue Flagyl and in the ensuing days they would be able to get a definite organism out of a culture. The patient from Renal received a left femoral venous dialysis catheter. This was placed by Cardiothoracic Surgery nurse practitioner. The patient continued to do poorly in the CTVSIU he however was on the SICU service being seen every day by the SICU team as well as Renal, Infectious Disease. He was then seen by critical nutrition for nutritional support. He was on CVVH. Renal was following him for that. Despite all intensive measures the patient continued to do poorly. The patient's abdomen continued to do poorly. They had a CT scan of his abdomen which showed no free fluid but he still underwent an exploratory laparoscopy. At that point he underwent the exploratory laparoscopy for questionable ischemic bowel, gangrene in his gallbladder. Postoperative diagnosis was ischemic small bowel. Exploratory laparotomy, SMA exploration, cecotomy, jejunostomy, mucous fistula with mesh closure. The findings show small bowel ischemia, LOT to TI in cecum, normal gallbladder, stomach and colon. SMA had a water .................... applicable explored and demonstrated flow in it. Small bowel demarcation at 8 cm from LOT to cecum. The patient was then returned to recovery room. However he continued to do poorly hemodynamically. He developed acidosis. The family at this point felt that they would not like any extraordinary measures and eventually the patient on [**2149-2-4**] underwent a PermaCath placement and a tracheostomy. The patient continued with dialysis. He was in ATN. The prognosis was poor at this point. Despite all intensive measures the patient became more and more acidotic over the ensuing days and on [**2149-2-22**] at 12:45 despite all aggressive measures Mr. [**Known lastname 37938**] continued to have severe, persistent acidosis and became asystolic. Atropine and Sodium bicarb were administered with no response. He was pronounced dead at 12:43 A.M. Family was informed. Dr. [**Last Name (STitle) 1537**] was informed. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 37939**] MEDQUIST36 D: [**2149-3-25**] 13:24 T: [**2149-3-26**] 09:58 JOB#: [**Job Number 37940**]

[ "584.5", "414.01", "518.5", "443.9", "578.9", "785.59", "790.7", "575.0", "433.10" ]

icd9cm

[ [ [] ] ]

[ "45.62", "31.1", "83.14", "46.21", "39.61", "38.12", "38.18", "36.12", "37.23" ]

icd9pcs

[ [ [] ] ]

2245, 7311

1896, 2227

1387, 1873

4,713

167,697

15002

Discharge summary

report

Admission Date: [**2127-2-28**] Discharge Date: [**2127-3-10**] Date of Birth: [**2060-4-1**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4748**] Chief Complaint: femoral-femoral bypass thrombus Major Surgical or Invasive Procedure: femoral-femoral thrombectomy, right Axillary to femoral bypass History of Present Illness: The patient is a 66M w/ s/p L common femoral to R profunda fem bypass on [**11-28**] for worsening rest pain and claudication (h/o L common iliac and SFA occlusion) p/w lack improvement from overall symptoms. Pt reports continued claudication pain, inability to ambulate more than 4 steps at a time. There is notable swelling/erythema and redness from ankle to knee. Denies any rest pains but more discomfort, explained as LLE cramping. No buttock pain, dependent rubor or need for positional relief to his LLE. He was seen and evaluated by Dr. [**Last Name (STitle) 1391**] in clinic on [**2127-2-28**] & admitted for pain control & further evaluation. Past Medical History: - CAD s/p 5 vessel CABG in [**10-3**] with LIMA->LAD, SVG->OM1->OM2, SVG-> ramus, SVG->RCA; s/p PTCA [**8-4**] s/p VT to ramus PCI, s/p LM/Cx PCI [**10-5**] Cath [**2122-5-6**]: 1. Severe native vessel coronary artery disease. 2. SVG --> OM1 --> OM2 is occluded. 3. SVG --> Ramus with serial stenoses. 4. SVG --> RCA patent. 5. LIMA --> LAD patent. 6. Successful stenting of the SVG-Ramus Cath [**2122-5-15**]: occlusion of SVG-Ramus stent - COPD, on intermittent home O2 - Leg cramps - Chronic back pain s/p MVA many yrs ago, s/p many back surgeries including steel rod placement - NIDDM - Hypertension - Hyperlipidemia - TIA (remote, 15-20 years ago) - GERD - s/p hernia repair Social History: Retired truck driver, now lives with wife and son. Smoking: 1ppd, down from [**3-6**] ppd, 30-40 pack-year history. EtOH: has not consumed EtOH for 15 years although drank a substantial amount before that. No illicit substance use. Family History: Mother died of MI at 73. Father had lung cancer, no known coronary dz. Older sister has diabetes. Has a daughter and son who are healthy. No known additional fam hx of stroke, MI Physical Exam: Gen: A+O x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size,non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Normal respiratory effort. Gastrointestinal: Non distended, No masses. Extremities: Noc/c/e. PULSES:R AT:D/D ,L PT:D/D Wound:C/d/i Pertinent Results: [**2127-3-10**] 01:50AM BLOOD WBC-5.3 RBC-2.98* Hgb-9.0* Hct-26.3* MCV-88 MCH-30.3 MCHC-34.4 RDW-15.0 Plt Ct-328 [**2127-3-9**] 02:37AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.6* Hct-27.6* MCV-86 MCH-30.2 MCHC-35.0 RDW-14.6 Plt Ct-300 [**2127-3-7**] 04:39AM BLOOD WBC-10.9 RBC-2.83* Hgb-8.5* Hct-25.0* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.4 Plt Ct-219 [**2127-3-5**] 09:13PM BLOOD WBC-12.1*# RBC-3.28* Hgb-9.9* Hct-28.7* MCV-88 MCH-30.1 MCHC-34.3 RDW-14.1 Plt Ct-217 [**2127-3-3**] 06:45AM BLOOD WBC-8.4 RBC-3.57* Hgb-10.9* Hct-31.5* MCV-88 MCH-30.4 MCHC-34.5 RDW-13.7 Plt Ct-214 [**2127-3-1**] 06:50AM BLOOD WBC-5.2 RBC-3.49* Hgb-10.5* Hct-31.6* MCV-91 MCH-30.2 MCHC-33.4 RDW-14.2 Plt Ct-197 [**2127-2-28**] 10:10PM BLOOD WBC-6.6 RBC-3.44* Hgb-10.8* Hct-31.4* MCV-91 MCH-31.5 MCHC-34.5 RDW-14.5 Plt Ct-183 [**2127-3-10**] 01:50AM BLOOD Plt Ct-328 [**2127-3-10**] 01:50AM BLOOD PT-23.4* PTT-72.8* INR(PT)-2.2* [**2127-3-9**] 02:37AM BLOOD PT-18.4* PTT-78.2* INR(PT)-1.7* [**2127-3-8**] 03:30AM BLOOD PT-14.1* PTT-81.3* INR(PT)-1.2* [**2127-3-6**] 03:06PM BLOOD PT-13.8* PTT-60.7* INR(PT)-1.2* [**2127-3-5**] 05:00AM BLOOD PT-13.5* PTT-84.0* INR(PT)-1.2* [**2127-3-1**] 06:50AM BLOOD PT-11.3 PTT-41.5* INR(PT)-0.9 [**2127-3-10**] 01:50AM BLOOD Glucose-210* UreaN-14 Creat-0.2* Na-139 K-3.9 Cl-101 HCO3-26 AnGap-16 [**2127-3-8**] 03:30AM BLOOD Glucose-145* UreaN-12 Creat-0.8 Na-136 K-3.9 Cl-102 HCO3-22 AnGap-16 [**2127-3-6**] 02:43AM BLOOD Glucose-146* UreaN-17 Creat-0.9 Na-137 K-5.1 Cl-106 HCO3-22 AnGap-14 [**2127-3-5**] 05:00AM BLOOD Glucose-200* UreaN-22* Creat-1.0 Na-135 K-5.2* Cl-98 HCO3-28 AnGap-14 [**2127-3-1**] 06:50AM BLOOD Glucose-255* UreaN-13 Creat-0.8 Na-133 K-4.1 Cl-97 HCO3-24 AnGap-16 Brief Hospital Course: The patient was admitted to the [**Hospital1 18**] for ischemic left foot.He was started on a heparin drip.He underwent vein mapping which showed narrow veins of LE but patent veins of the upper extremities. He also underwent a CTA which showed occlusion of the femoral-femoral bypass graft with poor inflow as well.The patient thus underwent an ax fem bypass with fem fem thrombectomy on the [**2127-3-5**].The patient desaturated in the PACU and was reitubated and taken to the CVICU.his chest xray showed some basal consolidation on the R lower lobe and he was started on vancomycin and zosyn.He also required some pressor support.On POD1 he was extubated and he was weaned off the pressors.On POD2,he was transferred to the VICU. He was started on diuresis as he had some pedal edema.His diet was advanced to a regular diet which he tolerated well.His foley was d/ced and he voided without any difficulty. His oxygen was slowly weaned down. On POD5, his xray showed that his RLL consolidation had resolved. He was tolerating a regular diet, voiding normally and his pain was well controlled. PT cleared him for home with PT. He was discharged home on bactrim and would follow up with Dr [**Last Name (STitle) 1391**] in [**2-2**] weeks. His coumadin and INR levels would be monitored by his PCP. Medications on Admission: Spiriva 1puff', Nexium 40', ProAir, Symbicort 160/4.5 2 puffs", Duragesic 75mcg q48h, Nicotine patch 21', Metoprolol 100', Furosemide 80', Effient 5mg', Simvastatin 20', Percocet [**2-2**] q4h:prh, [**Last Name (un) **] 5/40', Advair 500/50 1puff' Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. prasugrel 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*25 Tablet(s)* Refills:*0* 15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 17. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 18. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: please follow up with your PCP for appropriate dosing. Disp:*30 Tablet(s)* Refills:*2* 19. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: fem fem bybass thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**3-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2127-4-14**] 4:20 Please follow up with Dr [**Last Name (STitle) 1391**] in in [**3-6**] weeks.please call ph ([**Telephone/Fax (1) 4852**] for an appointment Completed by:[**2127-3-11**]

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icd9cm

[ [ [] ] ]

[ "38.93", "38.09", "96.71", "96.04", "39.29", "88.72" ]

icd9pcs

[ [ [] ] ]

7899, 7957

4370, 5671

334, 399

8025, 8025

2655, 4347

10894, 11194

2055, 2235

5969, 7876

7978, 8004

5697, 5946

8176, 10461

10487, 10871

2250, 2636

263, 296

427, 1085

8040, 8152

1107, 1789

1805, 2039

29,862

191,929

25341

Discharge summary

report

Admission Date: [**2199-9-20**] Discharge Date: [**2199-9-26**] Date of Birth: [**2159-12-27**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 613**] Chief Complaint: Swallowed broken glass Major Surgical or Invasive Procedure: Esophagoduodenoscopy History of Present Illness: Mr. [**Known lastname **] is a 39 year old male with a PMH significant for personality disorder with multiple foreign body ingestions, admitted for ingestion of multiple pieces of broken glass. He states that he is feeling increasingly depressed and swallowed glass in an attempt to kill himself. The patient was found with a self inflicted neck laceration next to a noose hanging from a tree. In the ED, the patient had a CXR and KUB that demonstrated severeal pieces of glass below the diaphragm. Surgery and GI were consulted, and the patient underwent EGD with removal of one [**Last Name (un) 63383**] of glass. The patient was transferred to the MICO for further monitoring, where he remained stable and was called out to the floor. Currently, he is complaining of [**9-8**] sharp, diffuse abdominal pain. Denies f/c/s, CP/SOB, n/v/d, HA, palpitations, dysuria, polyuria. He denies any recent bowel movement and has not had any hematochezia or melena. Past Medical History: 1. Multiple "suicide attempts" characterized by swallowing glass, razor blades and other foreign bodies 2. Bipolar disorder 3. Depression 4. s/p MVA, s/p splenectomy Social History: Smokes [**1-30**] PPD, recreational cocaine and marijuana use; occasional EtOH use. The patient is homeless. The patient was convicted as a level 3 sex offender in [**2185**]. Family History: Father alcoholic Sister with depression and multiple psychiatric hospitalizations Physical Exam: VS 97.5 128/92 78 16 97%RA Gen: NAD HEENT: Perrl, eomi, sclerae anicteric, MMM, OP clear without lesions, exudate or erythema. Neck supple without lymphadenopathy. CV: Nl S1+S2, no m/r/g Pulm: CTAB Abd: S/ND. Tender to palpation throughout. +bs Ext: No c/c/e Neuro: AOx3. CN II-XII intact. Pertinent Results: [**2199-9-23**] 06:45AM BLOOD WBC-6.4 RBC-4.53* Hgb-14.2 Hct-41.7 MCV-92 MCH-31.4 MCHC-34.1 RDW-13.1 Plt Ct-245 [**2199-9-20**] 01:10AM BLOOD Neuts-71.8* Lymphs-23.0 Monos-3.8 Eos-1.1 Baso-0.2 [**2199-9-20**] 04:54PM BLOOD PT-13.3 PTT-28.6 INR(PT)-1.1 [**2199-9-23**] 06:45AM BLOOD Glucose-86 UreaN-9 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-29 AnGap-10 [**2199-9-20**] 01:10AM BLOOD ALT-197* AST-133* AlkPhos-83 TotBili-0.3 [**2199-9-23**] 06:45AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.1 [**2199-9-21**] 05:55AM BLOOD Lithium-0.7 [**2199-9-20**] 01:10AM BLOOD ASA-NEG Ethanol-38* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR ([**9-20**]): Lateral view confirms suspicion for foreign body in the upper esophagus. These findings were discussed with the gastroenterology fellow, Dr. [**First Name (STitle) **] [**Name (STitle) 6220**], at the time of the exam CXR ([**9-21**]): There is no evidence of pneumothorax, pneumomediastinum or pneumoperitoneum. Cardiomediastinal contours are normal. The lungs are clear. Foreign body previously described in the esophagus is not clearly visualized in this examination. KUB ([**9-20**]): Five pieces of radiopaque foreign body identified within the stomach and first portion of the duodenum, likely the reportedly swallowed glass. KUB ([**9-21**]): Multiple glass fragments (four pieces) are located through the ascending and transverse colon. There is no pneumoperitoneum or bowel obstruction or ileus. KUB ([**9-22**]): Multiple dense foreign bodies (glass) project in the pelvis. They are in the distal descending colon, sigmoid, and rectum. Fecal material is in the colon. Osseous structures are unremarkable. KUB ([**9-23**]): PFI-Foreign bodies no longer seen. Brief Hospital Course: Mr. [**Known lastname **] is a 39 year old male with a PMH significant for psychiatric illness and multiple hospitalizations for foreign body ingestion admitted after a neck laceration and ingestion of several pieces of broken glass. 1. Foreign body ingestion: Appears to be broken glass, as one piece was removed by GI via EGD. Daily KUB radiographs were taken, which demostrated that the patient had cleared the broken glass. During his hospitalization, while under the supervision of a 1:1 sitter, the patient then swallowed a clip from his hospital room and a tube of toothpaste. A repeat EGD was performed, but GI was unable to remove any objects. The following day, while under the supervision of a Security sitter, he ingested two shower curtain hooks. 2 Psych: Patient has significant psychiatric illness with multiple foreign body ingestions/suicide attempts thought to be attention seeking behavior. Consult-liason psychiatry was consulted and the patient was cleared for discharge when medically stable. On initial attempt to discharge, the patient stated that, "you guys will have to scrape my body off the [**Location (un) 2452**] line train." Psychiatry was re-consulted and this was felt to be a pattern of the patient's underlying psychiatric illness. The patient on [**9-25**] became increasingly agitated and actively suicidal in his hospital room. He requested to be placed in leather 4 point restraints to prevent him from trying to throw himself through the window. He later freed himself from the restraints. A code purple was called, and the patient was placed in handcuffs and required chemical sedation to maximize his own safety. 3. Disposition: As the patient became increasingly agitated and difficult to control, he was unsafe to remain on CC7. Psychiatry felt that the patient was not a candidate for psychiatric hospitalization, so he was discharged from CC7 to the [**Hospital1 18**] Emergency Department seclusion room. Medications on Admission: 1. Clonazepam 0.5 mg PO TID 2. Lithium 300 QAM, 600 mg QHS Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lithium Carbonate 300 mg Capsule Sig: 1 tab QAM, 2 tab QHS Capsule PO . Discharge Disposition: Extended Care Discharge Diagnosis: Primary - Foreign body ingestion Secondary personality disorder/sociopathy with multiple foreign body ingesitons (glass, metal objects) . Per psych no major mental illness. Needs 1:1 sitter with patient in view at all times. No small objects are to be left within hand reach. No utensils on food trays. Status post splenectomy Hep C Discharge Condition: Patient was discharged to ED seclusion room in stable condition, with leather restraints on his feet and shackles on his hands. Discharge Instructions: PATIENT DISCHARGED TO EMERGENCY ROOM FOR PATIENT SAFETY 1. You were admitted because you ingested broken glass. We removed one piece of glass from your throat, and watched via xrays the rest of the pieces pass out of your body. You kept on swallowing foreign objects while hospitalized. You should stop swallowing foreign bodies. 2. As you are becoming increasingly agitated, you are being discharged to the [**Hospital1 18**] Emergency Department seclusion area. Followup Instructions: Please follow-up with your primary psychiatrist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2177**] on Friday ([**9-27**]) at 8 AM. You will need to establish primary care. You can get a PCP at [**Hospital1 2177**] by calling [**Telephone/Fax (1) 11463**]. You can get a PCP at [**Hospital1 18**] by calling ([**Telephone/Fax (1) 1300**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2199-9-27**]

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icd9cm

[ [ [] ] ]

[ "98.02", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

6095, 6110

3853, 5815

290, 313

6488, 6618

2119, 3830

7134, 7672

1708, 1793

5924, 6072

6131, 6467

5841, 5901

6642, 7111

1808, 2100

228, 252

341, 1306

1328, 1496

1512, 1692

1,569

100,318

13460

Discharge summary

report

Admission Date: [**2177-12-5**] Discharge Date: [**2177-12-12**] Date of Birth: [**2106-8-2**] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents / Morphine / Tylenol Attending:[**First Name3 (LF) 943**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: NONE History of Present Illness: 71 F with DM, cirrhosis [**3-7**] NASH, h/o gastric angioectasia (GAVE/watermelon stomach) with GIB, ESRD on HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], admitted [**12-5**] to medical floor with altered mental status suspected [**3-7**] hepatic encephalopathy. She improved overnight with lactulose. On the evening of [**12-6**], she had transient hypotension to 68 systolic/doppler which responded to fluid bolus to 98 systolic. She was transfered to the ICU for monitoring. Her BP on admission to the hospital was 110/50 and her baseline from previous discharge summaries is approx 110/50. Her BP on admission the ICU was 104/40. . Blood and urine culutres were drawn on admission. Urine shows 6-10WBC with moderate bacteria, small leuks and a pH of 9.0. Blood cultures with no growth to date. She was started on ciprofloxacin 500mg po Q24 hours by her medicine team. A diagnostic paracentesis was not performed. CXR on [**12-5**] showed an increasing size of a suspected right sided pleural effusion. She is not hypoxic or dypneic. She was noted to be oozing from peripharl IVs, have guiac posative stool and an INR of 1.8. She got 1 unit of FFP while on the floor [**12-6**]. Past Medical History: Recent history includes multiple admissions in [**5-7**], and [**9-9**] for confusion in the setting of lactulose noncompliance. In [**5-10**], she was diagnosed with GIB from gastric angioectasias/watermelon stomach. She was also found to have a portal vein thrombosis on ultrasound but was not anticoagulated for h/o GAVE, GIB, HIT. . OTHER PMH: - Portal vein thrombosis [**5-10**] but not anticoagulated for h/o GAVE, GIB, HIT - Type 2 diabetes. - End-stage renal disease, on hemodialysis M/W/F - Cirrhosis [**3-7**] NASH. - Gastric angioectasia with h/o GI bleeding in 4/[**2177**]. - Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. She has a prlonged mitral deceleration time and moderate MR. - ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR showed a small effusion - stayed stable in subsequent imaging. - Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**]. - History of seizure disorder, on [**Year (4 digits) 13401**]. - History of infection in the left knee. - History of MRSA and Clostridium difficile. - History of gram-positive rod bacteremia in 4/[**2177**]. - Status post ORIF of the left distal femur fracture in 12/[**2175**]. 11. Status post ORIF of the left distal femur fracture in 12/[**2175**]. Social History: Lives with family. Given recent admissions unclear if family capable of continued care. No current EtOH, tobacco or illicit drugs. Family History: Noncontributory. Physical Exam: Vitals on transfer from ICU to floor 98.1, 56, 95/36, 17, 99%/RA; I/O +3.3L in the ICU Tele showed Sinus Brady with occassional NSVT GENERAL: comfortable, in no acute distress. [**Year (4 digits) 4459**]: sclerae icteric, OP clear, MMM, EOMI HEART: [**4-8**] holo-systolic murmur, radiating to the axilla LUNGS: Clear to auscultation bilaterally, decreased on right BACK: No CVA tenderness ABDOMEN: Obese, soft, + bowel sounds, ND NT, unable to assess for organomegaly given habitus EXTREMITIES: 2+ edema bilaterally, 2+ DP pulses, LUE AV fistula with thrill NEURO: +asterixis, strength 5/5 bilateral lower extremities, [**6-7**] grip strength Pertinent Results: ON ADMISSION: [**2177-12-5**] 11:12AM BLOOD WBC-4.0 RBC-2.83* Hgb-10.0* Hct-31.7* MCV-112* MCH-35.2* MCHC-31.4 RDW-20.7* Plt Ct-59* [**2177-12-5**] 11:12AM BLOOD Neuts-71.2* Lymphs-15.8* Monos-5.8 Eos-6.8* Baso-0.3 [**2177-12-5**] 11:12AM BLOOD PT-19.2* PTT-40.8* INR(PT)-1.8* [**2177-12-5**] 11:12AM BLOOD Glucose-175* UreaN-24* Creat-5.2* Na-140 K-4.9 Cl-102 HCO3-28 AnGap-15 [**2177-12-5**] 11:12AM BLOOD ALT-12 AST-32 CK(CPK)-39 AlkPhos-161* Amylase-38 TotBili-5.9* [**2177-12-6**] 05:25AM BLOOD Albumin-2.3* Calcium-8.9 Phos-3.4 Mg-1.9 . CARDIAC ENZYMES [**2177-12-5**] 11:12AM BLOOD cTropnT-0.04* [**2177-12-6**] 05:25AM BLOOD cTropnT-0.04* [**2177-12-6**] 01:25PM BLOOD CK-MB-NotDone cTropnT-0.04* . WORK-UP [**2177-12-5**] 11:12AM BLOOD calTIBC-157* VitB12-1565* Folate-12.8 Ferritn-212* TRF-121* [**2177-12-5**] 11:12AM BLOOD Ammonia-287* [**2177-12-7**] 09:06AM BLOOD Lactate-2.3* [**2177-12-7**] 09:06AM BLOOD O2 Sat-95 [**2177-12-7**] 09:06AM BLOOD freeCa-1.05* . ON DISCHARGE: [**2177-12-12**] 04:20AM BLOOD WBC-4.1 RBC-2.36* Hgb-8.6* Hct-26.9* MCV-114* MCH-36.4* MCHC-32.0 RDW-19.4* Plt Ct-48* [**2177-12-12**] 04:20AM BLOOD PT-18.0* INR(PT)-1.7* [**2177-12-12**] 04:20AM BLOOD Glucose-124* UreaN-20 Creat-4.4* Na-138 K-4.2 Cl-107 HCO3-25 AnGap-10 [**2177-12-9**] 05:00AM BLOOD ALT-11 AST-33 LD(LDH)-247 AlkPhos-138* TotBili-3.9* [**2177-12-12**] 04:20AM BLOOD Phos-4.1 Mg-2.1 . URINE ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R . U/S ABD No ultrasound evidence of ascites. . CXR [**12-8**]:Moderate right pleural effusion is slightly smaller today. There is no pneumothorax or left pleural effusion. Heart size is borderline enlarged. Pulmonary vasculature is engorged, but there is no edema. No pneumothorax. . [**12-6**] ECG Sinus bradycardia, rate 53. Left anterior hemiblock. Intraventricular conduction delay. Non-specific lateral repolarization changes. Compared with tracing of [**2177-12-5**] no significant change. Brief Hospital Course: 71 F with cirrhosis [**3-7**] NASH, h/o gastric angioectasia (GAVE/watermelon stomach) with GIB, DM2, ESRD on HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], with mental status changes improved after lactulose administration, was in MICU for transient hypotension responsive to fluids, transferred to floor on [**2177-12-9**]. . 1) Hypotension: now resolved; contributed initially by several BMs, hypovolemia, UTI, HD with unknown removal of fluid. She responded well to fluids. . 2) Mental status changes: most likely secondary to hepatic encephalopathy for which the patient has had repeated admissions. Patient also has positive urine culture for what is felt to be a colonizer per ID no need to treat. Patient placed on lactulose for [**4-6**] bowel movements per day, continued of rifaximin. Blood cultures negative except for one that was felt to be a contaminant. Alert and oriented * 3 at discharge. --- If additional admissions, likely will be due to noncompliance as discussion with family revealed lactulose titrated to one bowel movement daily. Family educated that patient need more bowel movements per day given her liver function. . 3) Urinary Tract Infection: Vancomycin- resistant Enterococcus felt to be colonizer due to poor urine output in this patient with End Stage Renal Disease. Patient was given 2 doses of daptomycin, but ID felt if colonizer no need to treat. . 4) Effusion: likely chronic from cirrhosis. No urgency to tap. . 5) Cirrhosis [**3-7**] NASH: increasing ascites. Continued rifaximin, ursodiol, lactulose. Stopped lasix in setting of hypotension and patient on HD for fluid control. . 6) ESRD on HD: HD on M/W/F. Continued Sevelamer . 7) GAVE and GIB: baseline Hct 30; now stable. No active bleeding. . 8) DM2: Insulin standing and ISS. . 9) Acute on Chronic Diastolic Heart Failure: CXR shows increasing R pleural effusion and worsening CHF. Patient on HD for fluid control. . 11) HIT: Avoided all heparin products. . 12) Seizure disorder: Continue [**Month/Day (2) 13401**] at home dose . 13) Coagulopathy: pt received Vitamin K 5 mg PO in the ED. INR stable at 1.7. . 14) CODE: Full . 15) Disposition: Home. Family declined VNA. Medications on Admission: Levetiracetam 500 mg PO DAILY Furosemide 40 mg PO DAILY Pantoprazole 40 mg daily Ursodiol 300 mg PO BID Sevelamer 800 mg PO TID W/MEALS Propranolol 10 mg PO BID Rifaximin 400 mg PO TID Lactulose 10 g/15 mL Syrup, 30 ML PO Q8H Insulin Glargine 100 unit/mL Solution, 12 Units SC QHS Insulin Lispro 100 unit/mL Solution Sig: as directed by sliding scale Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Insulin Regimen Please continue taking your insulin as before: Glargine 12 Units at bedtime; Lispro per sliding scale 8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic encephalopathy Hypotension Discharge Condition: Stable Discharge Instructions: Please take all your medications, particularly your lactulose and follow up with all your appointments. Please report to you doctor or come to the emergency room if you have any worsening confusion, weakness, diarrhea, fever, abdominal pain or any concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2177-12-16**] 12:00 . Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**8-12**] days.

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

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327, 334

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73,713

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50315

Discharge summary

report

Admission Date: [**2149-5-17**] Discharge Date: [**2149-5-21**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3151**] Chief Complaint: hypoxemia Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 52F with history of likely COPD (on 2L O2 at home), T1-T2 spinal injury and subsequent paraplegia c/b recurrent UTI's ([**First Name3 (LF) 40097**] klebsiella) with multiple recent admissions for hypoxia/pneumonia presented to the ED with complaint of dyspnea and hypoxia 48 hours after discharge from [**Hospital1 18**] for similar complaint. During previous admission, patient came in with hypoxia and chest x-ray concerning for multi-focal pneumonia. She was started on empiric antibiotics, CT was negative for PE. Due to absence of other infectious symptoms - no fever or leukocytsosis - antibiotics were discontinued and she was treated with nebulizers as needed. She was discharged on home O2. Since discharge, she has had gradually worsening secretions - green, per husband. Despite aggressive chest PT by husband and PCA, she was found to be hypoxic in mid-80's today on pulse oximeter and unable to increase with additional oxygen. Poor Po intake, talking to herself for past 24 hours. She was brought to the ER for further evaluation. Of note, previous admission on [**4-17**] for RLL pna, dc'd on linezolid, cipro) with 3 days of levaquin, meropenem and 4 days of concomitant vancomycin before dc'ing due to improved clinical status. In the ER, initial vitals were afebrile, 78% on 4L with systolic blood pressure 110. On exam, she had diffuse expiratory wheezes bilaterally and 1+ non-pitting edema in bilateral lower extremities (baseline). Also, notable for leukocytosis. She recieved combivents with minimal improvement in oxygenation. She was placed on NRB then 50% venturi mask. ABG prior to transfer was 7.32/70/150 - on 6L NC. She recieved Vancomycin. Past Medical History: 1. T1-T2 paraplegia following MVC [**1-4**] 2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella 3. HCV, viral load suppressed 4. H/o recurrent PNAs: MRSA, Klebs, followed by Dr. [**Last Name (STitle) **] 5. Anxiety 6. DVT in [**2142**] - IVC filter placed in [**2142**] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Chronic gastritis 11. H/o obstructive lung disease 12. Anemia of chronic disease 13. s/p PEA arrest during hospitalization in [**2147-10-3**] Social History: She lives at home with her husband and 2 adolescent children. Her PCA and best friend, [**Name (NI) **], is with her much of the time and helps to take care of her. - Tobacco: 35 pack years, quit smoking 1-2 months ago - EtOH: Denies - Illicits: Denies Family History: Mother passed away with lung disease. Physical Exam: VS: Temp: 97.0 BP: 90/57 HR: 89 RR: 19 O2sat: 92% venturi 50% GEN: awake, but appears tired. HEENT: PERRL, EOMI. Dry mucous membranes. no JVD. left side of neck with some pain to palpation over trapezius. RESP: decreased BS at right base with inspiratory wheeze and associated thonchi, bronchial BS over upper anterior lung fields, rhonchi at left lung base. CV: RRR, no m/g/r ABD: soft, NT/ND, +BS, no ascites EXT: non-pitting edema of feet bilaterally, no clubbing or cyanosis/ SKIN: no rashes/no jaundice/no splinters NEURO: alert, oriented x 3, but falls asleep easily, inattentive. no cranial nerve deficits. no facial droop. moves bilateral upper extremities against gravity, paralyzed below T1-T2. Pertinent Results: [**2149-5-17**] 10:10PM BLOOD WBC-16.0*# RBC-3.32* Hgb-10.1* Hct-29.9* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.2 Plt Ct-198 [**2149-5-18**] 03:38AM BLOOD WBC-12.0* RBC-2.97* Hgb-9.0* Hct-27.0* MCV-91 MCH-30.2 MCHC-33.3 RDW-15.1 Plt Ct-170 [**2149-5-17**] 10:48PM TYPE-ART PO2-159* PCO2-70* PH-7.32* TOTAL CO2-38* BASE XS-7 [**2149-5-17**] 10:20PM LACTATE-1.0 [**2149-5-17**] 10:10PM GLUCOSE-122* UREA N-6 CREAT-0.3* SODIUM-138 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-34* ANION GAP-12 [**2149-5-17**] 10:10PM CK-MB-2 cTropnT-<0.01 proBNP-757* Chest X-ray [**2149-5-17**] - Findings suggestive of moderate pulmonary edema. Bibasilar opacities, could represent a combination of atelectasis and small effusions, however, superimpsed infection cannot be excluded. PFT's [**2148-9-30**] - FVC 25%, FEV1 31%, FEV1/FVC 125% (% expected) Chest CTA [**2149-5-12**] - No evidence of pulonary embolism. 2. Left upper lobe and lingular ground-glass opacities with smooth septal thickening. Differential diagnosis includes atypical infection, hemorrhage, or an unusual distribution of pulmonary edema. 3. Bibasilar atelectasis with possible coexistent aspiriation given plugging of the lower lobe bronchi and fluid-filled upper esophagus. 4. Stable appearance of soft tissue mass in the azygoesophageal recess since [**2148-2-24**]. Further evaluation with MRI may be helpful to distinguish duplication cyst from solid mass such as lymphadenopathy. 5. Right hilar lymphadenopathy, increased since the prior study, and likely reactive. Attention to this area at the time of MRI (if performed) would be helpful to ensure return to baseline size. If MRI is not performed to evaluate the azygoesophageal recess mass, then follow up contrast-enhanced CT would be recommended in 3 months. 6. Small right-sided pleural effusion. Microbiology: [**2149-5-18**] 3:52 am SPUTUM Source: Expectorated. **FINAL REPORT [**2149-5-20**]** GRAM STAIN (Final [**2149-5-19**]): THIS IS A CORRECTED REPORT ([**2149-5-19**]). Reported to and read back by DR. [**Last Name (STitle) 65353**], N ([**Numeric Identifier 104919**]) ON [**2149-5-19**] AT 12:30 PM. >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). PREVIOUSLY REPORTED ([**2149-5-18**]) AS:. <10 PMNs and >10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2149-5-20**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Ms. [**Known firstname **] [**Known lastname **] is a 52 female with a history of obstructive lung disease, paraplegia c/b recurrent UTI's and recent admissions for pneumonia admitted with hypoxia 48 hours after recent discharge. # Community Acquired Pneumonia and COPD Exacerbation: She required frequent nebulizers and suction in the medical intensive care unit but was transferred to the floor on hospital day three. Due to her history of [**Known lastname 40097**] in her lungs, she was maintained on vancomycin and meropenem while in house. Her sputum culture grew pseudomonas. The vancomycine was discontinued. The meropenem was switched to ertapenem for daily dosing. She was discharged home with services with a total two week course of antibiotics. She was also treated with frequent nebulizer treatments, which she also uses at home. Due to her history of COPD, a five day course of prednisone 60m daily was added. # Hypotension: In the MICU, she required fluid resuscitation and brief pressors for treatment of sepsis. She stabilized and was transferred to the regular medicine floor. # Chronic Pain: She was continued on her home regimen below. - continue methadone 5 mg TID - continue pregabalin - continue oxycodone 5 mg q8h prn pain - continue lidocaine patches # Anemia: Her hematocrit was stable. She has known anemia of chronic disease. # Gastritis - continued omeprazole, continue calcium carbonate # Hypothyroidism - continued levothyroxine # Depression - continued citalopram # Smoking cessation - continued nicotine patch . FEN: regular, IVF prn Access: right femoral central line PPx: heparin sc tid, omeprazole (home med) Comm: patient, husband [**Name (NI) **] [**Telephone/Fax (1) 104920**] [**Name2 (NI) **]ct: husband [**Name (NI) 7092**]: FULL Medications on Admission: (per DC summary [**2149-5-14**]) - albuterol sulfate 2.5 mg /3 mL (0.083 %) Q6h prn - ipratropium bromide 0.02 % Q6h prn - baclofen 20mg Qam, QHS - baclofen 10mg Q1600 - citalopram 20 mg QD - levothyroxine 88 mcg QD - methadone 5mg TID - omeprazole 20 mg EC [**Hospital1 **] - oxybutynin chloride 10mg Qam, Qhs - oxybutynin chloride 5 mg Q1600 - pregabalin 100 mg TID - calcium carbonate 200 mg [**Hospital1 **] - oxycodone 5 mg Q8 prn pain - nicotine 7 mg/24 hr Patch - polyethylene glycol 3350 17 gram qd - lidocaine 5 %(700 mg/patch) 4 patches/day - clonazepam 2mg qhs prn insomnia - bisacodyl 5 mg Tablet, Delayed Release QD Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 4. baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 5. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 10. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 11. pregabalin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). 12. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO BID (2 times a day). 13. prednisone 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily) for 1 days. Disp:*3 Tablet(s)* Refills:*0* 14. nicotine 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr Transdermal DAILY (Daily). 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: Four (4) Adhesive Patch, Medicated Topical DAILY (Daily). 16. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 17. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 18. trazodone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 19. estradiol 0.01 % (0.1 mg/g) Cream [**Hospital1 **]: One (1) Vaginal Twice daily (). 20. ertapenem 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous daily () for 10 days. Disp:*10 gram* Refills:*0* 21. Outpatient Lab Work [**2149-5-29**]: CBC with differential, BUN, Creatinin, AST, ALT, alkaline phophatase, total bilirubin. Have these labs drawn at your [**Company 191**] appointment for Dr. [**Last Name (STitle) 665**] to see. 22. clonazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day as needed for anxiety. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Hospital Acquired Pneumonia COPD Exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **]: It was a pleasure taking care of you at [**Hospital1 18**]. You were treated for hospital acquired pneumonia and for an exacerbation of COPD. Your respiratory status had deteriorated, and for this reason you had to be transferred to the medical intensive care unit. Upon returning to the hospital floor, your respiratory status improved. Your infection is caused by a bacteria called pseudomonas. You were treated with antibiotics, steroids, nebulizers, and lasix. You will have to continue intravenous antibiotics at home (see below). You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2425**] at [**Company 191**] on [**2149-5-29**] (see below), where you will have to get labs drawn. Please take the prescription for the lab draws necessary. Please make the following changes to your home medication regimen: 1) Take prednisone 60mg for one more day (on [**2149-5-22**]) 2) Take ertapenem 1 gram intravenously through your PICC for 10 days starting on [**2149-5-18**] Followup Instructions: You have the following appointments: Department: [**Hospital3 249**] When: THURSDAY [**2149-5-29**] at 10:20 AM With: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SURGICAL SPECIALTIES When: [**Hospital Ward Name **] [**2149-9-8**] at 11:45 AM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2149-6-1**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

11736, 11791

6791, 8571

315, 332

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2820, 2859

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360, 2033

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57,791

119,048

38508

Discharge summary

report

Admission Date: [**2107-5-12**] Discharge Date: [**2107-5-13**] Date of Birth: [**2051-12-19**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Penicillins / Amiodarone Attending:[**First Name3 (LF) 425**] Chief Complaint: afib with rvr and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 55M w PMHx diabetes, hypertension, hyperlipidemia, CAD s/p LAD stent [**4-/2106**], meningioma s/p resection c/b seizure disorder, former EtOH abuse, DM, CHF (EG 50-55%), afib on Dofetilide. The patient was in his usual state of health without chest pain, shortness of breath, palpitations, or syncope and was seen by Dr. [**Last Name (STitle) **] on [**5-2**] for management of pAF. At that time he was found to be in sinus, without signs of CHF, tolerating dofetillide without QTc prolongation. The decision was made to dc digoxin 250mcg daily and lasix 20mg daily and start the pt on lisinopril 20mg. He was also asked to switch from warfarin to dabigatran, though this was never filled due to pharmacy issues. He felt well until Monday when he felt SOB, chest tightness, with "fluid building up around" his heart. He also endorses consuming etoh, as much as [**6-5**] drinks while watching hockey... On [**5-10**] he presented to [**Location (un) 620**] after becoming acutely dyspneic with nonspecific CP. He denied palpitations or LE edema. He was given Lasix IV, morphine and started on a nitro gtt however his bp didn't tolerate (dropped to 80s/50s), BNP of 4734. He was ruled out for MI. CXR demonstrated a prominence of the pulmonary vasculature as compared with a previous read as acute CHF. Out of concern for pna he was given 1 dose of Levoflox in the ED. He was also given Haldo for ?agitation. Subsequent QTc prolongation was noted (max 600) and therefore his Dofetilide was put on hold. While off dofetillide he developed rapid AF with rates in the 120-130??????s, hemodyam stable with bp in 180-190 range. He was given lopressor 5mg IV, home nadalol and lisinopril and lasix. HR decreased to 100-110s' however BP is dropped to 80's. He received 2L NS and...The pt was transferred for management of a.fib. On admission to [**Hospital1 18**] CCU, his HR ranges from 100-130 and his sBP 110-130. He is free of complaints. . 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. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CAD s/p Promus stent x 2 to proximal/mid LAD [**4-/2106**] 3. OTHER PAST MEDICAL HISTORY: -Moderate congestive heart failure -Rapid atrial fibrillation -Atrial flutter ablation -Left parietal meningioma s/p resection c/b seizure disorder (most recent [**8-6**]) with intubation for aspiration pneumonia -Alcohol abuse -Obesity Social History: admits to etoh abuse (last drink [**2106-8-1**]), admits to quitting tobacco 2 weeks ago, denies IVDA, Lives with wife- has 4 children, works at [**Company **] and security Family History: Patient was adopted and does not know family history. Physical Exam: On admission: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Tachy, irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, decreased breath sounds bilaterally. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: On admission: [**2107-5-13**] 07:02AM BLOOD WBC-9.3 RBC-4.55* Hgb-14.2 Hct-41.8 MCV-92# MCH-31.1# MCHC-33.9 RDW-13.8 Plt Ct-205 [**2107-5-13**] 07:02AM BLOOD PT-16.9* INR(PT)-1.5* [**2107-5-13**] 07:02AM BLOOD Glucose-138* UreaN-20 Creat-0.7 Na-137 K-4.7 Cl-99 HCO3-29 AnGap-14 [**2107-5-13**] 07:02AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.8 . EKG: Afib @ 120, QT 410. . [**5-10**] CXR: This has suboptimal technical quality. There is general prominence of the pulmonary vasculature as compared with a previous examination from [**2106-10-27**] compatible with acute congestive failure. There are no acute parenchymal infiltrates and there is no definite pleural effusion. The heart is slightly enlarged as before. IMPRESSION: ACUTE CONGESTIVE FAILURE. . 2D-ECHOCARDIOGRAM: [**5-10**] (at [**Location (un) **]) The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with normal free wall contractility. 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. No pathologic valvular abnormality seen. Moderate diastolic dysfunction. Brief Hospital Course: ASSESSMENT AND PLAN: 55M w PMHx diabetes, hypertension, hyperlipidemia, CAD s/p LAD DESx2 [**4-/2106**], meningioma s/p resection c/b seizure disorder, EtOH abuse, DM, CHF (EG 50-55%), afib on Dofetilide who presented to OSH for acute CHF exacerbation and developed Afib with RVR. . # Atrial Fibrillation: The pt has a history of pAF resistent to electrical cardioversion. He was started on dofetilide in [**Month (only) 1096**] and remained in sinus without complication. Due to Levaquin and Haldol received at BIDN, in conjunction with Dofetilide, pt developed QTc prolongation on EKG (reportedly up to 600). Dofetilide was discontinued and pt re-developed afib with rvr which has proven difficult to control. On arrival to [**Hospital1 18**], QTc was < 500 msec and Dofetilide 250 mg [**Hospital1 **] was restarted. He returned to NSR. He was discharged to continue dofetilide 250 mg [**Hospital1 **] and coumadin daily. . # Hypotension: Per report from OSH, pt was alternating between hypertension and hypotension, stemming largely from the doses of beta blockade and vasodilation he received. He remained normotensive at [**Hospital1 18**]. . # Acute CHF exacerbation: Pt presented to OSH with acute CHF exacerbation likely [**12-29**] combination of dietary indiscretions and recent discontinuation of lasix and digoxin. He was restarted on digoxin 250 mcg per day and lasix 20 mg per day on discharge. . #. DM: Last A1c 6.6%, managed on Metformin 500mg [**Hospital1 **]. . #. CORONARIES: Patient with a history of CAD s/p DES to LAD. Continued ASA, Plavix, simvastatin, and fish oil. . # Alcoholism: given pt's anxiety, tachycardia, hypertension and hx of etoh abuse, will put on diazepam CIWA. . # Seizure d/o: Pt with hx of Meningioma s/p resection c/b seizure d/o. Continued LeVETiracetam 1250 mg [**Hospital1 **]. . DVT prophylaxis was with coumadin. The patient remained full code. Medications on Admission: MEDICATIONS: prior to OSH admission: Plavix 75 mg daily Dofetilide 500 mcg b.i.d. levetiracetam 1000 mg b.i.d. lisinopril 20 mg once daily metformin 500 mg b.i.d. nadolol 120 mg b.i.d. simvastatin 40 mg daily dabigatran 150 mg b.i.d magnesium oxide 400 mg b.i.d. fish oil capsules b.i.d. . On transfer from osh: Keppra 1250mg daily Simvastatin 40mg qHS Aspirin 325mg daily Plavix 75mg daily Fish Oil 1000mg TID Lisinopril 20mg daily Metformin 500mg [**Hospital1 **] Nadolol 120mg [**Hospital1 **] magnesium oxide 40mg TID *Tikisyn 500mcg [**Hospital1 **] held *Coumadin held Discharge Medications: 1. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. nadolol 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation with RVR Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 66162**], It was a pleasure participating in your care. You were transferred from [**Hospital1 **] for atrial fibrillation this rapid ventricular rate. You were restarted on Dofetilide and you returned to [**Location 213**] sinus rhythm. You are now on a lower dose of this medication (250mg every 12h). You were also restarted on Lasix 20mg daily and Digoxin 250mcg daily. You should continue on these medications. Please call or return to the hospital if you develop chest pain, shortness of breath, palpitations, or any other symptoms that concern you. Please START the following medications: - Lasix 20mg daily - Digoxin 250mcg daily The following medications have CHANGED: - Dofetilide is now 250mg every 12h (not 500mg) Followup Instructions: Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Tuesday [**2107-5-17**] at 12:15 PM Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 3858**] Please call Dr.[**Name (NI) 29750**] office ([**Telephone/Fax (1) 62**]) to arrange follow-up in 1 month.

[ "428.0", "250.00", "414.01", "303.90", "345.90", "V45.82", "428.33", "427.31", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9768, 9774

6249, 8145

332, 339

9847, 9847

4448, 4448

10780, 11253

3489, 3544

8771, 9745

9795, 9826

8171, 8748

9998, 10757

3559, 3559

2953, 3013

263, 294

367, 2844

4462, 6226

9862, 9974

3044, 3282

2866, 2933

3298, 3473

22,618

127,599

28511

Discharge summary

report

Admission Date: [**2152-1-3**] Discharge Date: [**2152-1-21**] Date of Birth: [**2084-12-28**] Sex: F Service: UROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 6157**] Chief Complaint: Invasive bladder carcinoma Major Surgical or Invasive Procedure: Radical cystectomy, pelvic lymphadenectomy and creation of ileal loop. Right and Left 8 French x 22 cm percutaneous nephroureteral stent placement. 5-French dual-lumen PICC line placement via left basilic vein approach; ultrasound-guided venipuncture. History of Present Illness: Mrs. [**Known lastname 931**] is a 66-year-old female diagnosed w/ muscle invasive bladder cancer. Recently she was found to have bilateral hydronephrosis as a result of bladder wall thickening -- partially due to her TURBT from [**Hospital3 6265**] and partially from her bladder cancer that is located near the right ureteral orifice. She has had [**11-14**] lbs weight loss in the last 2 months. She has some urinary urgency/frequency with the two ureteral stents and currently she's wearing a urinary protective diaper b/c of her severe urinary symptoms Past Medical History: RA, osteoporosis, bladder CA Hysterectomy and bilateral oophorectomy, TURBT at [**Hospital3 3583**] on [**2151-10-29**]; Bilateral ureteral stent placements Social History: She smokes one pack of cigarettes per day. She denies any alcohol or IV drug abuse. Physical Exam: PHYSICAL EXAMINATION: VITAL SIGNS: 152/69, 100, 16 HEAD AND NECK: Exam does not reveal any supraclavicular lymphadenopathy. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender. There is no flank tenderness or discomfort or palpable abdominal mass or inguinal ymphadenopathy. She has a well healed suprapubic surgical scar. Pertinent Results: [**2152-1-21**] 05:20AM BLOOD WBC-13.2* RBC-3.36* Hgb-9.9* Hct-29.7* MCV-88 MCH-29.5 MCHC-33.5 RDW-16.1* Plt Ct-499* [**2152-1-19**] 05:24AM BLOOD WBC-12.7* RBC-3.47* Hgb-10.0* Hct-29.7* MCV-86 MCH-28.9 MCHC-33.7 RDW-16.0* Plt Ct-546* [**2152-1-15**] 04:32AM BLOOD WBC-14.1* RBC-2.82* Hgb-8.1* Hct-23.9* MCV-85 MCH-28.7 MCHC-33.7 RDW-16.4* Plt Ct-591* [**2152-1-12**] 10:00AM BLOOD WBC-30.5* RBC-3.34* Hgb-9.6* Hct-29.6* MCV-89 MCH-28.8 MCHC-32.5 RDW-17.0* Plt Ct-581* [**2152-1-10**] 07:28PM BLOOD WBC-18.7* RBC-3.45* Hgb-10.0* Hct-30.8* MCV-89 MCH-29.0 MCHC-32.5 RDW-17.2* Plt Ct-485* [**2152-1-6**] 01:03AM BLOOD WBC-16.5* RBC-3.15* Hgb-9.7* Hct-26.5* MCV-84 MCH-30.8 MCHC-36.6* RDW-16.4* Plt Ct-182 [**2152-1-3**] 05:15PM BLOOD WBC-10.0 RBC-3.54* Hgb-10.9* Hct-29.1* MCV-82 MCH-30.8# MCHC-37.4*# RDW-15.3 Plt Ct-161# [**2152-1-12**] 10:00AM BLOOD Neuts-92.9* Bands-1.0 Lymphs-1.0* Monos-5.1 Eos-0 Baso-0 [**2152-1-11**] 06:55AM BLOOD Neuts-82.2* Bands-0 Lymphs-7.8* Monos-6.5 Eos-3.3 Baso-0.2 [**2152-1-21**] 05:20AM BLOOD Plt Ct-499* [**2152-1-19**] 05:24AM BLOOD Plt Ct-546* [**2152-1-15**] 04:32AM BLOOD Plt Ct-591* [**2152-1-12**] 10:00AM BLOOD Plt Smr-HIGH Plt Ct-581* [**2152-1-10**] 06:40AM BLOOD Plt Ct-397 [**2152-1-3**] 11:00AM BLOOD PT-15.3* PTT-32.1 INR(PT)-1.4* [**2152-1-21**] 05:20AM BLOOD Glucose-74 UreaN-14 Creat-0.4 Na-132* K-3.8 Cl-99 HCO3-26 AnGap-11 [**2152-1-17**] 04:17AM BLOOD Glucose-123* UreaN-8 Creat-0.3* Na-132* K-4.6 Cl-101 HCO3-27 AnGap-9 [**2152-1-12**] 10:00AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-137 K-3.6 Cl-106 HCO3-20* AnGap-15 [**2152-1-8**] 09:30PM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-137 K-3.9 Cl-106 HCO3-24 AnGap-11 [**2152-1-5**] 01:49AM BLOOD Glucose-86 UreaN-15 Creat-0.8 Na-138 K-4.0 Cl-111* HCO3-20* AnGap-11 [**2152-1-3**] 05:15PM BLOOD Glucose-144* UreaN-8 Creat-0.5 Na-136 K-3.7 Cl-108 HCO3-17* AnGap-15 [**2152-1-16**] 05:20AM BLOOD ALT-15 AST-14 AlkPhos-142* Amylase-19 TotBili-0.2 [**2152-1-4**] 02:37PM BLOOD CK(CPK)-133 [**2152-1-3**] 08:50PM BLOOD CK(CPK)-213* [**2152-1-6**] 01:03AM BLOOD cTropnT-<0.01 [**2152-1-4**] 02:37PM BLOOD CK-MB-5 cTropnT-<0.01 [**2152-1-3**] 08:50PM BLOOD CK-MB-5 cTropnT-<0.01 [**2152-1-21**] 05:20AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 [**2152-1-18**] 04:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8 [**2152-1-15**] 04:32AM BLOOD Albumin-1.5* Calcium-7.5* Phos-3.7 Mg-1.3* Iron-28* [**2152-1-10**] 05:35PM BLOOD Albumin-2.2* Calcium-8.4 Phos-2.7 Mg-2.9* [**2152-1-5**] 01:49AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.2 [**2152-1-15**] 04:32AM BLOOD calTIBC-101* Ferritn-233* TRF-78* [**2152-1-13**] 07:00AM BLOOD Vanco-15.3 [**2152-1-4**] 11:22AM BLOOD Type-ART pO2-182* pCO2-38 pH-7.38 calTCO2-23 Base XS--1 [**2152-1-3**] 05:17PM BLOOD Type-ART pO2-277* pCO2-43 pH-7.23* calTCO2-19* Base XS--9 Comment-MISLABELLE [**2152-1-3**] 02:47PM BLOOD Type-ART pO2-244* pCO2-43 pH-7.23* calTCO2-19* Base XS--9 [**2152-1-3**] 12:44PM BLOOD pO2-241* pCO2-42 pH-7.20* calTCO2-17* Base XS--10 [**2152-1-3**] 11:14AM BLOOD Type-ART Tidal V-555 FiO2-50 pO2-222* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED [**2152-1-3**] 03:32PM BLOOD Glucose-133* Lactate-5.2* Na-134* K-3.9 Cl-113* [**2152-1-3**] 01:31PM BLOOD Glucose-149* Lactate-6.7* Na-134* K-3.6 Cl-113* [**2152-1-3**] 12:05PM BLOOD Glucose-154* Lactate-4.5* Na-133* K-3.9 Cl-114* [**2152-1-3**] 11:14AM BLOOD Glucose-144* Lactate-3.3* Na-134* K-3.4* Cl-110 [**2152-1-3**] 03:32PM BLOOD Hgb-10.3* calcHCT-31 [**2152-1-3**] 01:31PM BLOOD Hgb-10.2* calcHCT-31 [**2152-1-3**] 11:14AM BLOOD Hgb-7.4* calcHCT-22 [**2152-1-3**] 03:32PM BLOOD freeCa-1.07* [**2152-1-3**] 01:31PM BLOOD freeCa-1.06* [**2152-1-3**] 11:14AM BLOOD freeCa-1.15 Brief Hospital Course: Patient presented [**2152-1-3**] for her opertation which was a cystectomy and creation of ileal loop. The patient tolerated the procedure well. She was taken to the intensive care unit intubated under stable conditions with an NGT and JP drains and was on Levaquin. On POD1 the patient was extubated. On POD3 she was transferred out of the ICU. On POD 4 her NGT was discontinued. On POD6 her diet was advanced to clears and her R stent was taken out. On POD7 the patient started complaining of increased abdominal pain. On POD8 the patient had a persisent left lower lobe consolidation despite treatemtn with Levaquin. ID was consulted. The patient was aslo placed on Levofloxacin/ Vancomycin and Flagyl per ID recomendation. On POD9 a CT scan was obtained. The results were: 1. Status post cystectomy with ileal conduit. There is extravasation of contrast at the left ureteral anastomosis with contrast layering in a large pelvic fluid collection. There is an additional fluid collection posterior to this which does not have contrast within it. These collections are likely an urinoma. Given the patient's clinical history of leukocytosis and fever, infection of the fluid cannot be excluded. Drainage could be performed via CT guidance and a posterior approach, though it would be technically difficult.. 2. Persistent bilateral hydronephrosis. 3. Moderate left-sided pleural effusion and smaller right-sided pleural effusion. 4. Fluid in the peritoneal cavity and subcutaneous tissues. A left percutaneous nephroureteral stent was placed by IR and she had CT guided drainage of her pelvic urinoma with a pigtail catheter placement. A loopogram was obtained which suggested a right ureteroleal anastamotic leak. A percutaneous nephroureteral stent was placed by IR. A PICC line was also placed and TPN was started. The patient then began to progress well. Her WBC count decreased and stabilized and she started to tolerate more PO intake. Her JP drains were discontinued. Before her discharge a final CT scan was obtained. Ther results were:1. Marked reduction in size of pelvic fluid collection (urinoma) with pigtail catheter in place. 2. Bilateral percutaneous nephroureteral stents in place, with the right stent terminating in the ileal conduit and left stent terminating in the distal ileostomy. 3. Bowel loops are unremarkable and there is no evidence of abscess. 4. Decrease in the amount of ascites with small residual collection in left lower quadrant. Diffuse anasarca remains. 5. Decreased size of moderate left-sided pleural effusion with resolution of right-sided pleural effusion A pigtail creatinine was obtained which was still high so the drain was left in place. The patient was discharge to and acute care facility in stable condition on antibiotics, TPN, with left and right NT tubes and a pigtail catheter. Medications on Admission: Plaquenil 200mg [**Hospital1 **], methotrexate 10mg once per week, prednisone, folate 1mg qd, Boniva 150mg once per month, Urised for bladder discomfort. Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*14 Tablet(s)* Refills:*2* 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection [**Hospital1 **] (2 times a day). Disp:*60 5000 units* Refills:*2* 6. Lab Please do a Vancomycin trough after the third dose and Fax the results to the [**Hospital **] clinic at [**Hospital1 18**] ([**Telephone/Fax (1) 4170**] cc: DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69082**] 7. Lab Patient will need CBC, Chem7, LFT's weekly- these results can also be sent to the [**Hospital **] clinic. Also send to Dr [**Last Name (STitle) 69083**] his office number is ([**Telephone/Fax (1) 4230**] 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Insulin Regular Human 100 unit/mL Solution Sig: QS Injection ASDIR (AS DIRECTED). Disp:*qs qs* Refills:*2* 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 2 weeks. Disp:*qs qs* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: bladder cancer Discharge Condition: good Discharge Instructions: -please keep daily calorie counts of oral intake -TPN - continue until pt is reaching daily calorie goals -PICC - flush daily -bilateral nephrostomy tubes - flush daily with 10cc NS each -continue antibiotics for 2 more weeks from day of discharge (last day Friday [**2-4**]) -please do [**Hospital1 **] WTD dressing changes to abdominal wound -QD R and L NT and pigtail drain dressing changes- cleanse with 1/2 strength hydrogen peroxide and dry sterile dressing -please do fingersticks QID- adjust as needed Followup Instructions: Dr. [**First Name (STitle) **] [**Name (STitle) 4229**], [**Telephone/Fax (1) 10941**], call for appt. She should be seen [**Last Name (LF) **], [**2-1**] in the urology office, [**Location (un) 470**] [**Hospital Ward Name 23**] Building. Completed by:[**2152-1-21**]

[ "496", "997.5", "305.1", "591", "112.9", "041.11", "789.5", "198.89", "188.8", "714.0", "733.00", "486", "196.6", "511.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "57.71", "03.90", "87.78", "56.51", "54.91", "40.3", "59.8", "87.75", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9986, 10058

5551, 8386

298, 553

10117, 10124

1839, 5528

10682, 10954

8591, 9963

10079, 10096

8412, 8568

10148, 10659

1441, 1441

1463, 1820

232, 260

581, 1143

1165, 1323

1339, 1426

9,330

152,102

18641

Discharge summary

report

Admission Date: [**2132-5-29**] Discharge Date: [**2132-6-8**] Date of Birth: [**2063-1-21**] Sex: F Service: CAR. [**Doctor First Name 147**]. HISTORY OF PRESENT ILLNESS: A 69-year-old female with hypertension, hypercholesterolemia, history of lung cancer and asthma who had episodes of band-like chest pain times three on [**5-29**]. Upon arrival to the hospital was found to have ST segment changes on her electrocardiogram and was found to have a picture of unstable angina. Was worked up for possible myocardial infarction. She was placed on heparin, GGT, aspirin, statin and beta blocker. Cardiac catheterization believed OMCA distal involving LAD origin 50-60%, proximal LAD was 95% involved and the RCA had 95% in the proximal. PHYSICAL EXAMINATION ON ADMISSION: Patient was afebrile at 98.1, blood pressure of 135/80, pulse 69, respiratory rate 20. She was 98% on three liters. She was in no acute distress. HEENT was unremarkable. Lungs were clear. Heart was regular without rub or murmur. Abdomen was soft, non-tender with good bowel sounds. Extremities did not show any edema or calf tenderness. LABORATORY ON ADMISSION: BUN and creatinine were 30 and 1.3 respectively with white count of 11.4 and hematocrit 35.7. Platelet count was 388. PT was 12.4, PTT was 24.2, INR was 1.0. ELECTROCARDIOGRAM: Showed ST segment depression in V2, V3 and V4. HOSPITAL COURSE: She was taken to the Operating Room on [**5-30**] of [**2131**] where she underwent a three vessel coronary artery bypass graft. All the vein grafts were used. The first one was an saphenous vein graft to left anterior descending. The next was an saphenous vein graft to descending right coronary artery. Next was saphenous vein graft to obtuse marginal. The patient crashed on cardiopulmonary bypass. Cardiopulmonary bypass times 159 minutes and crossclamp time was 77 minutes. She was taken to the Cardiac Surgery Recovery Unit postoperatively where she was extubated on postoperative day three and had her drips slowly weaned. Her ejection fraction was found to be 65% on TTE on postoperative day two. She was transferred to the floor on postoperative day four where she did receive blood transfusion to increase her hematocrit but otherwise was simply diuresed aggressively. There were no other postoperative complications noted. In terms of labs, at the time of discharge her final hematocrit improved to 29.2. Otherwise BUN and creatinine were 36 and 1.0. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: Rehabilitation. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting. 2. History of lung cancer status post resection. 3. Asthma. 4. Hypothyroidism. 5. Hypertension. 6. Congestive heart failure. 7. Acid reflux. 8. Hyperlipidemia. 9. Arthritis. 10. Paget's disease. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg p.o. b.i.d. 2. Potassium chloride. 3. Lasix 40 mg p.o. b.i.d. 4. Lipitor 40 mg p.o. q. day. 5. Levothyroxine 100 mcg p.o. q. day. 6. Fluticasone. 7. Albuterol. 8. Aspirin. 9. Percocet. 10. Ranitidine. 11. Lasix 60 mg p.o. b.i.d. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 1537**] in four weeks and she is also to follow up with primary care physician and cardiologist within two weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 51169**] MEDQUIST36 D: [**2132-6-8**] 10:58 T: [**2132-6-8**] 11:21 JOB#: [**Job Number 51170**]

[ "493.90", "428.0", "272.0", "401.9", "V10.11", "244.9", "414.01", "731.0", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.13", "37.22", "88.55", "39.61", "88.53" ]

icd9pcs

[ [ [] ] ]

2579, 2856

2879, 3137

1416, 2500

3149, 3604

2515, 2558

194, 784

1170, 1398

9,600

191,700

26253+57491

Discharge summary

report+addendum

Admission Date: [**2106-4-7**] Discharge Date: [**2106-4-18**] Date of Birth: [**2056-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base / Penicillins Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Tracheobronchomalacia. Major Surgical or Invasive Procedure: Right thoracotomy with the posterior membranous wall tracheoplasty with mesh. 2. Left main bronchus bronchoplasty with mesh. 3. Right main bronchus and bronchus intermedius plasty with mesh. 4. Flexible bronchoscopy. History of Present Illness: The patient is a delightful 48- year-old gentleman who suffers disabling severe cough and coughing spells and severe dyspnea. He has been found to have severe tracheobronchomalacia. Past Medical History: tracheobronchial malacia Social History: married , two chidren, works as salesman which requires driving. tobacco: 1.5 packs per day x 4yrs -quit 25 yrs ago Family History: mother-breast cancer, father-cardiac disease Physical Exam: general: Pertinent Results: CXR: [**2106-4-12**] Right-sided chest tube/drain has been removed, with no evidence of pneumothorax. Right-sided partially loculated pleural effusion and atelectatic changes in the mid and lower lung appear unchanged in this patient status post recent thoracotomy for tracheal surgery. Left lung is grossly clear except for discoid atelectasis at the left base. Brief Hospital Course: Pt was admitted and taken to the OR on [**2106-4-7**] for Right thoracotomy with the posterior membranous wall, tracheoplasty with mesh, Left main bronchus bronchoplasty with mesh, Right main bronchus and bronchus intermedius plasty with mesh, Flexible bronchoscopy. Right chest tube was placed in the OR to sxn w/ no air leak. An epidural was placed and pt was followed by the acute pain service for pain control. Post op pt was admitted to the ICU for monitoring. Maintained on prophylactic IV clinda. On POD#1 pt was transferred out of the ICU to the floor for ongoing post op care. Progressed well post operatively, [**Last Name (un) 1815**] reg diet, amb on roomair w/ sats high 90's. On POD#4 epidural was accidentially dislodged. Per the suggestion of the acute pain service, pt was started on oxcontin and oxcodone for pain control w/ good effect. POD#5 a bronch was done to which revealed mild/mod cervical stenosis and right mainstem and supraglottic edema. Temp spike to 101.5 on POD#5-pan cultured which showed no growth. He continued to be febrile for the next 3 days and despite negative culture data, he was begun on empiric levofloxacin in addition to the clindamycin and vancomycin. On POD 9 his thoracotomy incision was explored locally given some increase in erythema and this revealed only hematoma abd was culture negative. He did eventually defervesce on POD 10 and felt well. His pain was well controlled at this juncture on a combination of PO oxycontin and percocet and he was ambulating well. He had good return of bowel and bladder function and was ready for discharge. Medications on Admission: Nifedipine, Clonazapam 1 [**Hospital1 **] ,hycodan 5/1.5mg(3-5 tabs Q 5hours) Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for const. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*80 Tablet(s)* Refills:*0* 6. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO twice a day as needed for pain. Disp:*120 Tablet Sustained Release 12 hr(s)* Refills:*0* 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: tracheobronchial malacia s/p tracheoplasty Discharge Condition: good Discharge Instructions: call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you develop chest pain, fever, chills, shortness of breath, redness or drainage from your chest incision. You may shower. After showering, pat your incisions dry. The steri-strips will fall off in time. Followup Instructions: Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up appointment He should also follow-up with interventional pulmonology in 3 month's time for repeat bronchoscopy Name: [**Known lastname 11469**],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Unit No: [**Numeric Identifier 11470**] Admission Date: [**2106-4-7**] Discharge Date: [**2106-4-18**] Date of Birth: [**2056-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base / Penicillins Attending:[**Last Name (NamePattern1) 10570**] Addendum: This patient had a small area of erythema at his thoracotomy incision. On CT scan, there was a fluid collection at this level in the subcutaneous tissue. The incision was opened given that the patient had fevers and a leukocytosis. This revealed a sterile hematoma. The diagnosis is incisional hematoma. Discharge Disposition: Home [**First Name4 (NamePattern1) 904**] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 1370**] Completed by:[**2106-5-4**]

[ "786.2", "530.81", "E879.8", "401.9", "519.19", "780.6", "998.89", "E878.4", "715.96", "998.12", "135" ]

icd9cm

[ [ [] ] ]

[ "33.48", "33.22", "31.79", "03.90" ]

icd9pcs

[ [ [] ] ]

5530, 5707

1447, 3052

329, 559

4263, 4270

1059, 1424

4588, 5507

969, 1015

3181, 4147

4197, 4242

3078, 3158

4294, 4565

1030, 1040

266, 291

588, 771

793, 820

836, 953

31,128

177,150

33733

Discharge summary

report

Admission Date: [**2190-4-25**] Discharge Date: [**2190-5-5**] Date of Birth: [**2113-3-23**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Emergent repair of Asc. Aorta/hemiarch(#36Gelweave)AVR(#21 CE Magna pericardial)CABGx1(SVG-PDA)[**4-25**] History of Present Illness: 77 y/o woman with 1 week of vague chest discomfort, worsened on day of admission, presented to OSH, found to have Type A aortic dissection, transferred for definitive care Past Medical History: 50 pk yr smoker s/p hysterectomy s/p cataract extractions Social History: Lives independently 50 pk year smoker Family History: non-contributory Physical Exam: Deferred - patient taken emergently to operating room. Discharge: VS T 97 HR 83 SR BP 129/82 RR 18 O2sat 95% 2LNP Gen NAD, sitting in chair Neuro Alert oriented to person/place(city)/time(month). Left upper and lower extremity weakness, UE>LE. Strength improved over last several days. Pulm Scattered rhonchi CV RRR, no murmur. Sternum stable, incision CDI. Lft clavicle incision w/steris CDI Abdm Soft, NT/+BS Ext Warm 1+ pedal edema bilat Pertinent Results: [**2190-5-5**] 06:15AM BLOOD WBC-14.7* RBC-3.12* Hgb-9.2* Hct-28.3* MCV-91 MCH-29.6 MCHC-32.7 RDW-13.9 Plt Ct-358 [**2190-5-4**] 05:10AM BLOOD WBC-15.4* RBC-2.99* Hgb-8.9* Hct-27.1* MCV-91 MCH-29.9 MCHC-33.0 RDW-14.0 Plt Ct-371 [**2190-5-3**] 06:10AM BLOOD WBC-17.3* RBC-3.06* Hgb-9.3* Hct-27.8* MCV-91 MCH-30.5 MCHC-33.5 RDW-14.1 Plt Ct-444* [**2190-4-25**] 06:48AM BLOOD WBC-13.0* RBC-2.45* Hgb-7.2* Hct-22.1* MCV-90 MCH-29.4 MCHC-32.6 RDW-13.0 Plt Ct-152 [**2190-5-5**] 06:15AM BLOOD PT-18.1* INR(PT)-1.7* [**2190-5-4**] 05:10AM BLOOD PT-24.6* INR(PT)-2.4* [**2190-5-3**] 06:10AM BLOOD PT-24.5* PTT-38.9* INR(PT)-2.4* [**2190-5-2**] 04:30AM BLOOD PT-24.8* PTT-39.0* INR(PT)-2.4* [**2190-4-25**] 06:48AM BLOOD PT-16.5* PTT-58.6* INR(PT)-1.5* [**2190-5-5**] 06:15AM BLOOD UreaN-14 Creat-0.4 K-3.7 [**2190-5-3**] 06:10AM BLOOD Glucose-81 UreaN-19 Creat-0.5 Na-144 K-4.0 Cl-110* HCO3-22 AnGap-16 [**2190-4-25**] 08:21AM BLOOD UreaN-11 Creat-0.5 Cl-116* HCO3-20* [**2190-5-2**] 10:55AM BLOOD ALT-26 AST-25 LD(LDH)-342* AlkPhos-71 Amylase-17 TotBili-0.3 [**2190-4-30**] 01:23AM BLOOD ALT-19 AST-24 LD(LDH)-410* AlkPhos-63 Amylase-15 TotBili-0.4 RADIOLOGY Final Report CHEST (PA & LAT) [**2190-5-2**] 1:36 PM CHEST (PA & LAT) Reason: pna [**Hospital 93**] MEDICAL CONDITION: 77 year old woman with inrease WBC REASON FOR THIS EXAMINATION: pna CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2190-4-29**]. FINDINGS: As compared to the previous examination, the introduction sheath right has been removed. Otherwise, the radiograph is almost unchanged. There is slight cardiomegaly with retrocardiac atelectasis and evidence of bilateral pleural effusion that lead to blunting of the costophrenic sinuses. In the interval, no parenchymal opacities suggestive of pneumonia have occurred. Unchanged surgical clips in projection over the lateral aspect of the second and third rib. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 78045**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78046**] (Complete) Done [**2190-4-25**] at 3:39:16 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-3-23**] Age (years): 77 F Hgt (in): 62 BP (mm Hg): 112/84 Wgt (lb): 150 HR (bpm): 92 BSA (m2): 1.69 m2 Indication: Intra-op TEE for Type A dissection repair ICD-9 Codes: 440.0, 441.00, 424.1 Test Information Date/Time: [**2190-4-25**] at 03:39 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 69 ml/beat Left Ventricle - Cardiac Output: 6.36 L/min Left Ventricle - Cardiac Index: 3.76 >= 2.0 L/min/M2 Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: *4.8 cm <= 3.4 cm Aorta - Arch: *3.3 cm <= 3.0 cm Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: *2.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *26 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Aortic Valve - LVOT pk vel: 0.90 m/sec Aortic Valve - LVOT VTI: 22 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic 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. Moderately dilated ascending aorta. Mildly dilated aortic arch. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. Ascending aortic intimal flap/dissection.. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) Moderate (2+) AR. MITRAL VALVE: Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. 6. Physiologic mitral regurgitation is seen (within normal limits). 7. There is a small pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being A paced. 1. A bioprosthesis is well seated in the Aortic position. Leaflets move well. No significant AI. Mean gradient of 10 mm of Hg with CO of 4.2 l/min. 2. Biventricular function is preserved. 3. An ascending aortic graft is noted. 4. Other changes 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) **] [**2190-4-25**] 07:13 RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2190-4-29**] 4:58 PM CT HEAD W/O CONTRAST Reason: assess for cva [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p AVR/Asc Ao repair/cabg REASON FOR THIS EXAMINATION: assess for cva CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 77-year-old female status post aortic valve replacement and CABG. Please assess for CVA. TECHNIQUE: Non-contrast head CT. COMPARISON: None. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. There is extensive periventricular and subcortical white matter hypodensity, most consistent with sequelae of chronic small vessel ischemic disease, and there is probably a more focal area of chronic encephalomalacia in the left occipital lobe. Mild ventricular prominence may be consistent with age-related atrophy. Otherwise, ventricles and sulci are unremarkable in size and configuration. There is no fracture. Note is made of marked calcification of the bilateral cavernous internal carotid arteries, basilar artery, and bilateral vertebral arteries. Minor mucosal thickening is seen in the ethmoid air cells. IMPRESSION: No acute intracranial process. Marked chronic microangiopathic changes. Please note that MRI, with diffusion-weighted imaging is more sensitive for the detection of acute brain ischemia. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Brief Hospital Course: She was admitted directly to the OR for emergent repair of Type A aortic dissection, please see OR report for details. In summary she had an Ascending Aorta Hemiarch Replacement with 26mm Gelweave graft/Aortic valve replacement with 21mm CE Magna pericardial valve/CABGx1 with SVG-PDA. Her bypass time was 152 minutes, her crossclamp time was 136 minutes, and circulatory arrest time was 1 minute/total body with 25 minutes for lower body circ arrest. She tolerated the operation and was transferred to the ICU in stable condition. She was kept sedated throughout the operative day, on POD1-2 she was slowly diuresed and weaned form the venitlator and was extuabted on POD #3. She was noted to have Left sided weakness, a Head CT was negative despite continued left sided weakness, she was seen by PT/OT. She remained in the ICU for pulmonary toilet, hemodynamically she was stable and her respiratory status improved and was transferred to the floor on POD #6. A u/a revealed UTI and she was started on cipro. Over the next several days the patients activity was advanced with the assistance of nursing and PT. Her medical regime was refined and on POD 10 she was transferred to rehabilitation. Medications on Admission: None. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day): Until fully ambulatory. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 24402**], ME Discharge Diagnosis: s/p emergent Asc Ao replacement/AVR/CABG Post-operative left sided weakness UE>LE PMH:Type A Aortic Dissection/coronary sinus dissection s/p hysterectomy s/p cataract removal tobacco abuse Discharge Condition: stable Discharge Instructions: No lifting > 10 # for 10 weeks may shower, no creams or lotions to any incisions no driving for 1 month Followup Instructions: With PCP [**Last Name (NamePattern4) **] [**3-14**] weeks with Dr. [**First Name (STitle) **] in [**5-15**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2190-5-5**]

[ "424.1", "599.0", "401.9", "441.01", "414.01", "729.89", "305.1", "997.09", "423.0" ]

icd9cm

[ [ [] ] ]

[ "38.45", "36.11", "88.72", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

12392, 12470

9741, 10941

330, 438

12703, 12712

1289, 2526

12864, 13099

791, 809

10997, 12369

8290, 8335

12491, 12682

10967, 10974

12736, 12841

824, 1270

280, 292

8364, 9718

466, 639

661, 720

736, 775

14,520

136,081

4209

Discharge summary

report

Admission Date: [**2185-4-28**] Discharge Date: [**2185-5-10**] Date of Birth: [**2135-1-27**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Augmentin / Lisinopril / Metoprolol Attending:[**First Name3 (LF) 9002**] Chief Complaint: Hypotension, hypoxia. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 50 yo female with PMHx sig. with HTN, ESRD on HD, sarcoidosis, pulmonary HTN, HIT, and epilepsy who presents with hypotension and tachypnea. Patient woke up this morning and felt fine. She did slightly stumble on her way down the stairs to go to HD but did not fall. Her husband drove her to HD. From getting out of the car to walking into the [**Hospital **] clinic, she became short of breath. Her VS there included T97, SBP 85. She reported feeling dizzy and fatigued in addition to her SOB. She did not get HD. She denies any confusion, LOC, vision changes, CP, palpitations, cough, recent URI symptoms, orthopnea, N/V, abdominal pain, diarrhea, constipation, blood in the stool, melena. She has not had pedal edema in the last couple of weeks. She denies any changes in weight. She is on 3L NC at home. Yesterday she had a new HD catheter placed in the LIJ; the RIJ was pulled. Pt reported a low grade temp of 100.3 last night. Otherwise, she has been afebrile. In the ED, initial VS were: 97.7 87 92/61 22 99. Pt has been afebrile in the ED. Pt received 1 L NS. BP remained in 80s/50s with HR in 80s-90s. CXR was unremarkable. Renal was consulted. Pt received kayexlate, insulin, and bicarb for hyperkalemia. Zosyn and vanc for unknown infection. Pt was placed on levophed at 31.5. Current VS are: 97.6, 89, 101/62, 32, 97% on NRB. Past Medical History: -Heparin-induced thrombocytopenia (HIT) -Hypertension (HTN) -End-stage renal disease (ESRD) on dialysis -sarcoidosis -epilepsy -chronic pancreatitis -secondary hyperparathyroidism -hyperlipidemia (HL) -anemia -angioectasias of the stomach and colon. Social History: Lives at home with husband. 4 children, 3 grandchildren. She does not smoke, use alcohol or drugs. She is a previous substance abuse counselor. She is currently on medical disability due to her multiple medical illnesses. Family History: father-kidney failure 70 mother-HTN, breast ca, diagnosed at 68 uncle-kidney resection Physical Exam: On admission: General Appearance: Well nourished, No acute distress. Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: normal S1/S2, S4, Systolic murmur Respiratory / Chest: Symmetric expansion, fine crackles, L > R Abdominal: Soft, Non-tender, Bowel sounds present Skin: Warm Neurologic: Attentive, Follows simple commands, oriented x3 Pertinent Results: Labs on admission: [**2185-4-28**] 01:45PM BLOOD WBC-6.7 RBC-3.44* Hgb-11.0* Hct-34.2* MCV-99* MCH-32.1* MCHC-32.3 RDW-19.3* Plt Ct-252 [**2185-4-28**] 01:45PM BLOOD Neuts-84.2* Lymphs-11.2* Monos-2.2 Eos-1.7 Baso-0.7 [**2185-4-28**] 08:10PM BLOOD PT-14.7* PTT-34.0 INR(PT)-1.3* [**2185-4-28**] 01:45PM BLOOD Glucose-119* UreaN-55* Creat-8.4*# Na-133 K-6.8* Cl-94* HCO3-22 AnGap-24* [**2185-4-28**] 08:10PM BLOOD ALT-20 AST-38 LD(LDH)-319* CK(CPK)-114 AlkPhos-627* TotBili-1.1 [**2185-4-28**] 08:10PM BLOOD CK-MB-3 cTropnT-0.09* proBNP-[**Numeric Identifier 18308**]* [**2185-4-28**] 01:45PM BLOOD Calcium-9.1 Phos-4.1 Mg-3.0* [**2185-4-28**] 01:51PM BLOOD Glucose-115* Lactate-2.8* K-6.3* [**2185-4-28**] 01:51PM BLOOD Hgb-11.5* calcHCT-35 Chest x-ray [**2185-4-28**]: No significant interval change when compared to the previous study with chronic interstitial parenchymal opacities compatible with the patient's underlying sarcoidosis. No evidence of pneumothorax. CT chest [**2185-4-28**]: 1. Slight worsening of extensive interstitial opacities which may be due to differing phase of respiration during scanning, although mild superimposed interstitial edema on chronic interstitial disease cannot be excluded. No focal consolidation identified. Correlate clinically. Follow up chest x-ray may be beneficial if diuresed. 2. Small right pleural effusion. 3. Hemodialysis catheter is seen terminating within the right atrium. Chest x-ray [**2185-4-29**]: No acute change. Diffuse interstitial opacities involving the middle and upper lungs bilaterally are stable in appearance. No new opacity. Stable prominence of the cardiac silhouette with dual-lumen catheter in place. C.diff [**2185-4-30**]: Feces negative for C.difficile toxin A & B by EIA. . . CTA Chest [**2185-5-3**] IMPRESSION: 1. Negative examination for pulmonary embolism or aortic dissection. 2. Long tubular filling defect noted extending from distal right subclavian vein, through right brachiocephalic vein, into the superior vena cava is compatible with thrombus, probably related to prior hemodialysis catheter placed on right side. 3. Focal area of worsening of the pre-existing extensive interstitial lung disease suggest superimposed acute inflammatory/infection process. 4. Enlarged mediastinal and hilar lymph nodes. 5. Interval resolution of the right pleural effusion. Brief Hospital Course: This is a 50 year old female with past medical history significant for HTN, ESRD on HD, sarcoidosis, pulmonary HTN, HIT, and epilepsy who presented with hypotension and hypoxia. #. Hypotension: The patient initially required Levophed to maintain SBP 95-105, however did not become symptomatic aside from some lightheadedness prior to admission. The patient reported that her usual BP at home was 160-180/90-110. This was felt to be most likely secondary to sepsis. The pt had mild tenderness at both line sites (right HD line had been removed on [**2185-4-27**] and re-sited to left) but denied any significant drainage. The patient spiked a fever to 102.9 and received blood cultures from peripheral vein and CVC. Blood cultures never grew an organism, including 1 set from the pt's new HD line. She was weaned from pressors and restarted on home Sildenafil. She was started on antibiotics to cover health-care associated infections with Vanc and Zosyn. ECHO on [**2185-4-29**] was negative for vegetations, but did show mild global systolic dysfunction and severe pulmonary hypertension. On [**2185-4-29**], the patient became tachypneic and hypoxic at dialysis, had an ABG of 7.56/36/98 and was transferred back to MICU. This resolved and she was called out to the floor on [**2185-4-30**]. The pt completed a 10 day course of vancomycin and ciprofloxacin for presumed line infection (from the dialysis catheter that had been removed on [**2185-4-27**]). . # Hypoxia: On the floor the pt was noted to have increased oxygen requirements when compared to her home oxygen needs (oxygen for climbing stairs, other exertional activities), and it was unclear if this was related to worsening of sarcoid (DLCO lower in [**4-4**]) versus an acute process. CXR did not show evidence of pna. The pt had a CT-A which did not show PE, but did reveal a long tubular filling defect noted extending from distal right subclavian vein, through right brachiocephalic vein, into the superior vena cava which was compatible with thrombus, probably related to prior hemodialysis catheter placed on right side. The pt was then started on argatroban (given history of HIT) and coumadin. The pt was discharged on coumadin with plans to have her INR followed through the [**Company 191**] coumadin clinic. On discharge the pt was noted to be off oxygen and breathing comfortably on room air. . #. Hyperkalemia: The patient received insulin, bicarb, and kayexylate. A hemolyzed specimen measured 6.8, however her K was then measured at 5.5. Her ECG did not show any significant changes, and her potassium corrected with dialysis the following day. . #. ESRD on HD: The patient was followed by the nephrology service during this admission and dialyzed on her regular Tuesday, Thursday, Saturday schedule. . #. Pulmonary HTN: Her Sildenafil was initially held due to hypotension however this was restarted on [**2185-4-29**]. When the pt was noted to have persistent hypoxia, a pulmonary consult was requested and the pt's outpatient pulmonologist recommended that Sildenafil be stopped as it did not seem to be helping the pt. . #. Epilepsy: Last seizure was 2 years ago. Lamotrigine was continued. Medications on Admission: Hydroxyzine HCl 25 mg PO BID Ursodiol 200 mg TID Lamotrigine 150 mg Tablet PO BID Lorazepam 0.5 mg prn seizure Losartan 150 mg [**Hospital1 **] Nifedipine 90 mg ER [**Hospital1 **] Sevelamer Carbonate 800 mg PO TID W/MEALS Revatio 20 mg PO three times a day Oxygen 2-4L continuous Colace 100 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 2. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. LaMOTrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for seizure. 7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 8. Losartan 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. 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* 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*100 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Sepsis secondary to a line infection, venous thrombosis Secondary: End-stage renal disease, hypertension, seizure disorder, pulmonary hypertension Discharge Condition: Breathing comfortable on 3L oxygen by nasal cannula and saturating 99%. When taking off nasal cannula, pt continues to feel at baseline on room air and is comfortable at 88% saturation on room air. Discharge Instructions: You were admitted with low blood pressure and difficulty breathing. You were treated in the ICU initially, and then you were transferred to the floor. You were not found to have any pneumonia, and you were treated for an infection of the dialysis catheter that had been removed one day prior to your hospitalization. You finished a 10 day course. You were also found to have a blood clot in your blood vessels. It is important that you take the warfarin as instructed. Your medications have been changed. Please follow the discharge medication instructions closely. Please note that you are to take warfarin (Coumadin) 2.5 mg once a day until Thursday, [**2185-5-12**], when your INR level will be checked at dialysis. Results are to be faxed to [**Company 191**] anticoagulation service at fax number [**Telephone/Fax (1) 3534**] (Phone [**Telephone/Fax (1) 2173**]). The [**Company 191**] anticoagulation staff will then contact you to inform of any warfarin dosing change. . If you develop shortness of breath, chest pain, palpitations, or any other concerning symptom, please call your primary care doctor or return to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2185-5-6**] 11:30 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2185-5-18**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2185-5-18**] 2:20

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icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

9893, 9899

5124, 8301

335, 342

10099, 10299

2746, 2751

11491, 11975

2252, 2340

8652, 9870

9920, 10078

8327, 8629

10323, 11468

2355, 2355

274, 297

370, 1724

2765, 5101

1746, 1997

2013, 2236

21,559

184,998

2145

Discharge summary

report

Admission Date: [**2168-7-12**] Discharge Date: [**2168-7-20**] Date of Birth: [**2096-9-28**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This 71-year-old female with a history of aortic stenosis and of coronary artery disease presents with a complaint of nausea. She also had chest pain and shortness of breath. She was previously admitted in [**Month (only) 116**] and [**Month (only) **] with aortic stenosis and coronary artery disease but declined surgery at that time. Her catheterization of [**2168-6-2**], revealed an ejection fraction of 55%, anterolateral hypokinesis, apical hypokinesis, a proximal 70% right coronary artery lesion, a 30% left main lesion and her saphenous vein graft times two from [**2164**] were 100% occluded. The left internal mammary artery was patent to the distal left anterior descending artery. She was status post coronary artery bypass graft times three in [**2164**]. PAST MEDICAL HISTORY: Significant for a history of aortic stenosis with an aortic valve area of 0.7 cm/squared, a history of coronary artery disease status post coronary artery bypass graft times three in [**2164**], history of breast cancer status post left lumpectomy, history of stable angina, history of endometrial polyps. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q. day. 2. Lipitor 10 mg p.o. q. day. 3. Norvasc 5 mg p.o. q. day. 4. Ambien 5 mg p.o. q. hs. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She does not smoke cigarettes, does not drink alcohol. She lives with her husband. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: She is a well-developed, well-nourished, white female in no apparent distress. Vital signs stable, afebrile. HEENT examination: Normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple with full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs had a few bibasilar crackles. Cardiovascular examination: Regular rate and rhythm, 3/6 systolic murmur. Abdomen was obese, soft, non-tender with positive bowel sounds. No masses or hepatosplenomegaly. Extremities had trace edema bilaterally. Neuro examination was nonfocal. HOSPITAL COURSE: The patient had several discussions with her family and Dr. [**Last Name (STitle) 1537**] and agreed to surgery and on [**2168-7-14**], she underwent a re-do sternotomy with an aortic valve replacement with a #21 mm pericardial [**Last Name (un) 3843**]-[**Doctor Last Name **] valve. Crossclamp time was 71 minutes. Total bypass time 93 minutes. She was transferred to the Surgical Intensive Care Unit in stable condition on propofol. She was stable postoperative night and was extubated. She was on some nitroglycerin postoperative day one. This was weaned off. The patient also had her chest tubes discontinued and she was very agitated and had some delirium. On postoperative day two she had improved somewhat but she was still anxious. She was diuresed and required respiratory therapy and she was transferred to the floor on postoperative day three. She continued to have intermittent lethargy due to sedation and then she would be agitated. She was also refusing to eat but eventually this resolved with Haldol and she did take better p.o. On postoperative day four she had all cardiac pacing wires discontinued. On postoperative day six she was discharged to rehab in stable condition. LABORATORY ON DISCHARGE: Hematocrit 24.9, white count 10,800, platelet count 386,000. Sodium 139, potassium 4.1, chloride 102, CO2 32, BUN 10, creatinine 0.5, blood sugar 117. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. times seven days. 2. KCl 20 mEq p.o. b.i.d. times seven days. 3. Tylenol No. 3 one to two p.o. q. 4-6h. p.r.n. pain. 4. Haldol 1 mg p.o. t.i.d. p.r.n. 5. Lopressor 100 mg p.o. b.i.d. 6. Vitamin C 500 mg p.o. b.i.d. 7. Iron 325 mg p.o. q. day. 8. Lipitor 10 mg p.o. q. day. 9. Colace 100 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: She will be followed by Dr. [**Last Name (STitle) 11488**] in one to two weeks and Dr. [**Last Name (STitle) 1537**] in four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2168-7-19**] 16:37 T: [**2168-7-19**] 16:07 JOB#: [**Job Number 11489**]

[ "424.1", "428.0", "413.9", "300.00", "414.02", "401.9", "278.00", "293.0", "272.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1579, 1594

3706, 4045

1292, 1460

2297, 3515

4070, 4485

1652, 2279

3530, 3683

1614, 1629

160, 936

959, 1266

1477, 1562

5,901

160,102

46460

Discharge summary

report

Admission Date: [**2107-7-18**] Discharge Date: [**2107-8-10**] Date of Birth: [**2033-4-27**] Sex: F Service: MEDICINE Allergies: Risperdal / Ace Inhibitors Attending:[**First Name3 (LF) 29767**] Chief Complaint: Flacid paralysis of lower extremities Major Surgical or Invasive Procedure: 1. T8-L2 fusion. 2. Multiple thoracic laminotomies. 3. Laminectomy of L1. 4. Segmental instrumentation, T8-L2. 5. Right iliac crest autograft. 6. Anterior decompression 7. Posterior decompression 8. T11/L1 fusion 9. PEG tube placement 10. PICC line placement History of Present Illness: 74F with hx of dementia, schizophrenia and recent T12 compression fx who presented to [**Hospital1 18**] on [**7-18**] with placcid paralysis and found to have cord compression. Per notes, pt fell on [**6-19**] and since then has had persistent back pain and refuses to move leg. Patient was reportedly ambulating with cane prior to fall. Lumbarsacral spine and pelvis Xray at that point was negative for fracture. Patient then noted to have decreased Hct and Na. Given long history of smoking, CT chest done on [**7-13**] for malignancy workup. It showed nonpathologic compression T12 fracture. It also showed RLL consolidation for which she completed treatment of levaquin for 7 d. On day of admission, pt presented with flaccid paralysis. MR T spine show severe T12 compression fracture with retropulsed fragment causing severe canal stenosis, concerning for cord compression. Patient recieved steroids in ED and was admitted to the medicine service. Past Medical History: dementia schizophrenia history of chronic GI bleed and refused GI workup in the past anemia GERD COPD (last PFT in [**2095**]: FEV1/FVC of 73, FEV1 71% of predicted) hypertension benign neoplasm of colon diabetes mellitus osteoarthritis neuropathy, urinary incontinence Social History: Ms. [**Known lastname 7168**] is a nursing home resident. She worked in the past as a secretary. She is a smoker up to two packs per day. Rare alcohol use. Family History: There is one sibling with schizophrenia. Physical Exam: temp 98, BP 151/77, HR 106, R 33, O2 97% on NRB Gen: elderly female in moderate resp distress, grunting occasionally, using some accessory muscles HEENT: MM dry, EOMI, pupils dilated, reactive to light CV: heart sounds not heard [**2-10**] rhoncherous breath souds Chest: no crackles at bases, exp wheezes bilaterally; chest tube in left side Abd: hypoactive bowel sounds, nontender, soft Sacrum: small 2cm area of erythema Ext: 2+ DP, no edema Neuro: AO x 2 (not to place), CN 2-12 intact, 4+/5 strength in upper ext, won't move lower ext; ? decreased sensation in lower ext; 1+ DTRs in lower ext, 2+ DTRs in upper ext; Babinski neither up nor downgoing Pertinent Results: CXR: Persistent left retrocardiac opacity and left pleural effusion. . Echo on [**2107-7-19**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) left ventricular diastolic dysfunction. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . MR L SPINE SCAN [**2107-7-17**] Compression fracture at T12 with severe canal compromise. This is incompletely imaged on this examination and the thoracic spine MR should be obtained. Distended bladder could be due to cord compression. . MR CONTRAST GADOLIN [**2107-7-18**] Compression of the T12 vertebral body with large retropulsed osseous fragment resulting in marked cord compression and cord edema at the level of compression and in the conus. There are some features of the compression which raise the possibility of this being a pathologic fracture rather than a simple insufficiency fracture. . CHEST (PORTABLE AP) [**2107-7-19**] 10:48 PM The endotracheal tube previously in the right main bronchus has been repositioned to standard placement at the level of the sternal notch and, accordingly, the previously collapsed left lung has reexpanded. A pleural tube projects over the base of the left chest. There is no pneumothorax or appreciable pleural effusion. Heart is top normal size. There is engorgement of hilar and pulmonary vasculature suggesting borderline cardiac dysfunction or volume overload. Tip of the left subclavian catheter projects over the upper SVC. Nasogastric tube ends in the stomach. . CHEST PORT. LINE PLACEMENT [**2107-7-19**] 9:45 PM Total collapse of the left lung secondary to ET tube tip in the right main bronchus. Right basal consolidation. Small left basilar pneumothorax. Left subclavian line tip in the SVC. . T12 VERTEBRAL BODY R/O TUMOR Pathology: Bone with focal necrosis, reactive changes, intramedullary fat necrosis and granulation tissue consistent with healing fracture. Hyaline cartilage. No osteomyelitis seen. No evidence of malignancy. . BILAT LOWER EXT VEINS PORT [**2107-7-21**] 1:28 AM BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral and popliteal veins were performed. These demonstrate normal compressibility, flow, augmentation, and waveforms. No intraluminal thrombus identified. IMPRESSION: No evidence of bilateral lower extremity DVT. . EKG [**2107-8-7**]: Baseline artifact. Rhythm is most likely sinus tachycardia. ST segment elevation in leads VI-V2. Q waves in leads VI-V3. Findings suggest anteroseptal myocardial infarction/injury of undetermined age. There are also lateral ST segment depressions suggestive of myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of 7 14-06 anterior and anterolateral abnormalities persist. . ECHO [**2107-8-9**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%), without regional wall motion abnormalities. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-10**]+) aortic regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. IMPRESSION: Symmetric LVH with preserved global and regional biventricular systolic function. Mild-to-moderate aortic regurgitation. Compared with the prior study (images reviewed) of [**2107-7-19**], the findings appear similar. LABS: [**2107-8-10**] 06:00AM BLOOD WBC-9.8 RBC-3.06* Hgb-9.3* Hct-26.3* MCV-86 MCH-30.4 MCHC-35.3* RDW-19.0* Plt Ct-359 [**2107-7-18**] 02:00PM BLOOD WBC-11.4*# RBC-4.43 Hgb-11.4*# Hct-34.0* MCV-77*# MCH-25.7*# MCHC-33.5# RDW-16.8* Plt Ct-623*# [**2107-8-9**] 05:20AM BLOOD Neuts-85.6* Lymphs-6.3* Monos-2.6 Eos-5.4* Baso-0.2 [**2107-7-18**] 02:00PM BLOOD Neuts-79.7* Lymphs-12.0* Monos-5.4 Eos-1.9 Baso-1.0 [**2107-8-9**] 05:20AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+ [**2107-8-10**] 06:00AM BLOOD Plt Ct-359 [**2107-8-10**] 06:00AM BLOOD PT-12.5 PTT-24.3 INR(PT)-1.1 [**2107-8-4**] 05:50AM BLOOD PT-14.9* PTT-26.1 INR(PT)-1.3* [**2107-7-18**] 02:00PM BLOOD PT-13.2* PTT-24.0 INR(PT)-1.2* [**2107-8-10**] 06:00AM BLOOD Glucose-97 UreaN-16 Creat-0.4 Na-135 K-4.1 Cl-97 HCO3-27 AnGap-15 [**2107-7-18**] 02:00PM BLOOD Glucose-119* UreaN-28* Creat-1.0 Na-136 K-4.7 Cl-97 HCO3-27 AnGap-17 [**2107-8-10**] 06:00AM BLOOD ALT-43* AST-31 LD(LDH)-374* AlkPhos-158* Amylase-34 TotBili-0.7 [**2107-8-7**] 04:38PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2107-7-22**] 01:11AM BLOOD CK-MB-19* MB Indx-4.3 cTropnT-0.18* [**2107-8-10**] 06:00AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.9 Mg-1.9 [**2107-8-9**] 05:20AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.7 Mg-1.7 [**2107-8-9**] 05:55PM BLOOD Vanco-19.0* [**2107-7-27**] 07:15AM BLOOD Vanco-13.9* [**2107-7-29**] 06:06AM BLOOD Type-ART pO2-126* pCO2-43 pH-7.43 calTCO2-29 Base XS-4 [**2107-7-29**] 06:06AM BLOOD freeCa-1.19 [**2107-8-10**] 06:00AM BLOOD VITAMIN D 25 HYDROXY-PND Brief Hospital Course: On [**7-19**], pt was taken to OR by ortho spine for a thoracotomy with T12 vertebrectomy with T11-L1 fusion with plans to take her back on [**7-22**] for posterior approach. During the operation, pt had left lung collapse requiring a chest tube. At this point, she was started on Levo/Flagyl. During her stay, pt was noted to have occasional episodes of tachypnea, tachycardic to the 110s and hypertensive to the 190s. She responded well to hydralazine and morphine. LENIs were done to rule out DVT and were negative. On day of transfer to ICU, pt was found to have a HR in the 120s, RR in the 40s, satting 85% on 50% face mask --> 94% on NRB. (During her stay, she had been 91% on RA --> 99% on 50% face mask.) She was given lasix 20mg IV x 1 and improved somewhat symptomatically. Two houws later, she again was found in resp distress and was given 20mg more of lasix. She had put out 1.3L in response to the two boluses of lasix and her saturations had improved to 97% on NRB with a decrease in her resp rate. She was then transferred to the ICU for closer monitoring of her resp distress. . Initially in ICU, pt appeared more comfortable, satting 97-99% on NRB with RR in the mid 20s. She was given 1" of nitropaste and 1mg of morphine to help with agitation. Thirty minutes after her arrival to ICU, she had another episode of respiratory distress. However, now, pt was noted to have inspiratory stridor asociated with RR to the 40s, diaphoresis and tachycardia. Also, of note, the submental area of her neck appeared to be swollen but unclear what her baseline is. She was emergently intubated using fiberoptic bronchoscopy given her difficult airway. On bronchoscopy, she was noted to have a very small airway with diffuse swelling and copious secretions. She was intubated successfully and her heart rate improved to the 80s. Her BP also dropped into the 50s so she was started on neosynephrine. . The remainder of her hospital course was complicated by the following issues: . 1) Resp Distress: In consideration of stridor which precipitated previous respiratory failure, it is possible that pt had laryngeal edema from prior intubation (during first surgery). Then she also had either pneumonia or diastolic heart failure (or both) that caused some resp distress. Her resp distress may have then exacerbated her pre-existing edema. In addition, the increased negative pressure from her resp distress through a narrowed airway may have caused some pulm edema. Patient was intubated for resp. distress and found to have laryngeal edema during intubation. Neck CT [**7-23**] showed some edema of laryngeal soft tissues around ETT. No new medications were on board; however it was considered that this may have been angioedema from ACEI. Her ACE-I was thus discontinued. Pt was extubated successfully on [**7-26**]. Sputum from [**7-22**] grew out MRSA, now s/p 10 day course of vancomycin. CXR during episode of desaturation on [**8-7**] reveals worsening pulmonary edema. ACE inhibitor was held due to questionable adverse reaction in context of respiratory difficulty. Patient was diuresed to maintain negative fluid balance and urine output was adequate. She did not have further episodes of desats and remained stable on room air. Patient produced adequate secretions with deep suctioning and sputum gram stain was negative and preliminary culture had no growth. She was taken off contact precautions since she was not actively infected with MRSA. She received Muciprocin x 5 days [**Hospital1 **] for MRSA positive nasal swab. . 2) T12 compression fracture with cord compression: Patient was status post anterior and posterior decompression surgeries, performed by Dr [**Last Name (STitle) 363**]. The chest tube from prior surgery was removed and a drain was placed. Steroids were discontinued on [**7-27**]. Drain was removed [**7-28**]. Patient continued to remain paralyzed in her bilat LEs. Cultures taken of wound during OR proceedings negative for organisms. Pain control with IV morphine, tylenol was adequate. . 3) Hypertension: Necessary to control pain in order to control BP. BP stabilized, back on BB, holding AceI. . 4) Diastolic heart failure: On recent echo ([**7-19**]), EF hyperdynamic with evidence of diastolic heart failure. Beta blocker was resumed once BP was stable. Patient has had slightly elevated cardiac enzymes likely from chronic left ventricular strain in context of CHF. Decision was made not to heparinize since EKG did not reveal ST changes lowering concern for infarct. Patient had a repeat echo on [**8-9**] to evaluate for worsening CHF given pulmonary edema and revealed EF 55% with similar findings to prior study. . 5) Anemia: baseline hct in low 30's ([**2102**] is last documented), now in mid 20's but stable; she was transfused 1 unit pRBCs on [**8-7**] due to low hct and it remained around 27. Patient had hemolysis workup with haptoglobin, LDH, and t bili which were all within normal limits. She was guiaic negative. . 6) Schizophrenia- haldol IM Q month, Remeron, Zyprexa, and Trazodone 50 mg qhs. Patient had episodes of sun-downing as she was disoriented in the evenings to self and time. It was not clear whether this was her baseline mental status. LFTs were checked to evaluate delirium and showed mild elevation in ALT. Patient's lipitor dose was decreased by half. . 7) Diabetes mellitus: very low insulin need; continue RISS . 8) Hoarseness: Patient with new hoarseness s/p extubation, now improving. Per ENT consult, continue PPI and she will need to be scheduled for outpatient follow-up. . 10) FEN: Patient failed S&S on [**8-1**] and subsequently removed her own NGT. She was at that time without nutrition source. GI placed PEG on [**8-4**] and tolerated tube feeds well with no evidence of aspiration on deep suctioning. Patient was started on calcitonin for regulation of PTH's activity on bone resorption. Levels of PTH and vitamin OH-D were pending on discharge and will be followed up by PCP. . 11) Healthcare proxy: Patient is not competent with baseline dementia and psychiatric condition. Healthcare proxy and legal guardian is [**Name (NI) **] [**Name (NI) 68736**], ([**Telephone/Fax (1) 98705**] at Advoguard, Inc. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**] has been in touch with guardian regarding treatment goals and code status. . 12) Dispo: Continue PT. She will be discharged to [**Hospital1 1501**]. . 12) Code status - Full code. Medications on Admission: * Levofloxacin 500 mg IV Q24H * Metronidazole 500 mg IV Q8H * Lisinopril 20 mg * Atenolol 100 mg PO DAILY * InsulinSS * Ipratropium Bromide Neb 1 NEB IH Q6H * Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN * Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] * Acetaminophen (Liquid) 650 mg NG Q6H * Miconazole Powder 2% 1 Appl TP TID:PRN * Mirtazapine 30 mg PO HS * Benztropine Mesylate 1 mg PO BID * Dexamethasone 4 mg IV Q6H * Morphine Sulfate 1-2 mg IV Q4H * Docusate Sodium 100 mg PO BID * Multivitamins 1 CAP PO DAILY * Famotidine 20 mg IV Q12H * Nicotine Patch 14 mg TD DAILY * Guaifenesin 15 ml NG Q4H * Heparin 5000 UNIT SC TID Discharge Medications: 1. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) SSI Subcutaneous ASDIR (AS DIRECTED). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 19. Haldol Decanoate 50 mg/mL Solution Sig: One (1) 1 Intramuscular once a day as needed for agitation. 20. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety. 21. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every 4-6 hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Main diagnosis: T12 burst fracture and paraplegia s/p T8-L2 fusion on [**2107-7-26**] Respiratory distress Other diagnosis: dementia schizophrenia history of chronic GI bleed and refused GI workup in the past anemia GERD COPD (last PFT in [**2095**]: FEV1/FVC of 73, FEV1 71% of predicted) hypertension benign neoplasm of colon diabetes mellitus osteoarthritis neuropathy, urinary incontinence Discharge Condition: Fair. Discharge Instructions: Please take all medications. Followup Instructions: PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**] for further management. . Pt has an ortho appointment with Dr. [**Last Name (STitle) 363**] ([**Telephone/Fax (1) 3573**]) at 10:30 on [**8-24**], [**Hospital Ward Name 23**] 2 Orthopedics, and will require transportation for this.

[ "518.5", "294.8", "428.31", "285.9", "781.0", "518.0", "E941.0", "995.1", "V09.0", "806.25", "295.60", "250.00", "401.9", "496", "478.6", "482.41", "E928.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "43.11", "96.72", "84.51", "81.62", "96.6", "81.63", "99.04", "77.79", "03.53", "34.04", "81.05", "81.04" ]

icd9pcs

[ [ [] ] ]

17778, 17848

8842, 15293

326, 586

18286, 18294

2785, 8819

18371, 18673

2052, 2094

15984, 17755

17869, 18265

15319, 15961

18318, 18348

2109, 2766

249, 288

614, 1569

1591, 1862

1878, 2036

20,025

111,968

21183

Discharge summary

report

Admission Date: [**2110-6-13**] Discharge Date: [**2110-6-14**] Date of Birth: [**2050-6-20**] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old lady with past medical history significant for irritable bowel syndrome, hypertension, and hypercholesterolemia, who presents with bright red blood per rectum. The patient had a routine screening colonoscopy on [**2110-6-12**] at 11:30 a.m. She was found to have a polyp, which was removed. The patient was also noted to have mild diverticulosis. Around 5:30 p.m., the patient started to pass bright red blood per rectum approximately 100 to 400 cc every hour. She denied fever, chills, nausea, vomiting, or abdominal pain. She went to an outside hospital ED, but was transferred to [**Hospital1 18**] since her doctor was Dr. [**Last Name (STitle) 1940**] who is associated with [**Hospital1 18**]. In the ED, her vital signs were temperature 98, blood pressure 149/78, heart rate 80, respiratory rate 17, and saturating 97 percent on room air. Two large bore IVs were placed and the patient was resuscitated with 2 liters of IV normal saline. Her hematocrit was noted to drop from 39 to 22. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Inflammatory bowel disease. MEDICATIONS: 1. Diovan. 2. Premarin. 3. Lipitor. 4. Hydrochlorothiazide. ALLERGIES: CODEINE CAUSING NAUSEA. PHYSICAL EXAMINATION: Afebrile, heart rate 80, blood pressure 100/65, respiratory rate 15, and saturating 100 percent on room air. General: Pale, diaphoretic, alert female. HEENT: Oropharynx clear. Sclerae anicteric, but pale. Cardiovascular: The patient is tachy without murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft and nontender, normoactive bowel sounds, positive bright red blood in bedpan. Extremities: No clubbing, cyanosis, or edema. Pulses were 1 plus bilaterally. LABORATORY DATA: Chem-7 was unremarkable. CBC was remarkable for anemia with hematocrit of 27. KUB showing no free air. HOSPITAL COURSE: The patient was admitted to the MICU. On presentation to the MICU, she had a single IV. Initially her heart rate was in the 80s and her systolic blood pressure was in the 120s. However, she became more unstable and her heart rate jumped to 112 to 115 and her systolic blood pressure fell to the mid 90s. At this time a second IV was placed. The patient was transfused with packed red blood cells through both IVs. She remained tachycardiac and producing large amounts of blood per rectum. The decision was made to place a central line to allow for aggressive volume resuscitation. During the placement of the central line, the patient was complaining of some back pain, however, the wire fed easily and a 3-lumen catheter was placed. On chest x- ray, the catheter appeared to leave the subclavian vein into an internal mammary vein. However, since the central line both flushed and true blood, it was left in place temporarily. However, after the transfusion of 3 units of packed red blood cells the patient was stable, producing less blood per rectum, non-tachycardiac, the base systolic blood pressure in the 120s. Thus the central line was discontinued. The patient was seen by Dr. [**Last Name (STitle) 1940**] and the GI fellow. They took the patient to Endoscopy where they found red blood in the transverse, left, sigmoid, and rectum. There was no blood in the right colon. The polypectomy site was identified opposite the valve. It had a red clot on it, but was not bleeding. The clot was washed off. No bleeding was noted. Then 10 cc of epinephrine was injected 1:10,000 dilution into and around the base of the polypectomy. After this, BL-CAP electrocautery was applied for hemostasis successfully. There was no bleeding at the conclusion of the procedure. After this procedure, the patient's hematocrit remained stable. She was advanced to a clear liquid diet without difficulty. She had no additional episodes of bright red blood per rectum. Her diet was further advanced. She was monitored overnight and remained hemodynamically stable. She was discharged home the following day with followup to see Dr. [**Last Name (STitle) 1940**]. No changes to her medications were made. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: Gastrointestinal bleed status post polypectomy. DISCHARGE MEDICATIONS: No changes were made to her outpatient regimen. FOLLOWUP PLANS: The patient was asked to follow up with Dr. [**Last Name (STitle) 1940**] on Monday. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 39096**] Dictated By:[**Doctor Last Name 2020**] MEDQUIST36 D: [**2110-6-16**] 05:32:08 T: [**2110-6-16**] 06:14:05 Job#: [**Job Number 20597**]

[ "E878.8", "564.1", "998.11", "578.9", "272.0", "401.9", "276.5", "275.41" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "45.43" ]

icd9pcs

[ [ [] ] ]

4304, 4339

4434, 4833

4361, 4410

2066, 4282

1421, 2048

165, 1196

1219, 1398

46,373

163,904

18547

Discharge summary

report

Admission Date: [**2197-2-28**] Discharge Date: [**2197-3-24**] Date of Birth: [**2147-4-18**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: worsening fatigue and exertional Major Surgical or Invasive Procedure: [**2197-2-28**] redo MVR ( [**Street Address(2) 17009**]. [**Male First Name (un) 923**] mechanical) [**2197-3-3**] craniotomy History of Present Illness: 49yo female with congential heart disease(ASD and mitral repair at age 9)who was admitted to Good Samaritain in [**2196-7-6**] with NSTEMI and elevated BNP. She underwent extensive cardiac evaluation which showed normal coronary arteries, moderate mitral stenosis with severe pulmonary hypertension. Due to the above findings, she has been referred for redo operation. Surgery however has been delayed to due GI and pulmonary workup. After extensive preoperative evaluation by GI and pulmonary, she has finally been cleared to proceed with redo operation. Currently symptoms include worsening fatigue and exertional dyspnea. She also complains of intermittent chest pain, and occasional presyncope. She denies orthopnea and lower extremity edema. ** Recently treated for urinary tract infection with improvement in symptoms ** Past Medical History: Congenital Heart Disease NSTEMI in [**2196-7-6**] Pulmonary Hypertension Hypertension Dyslipidemia Paroxysmal Atrial Fibrillation, s/p Ablation History of Seizures History of Migraine HA Morbid Obesity Hypothyroid Depression/Anxiety Osteoarthritis Chronic Back Pain Diverticulosis Sleep Apnea - does not wear CPAP History of recurrent UTI - most recent in [**2197-1-5**] Chronic Anemia, unknown etiology Past Surgical History: - Atrial Septal Defect Closure and Mitral Valve Cleft repair via sternotomy in [**2156**] - AF Ablation at [**Hospital3 **] in [**2182**] - Left Foot Surgery x 3, most recent [**2193**] - Left rotator cuff surgery [**2192**] - Lap Cholecystectomy - Right Knee Surgery [**2191**] Social History: Lives: Home with father Occupation: On Disability Cigarettes: Never ETOH: Denies Illicit drug use: Denies Family History: Father had CABG at age 64. Paternal grandfather died of MI at age 61. Physical Exam: BP: 116/49 Pulse: 59 Resp: 18 O2 sat: 96% room air General: Obese female in no acute distress Skin: Dry [x] intact [x] well healed sternotomy scar noted upper extremities(left more than right) with minor erythema - appears more allergic than infectious reaction HEENT: PERRLA [x] EOMI [x] - teeth in poor repair Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade [**3-13**] LLSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None Neuro: Grossly intact, limited ROM of left shoulder Pulses: Radial Right: 1+ Left: 1+ Carotid Bruit Right: None Left: None Pertinent Results: TEE [**2197-2-28**]:Conclusions PREBYPASS No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is thinned out area at the septum primum consistent with previous pericardial septal patch. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Mild to moderate ([**2-6**]+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning, bileaflet mechanical prosthesis in the mitral position. Valvular MR is present which is appropriate in quantity and location for this type of prosthesis. No flow across the previous ASD repair is seen by color Doppler. The study is otherwise unchanged from the prebypass period. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2197-2-28**] 12:58 MRA head [**2197-3-3**]: FINDINGS: There is no significant interval change in the evolving extensive right MCA territory infarction involving the basal ganglia as well as the overlying cortex. The amount of midline shift and subfalcine herniation remains stable. The patient is status post right-sided hemicraniectomy. The right-sided MCA branches are not well visualized. A small extra-axial collection noted at the craniectomy site. The calcifications noted in the left frontal periventricular white matter are associated with mild amount of gliosis. There is no edema. No significant signal dropout is seen on the gradient echo images. IMPRESSION: No significant interval change in extensive evolving right MCA infarction. Small amount of blood products are noted relating to recent surgery. Left frontal periventricular calcifications do not demonstrate enhancement or mass effect. [**2197-3-24**] 01:42AM BLOOD WBC-9.7 RBC-3.04* Hgb-9.0* Hct-26.9* MCV-88 MCH-29.7 MCHC-33.6 RDW-16.5* Plt Ct-302 [**2197-3-24**] 02:41AM BLOOD PT-18.7* PTT-30.1 INR(PT)-1.8* [**2197-3-24**] 09:20AM BLOOD PTT-86.2* [**2197-3-24**] 01:42AM BLOOD Glucose-110* UreaN-28* Creat-0.5 Na-135 K-3.7 Cl-92* HCO3-35* AnGap-12 Radiology Report CHEST (PORTABLE AP) Study Date of [**2197-3-21**] 7:31 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2197-3-21**] 7:31 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 50962**] Reason: eval for consolidation/effusion Final Report INDICATION: 49-year-old female status post mitral valve replacement. COMPARISON: Multiple chest radiographs dating back to [**2-17**], [**2197**], most recent [**2197-3-14**]. TECHNIQUE: Portable upright AP chest radiograph. FINDINGS: There has been slight increase in lung aeration with corresponding decrease in bibasilar atelectasis. There is no pneumothorax or areas of focal consolidation concerning for infection. There is unchanged cardiomegaly and pulmonary edema. Right-sided PICC catheter is seen, unchanged in position in the upper right atrium. Tracheostomy tube is seen unchanged in position. Sternotomy wires remain unchanged in alignment and position with no obvious hardware failure. IMPRESSION: 1) Unchanged cardiomegaly and moderate-to-severe pulmonary edema. 2) Slight increase in lung aeration with decrease in bibasilar atelectasis. No pneumothorax. Brief Hospital Course: Admitted [**2197-2-28**] and underwent redo sternotomy/Mitral valve replacement with a [**Street Address(2) 44058**]. [**Male First Name (un) 923**] mechanical valve with Dr.[**Last Name (STitle) **]. Transferred to the CVICU in stable condition on titrated insulin, propofol, and phenylephrine drips. She developed neurologic deficits with L side weakness and R eye deviation upon weaning of sedation. Neurology was consulted and scanning revealed a right MCA distibution CVA. Intracranial pressures necessitated craniotomy on [**2-28**] with neurosurgery. She remained intubated and tube feeds were started. She required manitol and eventually became more alert. She had seizures immediately following her stroke and was treated with Keppra and Depakote. The seizures resolved and the Depakote was discontinued and the Keppra dose was decreased. The patient continued to improve and was weaned down in the ventilator. She underwent a tracheostomy and open G-J tube placement on [**3-14**] and has continued to wean. Currently she is on a trach collar during the day and CPAP on the vent at night. She has tried the Passe-Muir valve once this week and will take on to rehab with her. Neurologically she moves all extremities spontaneously with the exception of the LUE, and intermittently follows commands. Her staples from her craniotomy site and abdominal incision were discontinued on [**2197-3-24**]. She will return to see Dr. [**First Name (STitle) **] of neurosurgery and have head CT prior to her appointment on [**2197-4-27**]. Dr. [**First Name (STitle) **] will determine the timing of cranioplasty at that time. She needs to wear her helmet when she is out of bed. She has been anticoagulated with heparin and coumadin for her mechanical mitral valve and is currently on a heparin gtt at 1400 and will receive 3 mg of coumadin. Her INR goal is 2.5-3. She had a small amount of bleeding around the trach site this week and was scoped twice. There were no findings from this. The bleeding has now resolved. She is being transferred to [**Hospital1 **] [**Hospital1 8**] for further rehab. Medications on Admission: - BACLOFEN - 10 mg Tablet - 1 Tablet as needed for prn - BUTALBITAL-ASPIRIN-CAFFEINE - 50 mg-325 mg-40 mg Capsule - 1 Capsule as needed for prn - CARISOPRODOL - 250 mg Tablet - 1 Tablet once a day QPM - CITALOPRAM - 20 mg Tablet - 1 Tablet once a day - DIVALPROEX - 250 mg Tablet Extended Release 24 hr - 1 Tablet QAM and 2 Tablets QPM - FUROSEMIDE - 40 mg Tablet - 1 Tablet once a day - LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet once a day - LORAZEPAM - 2 mg Tablet - 1 Tablet as needed prn - METOPROLOL - 25 mg Tablet - 1 Tablet once a day - NABUMETONE - 750MG TWICE DAILY - NITROSTAT - 0.3 mg Tablet, Sublingual - 1 Tablet PRN - OMEPRAZOLE - 20 mg Capsule - 1 Capsule(s) by mouth twice a day - POTASSIUM CHLORIDE - 20 mEq Tablet - 1 Tablet(s) once a day - SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day - TRAMADOL - 50MG TWICE DAILY Medications - OTC - ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth once a day - MECLIZINE - (25 mg Tablet, Chewable - 1 Tablet as needed Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 4. magnesium hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) ML PO PRN (as needed) as needed for constipation. 5. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 7. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day). 8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. warfarin 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily at 4 PM: Titrate for an INR goal on 2.5 to 3. 10. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4 hours) as needed for pain. 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: 2-4 Puffs Inhalation Q4H (every 4 hours). 12. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO once a day for 7 days: then decrease dose to 200 mg PO daily. 13. simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 14. levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 15. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 16. furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Two (2) Injection twice a day. 17. heparin, porcine (PF) 10,000 unit/5 mL Solution [**Last Name (STitle) **]: One (1) 1400 Intravenous drip. 18. Ultram 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every 4-6 hours. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 8**] Discharge Diagnosis: congenital heart disease s/p redo MVR postop R MCA CVA s/p craniotomy prior ASD/MV repair NSTEMI in [**2196-7-6**] Pulmonary Hypertension Hypertension Dyslipidemia Paroxysmal Atrial Fibrillation, s/p Ablation History of Seizures History of Migraine HA Morbid Obesity Hypothyroid Depression/Anxiety Osteoarthritis Chronic Back Pain Diverticulosis Sleep Apnea - does not wear CPAP History of recurrent UTI - most recent in [**2197-1-5**] Chronic Anemia, unknown etiology Respiratory Failure-s/p tracheostomy [**2197-3-14**] G-J tube placement [**2197-3-14**] Past Surgical History: - Atrial Septal Defect Closure and Mitral Valve Cleft repair via sternotomy in [**2156**] - AF Ablation at [**Hospital3 **] in [**2182**] - Left Foot Surgery x 3, most recent [**2193**] - Left rotator cuff surgery [**2192**] - Lap Cholecystectomy - Right Knee Surgery [**2191**] Discharge Condition: Trach and PEG, on trach collar during the day, CPAP on vent at night. Alert, moves all extremities except left arm, intermittently follows commands. Incisional pain managed with oral analgesics Incisions: healing well, C/D/I Sternal: 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) 15497**] please call for an appointment when pt leaves [**Telephone/Fax (1) 50963**] Cardiologist:Dr. [**Last Name (STitle) 50964**] please call for an appointment when pt leaves [**Telephone/Fax (1) 50965**] Neurosurgery: Dr. [**First Name (STitle) **] [**2197-4-27**]@ 10:40 AM. Head CT prior to appointment at [**Hospital1 18**] [**Location (un) 470**] radiology [**Hospital Ward Name 517**]. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-4-27**] 10:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2197-4-27**] 11:00 **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 mechanical MVR Goal INR 2.5-3.5 First draw [**2197-3-25**] ***please arrange for coumadin follow-up prior to discharge from rehab Completed by:[**2197-3-24**]

[ "E878.1", "041.3", "V13.02", "416.8", "V12.59", "287.5", "518.51", "434.11", "412", "342.91", "424.0", "244.9", "997.02", "327.23", "599.0", "780.39", "562.10", "V13.65", "V58.61", "285.9", "278.01", "348.5" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.72", "33.22", "01.25", "35.24", "38.97", "01.26", "96.6", "46.32", "39.61" ]

icd9pcs

[ [ [] ] ]

12002, 12063

6845, 8956

321, 450

12967, 13254

3012, 6822

14178, 15272

2177, 2249

9996, 11979

12084, 12642

8982, 9973

13278, 14155

12665, 12946

2264, 2993

249, 283

478, 1307

1329, 1733

2053, 2161

51,201

172,389

48843

Discharge summary

report

Admission Date: [**2133-11-24**] Discharge Date: [**2133-11-27**] Date of Birth: [**2066-6-12**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2195**] Chief Complaint: Dyspnea, cough Major Surgical or Invasive Procedure: none History of Present Illness: 67 y/o spanish-speaking woman with h/o TBM s/p Y-stent placement [**5-21**] & removal [**7-21**], DM, AFib s/p PPM on coumadin, restrictive lung disease transferred from [**Hospital3 **] Medical Center for airway management. She initially presented there with 1 week of right-sided facial swelling, dysphagia, dyspnea, and cough with green sputum. No fever, chills, sweats, hemopytsis, difficulty managing secretions. Had negative throat swab at PCP's office. Was prescribed azithro x 6 days ending [**11-22**] but did not improve. Presented to [**Hospital3 **] ED because could not get another PCP appointment until [**11-26**]. Contrast CT of the neck performed to evaluate neck swelling showed lingual tonsillitis, likely reactive cervical lymphadenopathy, and significant narrowing of the supralaryngeal airway. Was treated with solumedrol 125 mg, clindamycin 900 mg IV, duonebs x 3. Transferred to [**Hospital1 18**] for advanced airway management. In the ED, initial VS 71 114/62 14 97%RA. Given morphine 2 mg IV x 1. After a discussion with ENT & IP, decision made not to scope and admit to MICU for observation. Vital signs prior to transfer 97.4 70 117/62 16 92%RA 98%2L. Past Medical History: -L MCA CVA with residual speech difficulties [**2128**] -Tracheobronchomalacia s/p Y-stent placement [**5-21**] & removal [**7-21**] due to recurrent pulmonary infection -Restrictive lung disease -DM -Chronic diastolic CHF -AFib s/p PPM placed [**7-17**] -HTN -GERD Social History: SOCIAL HISTORY: Former [**2-13**] ppd smoker, quit ~15 years ago. No ETOH. Family History: Non-contributory Physical Exam: Vitals - T 97.6 BP 105/60 HR 73 RR 18 02sat 96%2L GENERAL: Well-appearing woman, resp non-labored HEENT: sclera anicteric bilateral tonsillar enlargement with erythema no exudate NECK: fullness R>L with mild TTP no fluctuance, mass CARDIAC: reg rate nl S1S2 no m/r/g LUNGS: good air movement occasional stridor with deep inspiration no wheeze/rales/rhonchi ABDOMEN: soft NTND normoactive BS EXT: warm, dry no edema Pertinent Results: Admission Labs: . [**2133-11-24**] 08:30PM WBC-9.8# RBC-3.76* HGB-10.1* HCT-31.4* MCV-84 MCH-26.8* MCHC-32.0 RDW-14.5 [**2133-11-24**] 08:30PM NEUTS-94.1* LYMPHS-4.6* MONOS-0.5* EOS-0.7 BASOS-0.1 [**2133-11-24**] 08:30PM PLT COUNT-287 [**2133-11-24**] 08:30PM GLUCOSE-202* UREA N-17 CREAT-0.7 SODIUM-138 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18 [**2133-11-24**] 08:39PM LACTATE-1.6 . CT Head and Neck [**11-24**] - 1. Bilateral palatine tonsil enlargement causing marked narrowing and near complete obliteration of the trachea. No focal abscess identified. Underlying malignancy cannot be excluded. Direct visualization is recommended. 2. Bilateral cervical lymphadenopathy, likely reactive. 3. Prior left MCA territorial infarct. . CXR [**11-24**] - Cardiomegaly without evidence of acute pulmonary edema or infection. Brief Hospital Course: Ms. [**Known lastname 19987**] is a 67 y/o spanish-speaking woman with h/o tracheobronchomalacia s/p Y stent placement and removal, DM2, CVA admitted with lingual tonsillitis and concern for subtotal supralaryngeal airway obstruction on CT scan, no airway obstruction on evaluation by ENT. 1)Tonsilitis with subtotal airway impingement- She was initially transferred from [**Hospital3 **] to the MICU for concern for airway obstruction. She was continued on IV methylprednisolone and IV clindamycin overnight. She remained stable with no respiratory compromise. Airway was felt to be widely patent per ENT examination. On speaking with patient the chronicity of this is unclear as she is currently reporting that the tonsilar enlargement, right jaw pain and difficulty passing food have all been chronic symptoms for years with no recent worsening, however she did have recent URI and sore throat which made things more difficult for her. She was evaluated by speech and swallow and is safely swallowing thin liquids. Purees are easiest for her but she can safely advance as tolerated. No evidence of aspiration risk. Monospot was negative amd blood cultures with no growth. She was discharged to complete a five day course of clindamycin. Steroids were stopped on the day after admission. 2) Jaw pain, throat discomfort, arm/leg pain/numbness - all are long standing chronic issues, patient denies any acute worsening. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] aware of these issues and will continue to manage in an outpatient setting. 3) Chronic diastolic CHF - euvolemic on admission, now slightly dry with uptrending bicarbonate and BUN likely due to continuing furosemide with limited po intake. Furosemide was stopped on [**11-26**] and held on discharge and po intake was encouraged. She was continued diltiazem. 3)Afib s/p left temporal CVA - currently in paced rhythm at a normal rate. INR supratheraputic likely [**3-16**] clindamycin. Warfarin was held starting [**11-26**] and was not restarted on discharge as still on clindamycin. She will have INR check on [**11-30**] with communication with PCP before resuming her coumadin. 4)Normocytic anemia - hematocrit has been stable over the past year. Unclear what workup she has had for this by PCP but would benefit from iron studies, b12, folate, colonoscopy as oupatient if not already done. 5)DM2 - no acute issues. She was on insulin sliding scale during her admission as metformin was held. Metformin resumed upon discharge. She is not on ASA or ACEI. She will follow up with her PCP regarding consideration of starting these medications. 6)HTN - stable. She was continued on imdur, diltiazem. Lasix was held for minor dehydration. 7)COPD - stable, no evidence of exacerbation. She was continued on her outpatient advair, albuterol prn. 8)Depression - stable, continue fluoxetine 9)Code status: FULL (confirmed with daughter [**11-25**]) CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4186**], daughter, [**Telephone/Fax (1) 102611**] Medications on Admission: coumadin 3 mg daily insulin SS reglan 10 mg TID fluoxetine 20 mg daily loratadine 10 mg daily MVI daily metformin 100 mg [**Hospital1 **] accolate 20 mg daily furosemide 40 mg qAM, 20 mg qPM protonix 40 mg daily flomax 0.4 mg daily isosorbide 30 mg daily diltiazem 15 mg QID trazodone 100 mg nightly advair 500/50 1 puff [**Hospital1 **] duoneb prn flovent 110 mcg 4 puff [**Hospital1 **] miacalcin spray NS zaditor 1 gtt OU [**Hospital1 **] flonase NS senna 2 tab qhs Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Accolate 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 10. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. Miacalcin 200 unit/Actuation Aerosol, Spray Nasal 15. Zaditor 0.025 % Drops Sig: One (1) gtt Ophthalmic twice a day as needed for pruritis. 16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 20. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 days. Disp:*8 Capsule(s)* Refills:*0* 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 4 days. Disp:*10 Tablet(s)* Refills:*0* 22. Outpatient Lab Work CBC, Na, K, Cl, bicarbonate, BUN, Creatinine, PT, INR Please communicate results to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) **]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Tonsilitis Secondary Diagnosis: Type 2 Diabetes Neuropathic pain Atrial fibrillation s/p PPM CAD Anemia COPD Discharge Condition: stable tolerating po intake no respiratory distress Discharge Instructions: You were admitted to the hospital because of throat pain. There was concern at [**Hospital3 **] for tonsil swelling causing airway blockage. You were evaluated in the ICU by the ENT service and there was no airway blockage. You had a mono test which was negative. You were evaluated by the speech and swallow therapists who felt that you are safe to drink thin liquids. You were able to swallow pureed foods easiest but can eat other consistencies as you can tolerate. You were treated with the antibiotic clindamycin for a total of 5 days for tonsil infection. Medications: 1) You will need to finish taking the clindamycin until [**11-29**]. 2) Your lasix was held on [**11-29**] because you were dehydrated. Please do not restart this medication for at least 2-3 days until you are eating and drinking as usual. Please have Dr. [**Last Name (STitle) **] check your blood when you see him. 3) Your coumadin has been held since [**11-26**] and was not restarted on discharge. This level is probably elevated because of the clindamycin. You will need to have your INR checked on Monday [**11-30**]. Please do not restart your coumadin until you talk with Dr. [**Last Name (STitle) **] about your coumadin dose after this level is drawn. 4) You were were tried on gabapentin however you had some dizziness after taking one dose which was likely due to the gabapentin so this medication was stopped. Please take tylenol for your throat pain, 650mg every 6 hours. You were given a prescription for a small amount of oxycodone that you can use if you have pain not treated by the tylenol. You have anemia which has been present for some time. Please discuss this with Dr. [**Last Name (STitle) **] as it should be worked up. Please return to the hospital or call your doctor if you have difficulty breathing, inability to eat, chest pain, fevers or other worrisome symptoms. Followup Instructions: You will need to have blood work checked on Monday [**11-30**], including your INR, CBC and kidney function. The results will go to Dr. [**Last Name (STitle) **]. Please call his office to check on the results by Tuesday. You have an appointment scheduled to follow up with Dr. [**Last Name (STitle) **] on [**2133-12-10**] at 2:30. Please call his office if you need to reschedule [**Telephone/Fax (1) **].

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2112-2-29**] Discharge Date: [**2112-3-2**] Date of Birth: [**2055-6-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Failure of pacemaker Major Surgical or Invasive Procedure: Pacemaker implant and explant. History of Present Illness: Mr. [**Known lastname 46**] is a 56 year-old male with pmh of atrial fibrillation s/p AV ablation and pacemaker placement, dCHF, hypertension, and cerebral palsy who is being transferred from [**Hospital 882**] Hospital for pacemaker revision. . He presented to [**Hospital 882**] Hospital with persistent nausea, vomiting, and decrease oral intake on [**2-28**]. He had gone to the ED on [**2-26**] with similar symptoms and had been treated with IVF and discharged home. He was admitted and treated with IVF and zofran for a possible gastroenteritis. He was monitored on telemetry and was noted to have frequent pauses of greater then 5 seconds. He was known to have a pacemaker, but it was not capturing consistently. He was transferred to [**Hospital1 18**] for management of his pacemaker dysfunction. . Currently he denies chest pain, shortness of breath, nausea, dizziness, or other symptoms. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He admits to recent increased urinary frequency and slight dysuria. He had two negative UA at the OSH. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, Hypercholesterolemia 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: Atrial fibrillation s/p AV ablation and permenant pacemaker placement in [**2104**]. He had failure of the original pacemaker in [**2108**] and had a [**Company 1543**] pacemaker, Sigma SSR 303 placed. 3. OTHER PAST MEDICAL HISTORY: Diastolic CHF Hypertension Cerebral palsy with paraparesis Spina bifida Chronic leg cellulitis Social History: He lives alone. He works for the [**Location (un) 86**] Police. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: FAMILY HISTORY: +CAD, +DM. Physical Exam: GENERAL: Middle-aged male sitting in bed in NAD. Alert and appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: No JVD seen. CARDIAC: RRR, faint heart sounds. No MRG. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: + normoactive bowel sounds. Abdomen is soft, NTND. EXTREMITIES: No edema. SKIN: Venous stasis changes present in his lower extremitites. PULSES: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Discharge exam: unchanged with the exception of following: Chest: bilateral anterior shoulder dressings clean, dry and intact. Pertinent Results: [**2112-3-2**] 05:20AM BLOOD WBC-11.2* RBC-5.29 Hgb-15.1 Hct-44.2 MCV-84 MCH-28.4 MCHC-34.1 RDW-13.3 Plt Ct-233 [**2112-3-2**] 05:20AM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-141 K-3.4 Cl-104 HCO3-25 AnGap-15 Brief Hospital Course: Mr. [**Known lastname 46**] is a 56 year-old male with atrial fibrillation s/p AV ablation and pacemaker placement, dCHF, hypertension transferred for pacemaker revision. . # pacemaker malfunction: The patient has a history of atrial fibrillation s/p AV ablation and is pacemaker dependent. His pacemaker was failing to capture when he raised his left arm. He went into a junctional rhythm on the night of his admission when his pacemaker mode was changed to DDI with rate of 40. He was hemodynamically stable at this rate, and the following day the patient underwent explant of previous pacemaker and inplant of a new right sided pacemaker with a single ventricular lead. The patient's heartrate increased to 70 paced rythm. #Atrial fibrillation: The patient's coumadin was held and 2mg of vitamin K was given in anticipation of his pacemaker procedure. He was restarted on his home dose of coumadin to be followed by his PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] on discharge. # CORONARIES: The patient has no history of CAD. Medications on Admission: Amlodipine 5 mg po daily Atenolol 25 mg po daily Irbesartan 150 mg po daily Prochlorperazine 10 mg po q6h prn Tylenol 650 mg q6h prn Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO ONCE (Once). 3. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 5. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: pacemaker malfunction. Discharge Condition: Good, alert and orientated x3. Patient is ambulatory with crutches. Discharge Instructions: Dear Mr. [**Known lastname 46**], You were admitted to the hospital because you had a malfunctioning pacemaker. For this, your old pacemaker was removed and you had a new one implanted on your right side. Your heart rate was very low while before you had the new pacemaker implanted, but this normalized once you had the new pacemaker implanted. Your symptoms improved prior to your discharge. You should leave your right arm in the sling until you go to your follow-up appointment. Also, you should under no circumstances raise your right arm above shoulder height for 6 weeks as this may cause your pacemaker wires to move to an improper position. We understand that you at times require crutches for movement; you should use your crutches only with your left arm if at all possible. You have a follow-up appointment in the pacemaker clinic at the time written below. It is very important that you go to this appointment. You have been prescribed an antibiotic to take for 1 week as prophylaxis from your new pacemaker becoming infected. This antibiotic should not interfere with your coumadin, however you should follow up with your primary care provider to check your coumadin blood levels frequently. Your amlodipine was also increased to 10mg daily. You have been given tylenol with codeine to take as needed for pain for your pacemaker insertion. Followup Instructions: You have the following appointments scheduled: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-3-8**] 9:30 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-4-26**] 8:30 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Also, we have contact[**Name (NI) **] your primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] and informed him of your admission. They will be following up with your visiting nurse when they check your blood coumadin levels. You should also make an appointment to see him within the next 2 weeks. Completed by:[**2112-3-2**]

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icd9cm

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[ "37.85" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2174-4-21**] Discharge Date: [**2174-5-3**] Date of Birth: [**2118-11-1**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 78**] Chief Complaint: upper and lower extremity weakness Major Surgical or Invasive Procedure: [**2174-4-21**] ACDF C6-7 with drainage of abcess [**2174-4-23**] Corpectomies C6 and 7 quadraparesis [**4-27**] IVC Filter Placement History of Present Illness: This is a 55y/o F who presents with worsening LUE weakness and neck pain over the past 2 days. The patient also states b/l hand paresthesias. In addition, the patient states increasing upper and lower extremity weakness. The neck pain started 6 days ago and has waned before increasing over the past 2 days. The patient denies bowel or bladder incontinence. The patient denies chills/fever, new rashes, recent illnesses, recent surgery/dental procedures. Past Medical History: hypothyroidism, HTN, gastric bypass Social History: lives with husband, works as nurse Family History: nc Physical Exam: O: T: 99.9 BP:153/78 HR: 76 R 16 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: reactive EOMs intact Neck: Supple. No masses palpated. 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. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 3 3 3 3 3 3 3 3 3 3 3 L 2 2 2 2 2 3 3 3 3 3 3 Sensation: decreased sensation LE, paresthesias b/l hands Upon discharge: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: reactive EOMs intact Neck: Supple. No masses palpated. 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. Motor: D B T WE WF G FI IP Q H AT [**Last Name (un) 938**] G R 5 5 0 4- 3 4+ 3 4+ 5 5 4+ 4 5 L 5 4+ 0 4- 3 4+ 3 5 5 5 3 3 5 Pertinent Results: [**4-21**] MRI C-Spine (OSH): Cord compression at levels of C5, C6, and C7. Extensive soft tissue edema and mild enhancement involving the prevertebral space, ascending superiorly and inferiorly over the entire cervical spine. This appears to extend into the paraspinal soft tissues, most prominently over the inferior cervical spine and at the level of C6-C7 (presumed to represent an infection). There is an epidural abscess at the level of C6-C7 which causes the cord compression. Small paraspinal abscesses also appear to extend into the longus coli muscles at these levels. The extensive paraspinal soft tissue inflammatory changes and enhancement extends down to the level of the thoracic inlet. [**2174-4-22**] MRI Cspine 1. Status post C6-7 discectomy with no significant interval change in prevertebral fluid and soft tissue swelling. Interval air within the prevertebral soft tissues consistent with postoperative change. 2. No significant interval change in enhancing phlegmon/abscess in the anterior epidural space from C5 through C7 with severe spinal canal stenosis. Cord edema cannot be completely evaluated secondary to patient motion artifact. 3. Persistent soft tissue enhancement within the paraspinous soft tissues at C6-7. [**2174-4-23**] MRI L-spine 1. No finding to suggest vertebral osteomyelitis, discitis or epidural abscess in the lumbar spine. 2. No pathologic focus of enhancement. 3. L2-3 and L3-4: Disc degeneration, likely related to the levoscoliosis. At L3-4, an eccentric disc bulge to right narrows the caudal aspect of that neural foramen, likely impinging upon the exiting right L3 nerve root. [**2174-4-23**] MRI C, T-spine Postoperative changes in the cervical spine with no definite evidence for a residual epidural abscess, although evaluation is limited due to artifact. Slight interval increase in size of a collection in the right antero lateral neck extending to the midline prevertebral space. This is likely to be a postoperative collection and recommend attention on followup imaging. [**2174-4-27**] LENS [**Doctor Last Name **] scale and Doppler images of both common femoral, superficial femoral, popliteal and proximal calf veins were obtained. There was wall-to-wall flow with normal response to compression and augmentation in all visible veins. No DVT was present. IMPRESSION: No DVT in either lower extremity. [**2174-4-30**] CT C-spine 1. Prominent right paratracheal anterior neck soft tissue stranding with air-fluid collections increased from MRI of [**2174-4-23**] concerning for infection or hemorrhage. Further evaluation is limited due to lack of contrast. MRI or contrast-enhanced CT are recommended for further evaluation. 2. Probably expected post-surgical appearance of the anterior cervical fusion device at C5-8 with C6-7 corpectomy and regional prevertebral soft tissue prominence. No additional focal osseous abnormality. [**2174-5-1**] MRI C-spine Somewhat increasing extent of fluid within the prevertebral soft tissues at the caudal extent of the internal fixation device. It is impossible to determine whether this fluid is sterile or infected, nor whether the paraspinal soft tissue enhancing region is infected, either. [**2174-5-3**] Left Lower Extremity Ultrasound no evidence of deep vein thrombosis Brief Hospital Course: Ms. [**Name14 (STitle) 86056**] was admitted and brought emergently to the OR for ACDF C6-7 for drainage of abcess. She tolerated this procedure and remained intubated and transferred to ICU. Her post op exam showed poor motor function in upper extremities and no movement in lowers. She had repeat MRI that showed decompression of abcess but continued collection behind C6 and 7 vertebral bodies so she returned to OR for corpectomies C6 and 7. She was recovered in the ICU and was extubated on post op day #2. ID consult was obtained and recommendations followed. Patient was placed on naficillin 2g IV Q4H for staph coag + cultures. Patient was transferred to step down on [**4-26**]. Patient developed dysphasia and a dophoff was recommended. An IVC filter was placed as well as the dophoff in the OR on [**4-27**]. On [**4-28**], a nutrition consult and speech and swallow eval was ordered. Nutrition decreased her tubefeeds to goal rate of 62ml/hr and speech and swallow allowed her to take in pureed foods with nectar-thick liquids. Her strength comtinues to improve, but she remains weak distally in UE and LE. She failed a voiding trial overnight into [**4-30**]. A CT C-spine was done for this reason. There was suspicion of new soft tissue collection and MRI +/- was recommended by radiology. This was done on [**5-1**] and there was no sign of cord compression or hardware movement. She was afebrile. TEE was ordered per ID reqs but not performed due to absolute contraindication (per cardiology). ID is understanding and currently recommends longterm course (6-8wks plus) of nafcillin with outpt follow up and weekly labs. On [**5-2**] pt was seen in follow up by speech and swallow. Per their recommendations her diet was advanced to ground, her tube feeds & NGT were d/c'd. She was also started on calorie counts and ensure puddings. She was also seen by PT/OT and they have recommended discharge to inpatient rehab. On [**5-3**] the patient was again seen by speech and swallow, who recommended increasing diet to soft solids and thin liquids. Pt continued with clamping of foley catheter with unclamping every 4 hours for bladder training. She complained of some tenderness in her left lower extremity (questionable edema) therefore an ultrasound was obtained which revealed no deep vein thrombosis. At this time the patient was cleared for discharge to inpatient rehabilitation facility. Medications on Admission: metoprolol, synthroid, motrin, percocet, valium Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 10. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) 2gm Intravenous Q4H (every 4 hours): Pt to follow up with Infectious Disease who will decide end point (likely duration 6-8 weeks). 11. Diazepam 5 mg/mL Syringe Sig: One (1) 5mg Injection Q6H (every 6 hours) as needed for spasm. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) 2 ML (20 units) Intravenous PRN (as needed) as needed for line flush. 13. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1) 10 ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: cervical epidural abcess 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: CERVICAL (NECK) Spine Surgery Diet: ?????? You may resume your normal diet. ?????? You can help avoid constipation by eating a balanced diet including: fruits, vegetables, and whole grains (like multi-grain bread, cereals, and bran muffins). ?????? You may also take fiber supplements and over-the-counter stool softeners or laxatives such as Colace or Dulcolax ?????? You may find that softer foods or thick liquids are easier to swallow initially after surgery, but swallowing should become progressively easier. Activity: ?????? A collar has been ordered for you, wear it at all times except for when shaving or bathing. When the collar is off, keep your head in the same position as if the collar were still applied. ?????? Avoid lifting overhead. ?????? Avoid pushing/pulling and lifting over 15 lbs. ?????? Walking is a good exercise. Go for at least four short walks a day, even if inside your home. ?????? Do not drive while still required to wear the collar. ?????? Do not drive if you are taking pain medications, muscle relaxants, or if you are in pain. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour that you are awake. ?????? You may resume sexual activity when this is comfortable for you. ?????? You can return to work when you feel ready. However, you must stay within the [**5-2**] pound weight lifting restriction ?????? half days might be better at first. Wound Care: ?????? You may shower, however try not to let the water run directly over the incision. You [**Month (only) **] NOT soak the incision in a bathtub or pool for 4 weeks. If your wound gets wet, gently [**Last Name (LF) **], [**First Name3 (LF) **] NOT RUB the wound dry. ?????? Your incision was closed with dissolvable sutures under the skin. There are steri-strips in place, and these should stay on until the fall off on their own. The edges may begin to curl, and these may be trimmed. Pain: ?????? Hoarseness, sore throat, or difficulty swallowing may occur in some patients and should not be cause for alarm. These symptoms usually resolve in 1 to 4 weeks. ?????? Take your pain medication as prescribed. You will likely only require narcotic pain medication for 2-3 days. After that timeframe, over the counter Tylenol or Acetaminophen will be sufficient. Medications: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and be comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: ?????? Narcotic pain medication such as Dilaudid, Percocet or Vicodin ?????? Muscle relaxant such as Robaxin, Flexeril or Valium. Take these as needed for muscle spasm. They will make you sleepy, so do not drive while taking these medications ?????? An over the counter stool softener for constipation (try Dulcolax, Milk of Magnesia or ?????? Correctal at first and Magnesium Citrate or Fleets enema if needed). Miscellaneous: * You have had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing. * Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse. WHEN TO CALL THE DOCTOR ?????? A temperature of 101.5??????F or above ?????? Increased redness, soreness, swelling or foul-smelling drainage from the incision ?????? New or increased numbness, tingling, or weakness in any extremity ?????? New onset of bladder or bowel incontinence. ?????? Inadequate pain relief ?????? Nausea or vomiting ?????? Shortness of breath ?????? Pain in your calf Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] to be seen in 4 weeks. ??????You will need an MRI scan of the Cervical spine with gadolinium contrast. These appointments were already in the system and we have included them here as a reminder: Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2174-5-12**] 1:50 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2174-6-6**] 9:00 Completed by:[**2174-5-3**]

[ "V45.86", "338.19", "787.20", "V14.0", "324.1", "344.00", "518.4", "790.7", "482.41", "244.9", "997.39", "401.9", "041.11", "723.1", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "99.12", "81.02", "81.63", "38.7", "77.77", "96.6", "38.91", "81.04", "80.99", "80.51", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

9540, 9612

5663, 8079

325, 461

9681, 9683

2342, 5640

14433, 15073

1074, 1078

8178, 9517

9633, 9660

8105, 8155

9866, 11308

1093, 1345

251, 287

11320, 14410

1759, 1963

489, 947

9698, 9842

969, 1006

1022, 1058

7,815

113,156

10529

Discharge summary

report

Admission Date: [**2194-8-19**] Discharge Date: [**2194-8-26**] Date of Birth: [**2148-6-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Type I DM admitted for pancreatic transplant Major Surgical or Invasive Procedure: pancreas transplant [**2194-8-19**] History of Present Illness: 46 yo man s/p LRKT [**2191**] and failed pancreatic transplant [**2191**] here for his second pancreatic transplant. Past Medical History: DMI s/p pancreas/kidney transplant; pancreas transplant failed [**3-12**] thrombus ESRD s/p LRKT CAD s/p CABG s/p PTCA [**9-11**] HTN orthostasis, autonomic dysfunction GERD PUD hypertensive gastropathy s/p fem-[**Doctor Last Name **] polycythemia [**Doctor First Name **] grade II esophagitis Social History: EtOH 1/week, + tobacco 1pack/3 weeks; on disability, lives at home alone; is out at the Yacht club Family History: mother w/ breast ca; o/w DM/HTN/CVA/hyperchol Physical Exam: Gen: well appearing man, NAD HEENT: PERRL, oropharynx without erythema/exudate, neck supple without masses CV: RRR, no murmurs/rubs/gallops Lungs: CTA bilaterally Abd: soft, NT/ND, +BS with well-healing incision c/d/i Ext: no edema, no palpable pulses bilateral dorsalis pedis, warm extremeties bilaterally Neuro: alert and oriented x 3 Brief Hospital Course: Patient was admitted and underwent an uncomplicated pancreatic transplant on [**2194-8-19**]. He was stable postop and was transferred to the floor. He was placed on a dilaudid PCA for pain, and also started on a 200U heparin drip. He continued to do well with blood sugars well controlled ranging in the low 100's. He did experience two episodes of low blood sugar in the early post operative period with blood sugars in the 60's. He did well over the next few days while receiving his standard immunosuppresion protocol of ATG and Solumedrol. His diet was advanced to sips on post op day #4 which he tolerated well. Blood sugars continued to be well controlled with no insulin requirement. On postop day #6, the patient had two blood sugars levels of 213 and 214 respectively and was sent down for a pancreatic ultrasound. The ultrasound revealed good a-v flow through the pancreas and no major fluid collections. On post op day #7 he received an abdominal CT which revealed normal appearing pancreas and kidney with a small amount of fluid around the transplanted kidney. His blood sugars returned to [**Location 213**] with no other elevated levels. He was tolerating regular diet, maintaining normal blood sugars and was dischared on post op day #8 in good condition. Medications on Admission: Bactrim, Atorvastatin 10mg qd, Cellcept [**Pager number **] tid, Lantus 25U qhs, Reglan 10mg [**Hospital1 **], Prednisone 1mg tid, Protonix 40mg [**Hospital1 **], Midodrine 10mg [**Hospital1 **], Tacrolimus 0.5mg qhs, 1mg qAM, Florinef 0.1mg qd, Humalog insulin SS, Vitamin C, Ferrous gluconate, ASA 81mg 3X/week Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Monday-Wednesday-Friday. 9. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day: potassium level to be checked Thursday [**8-28**]. Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pancreas transplant [**2194-8-19**] DM Type I hypertension s/p cabg s/p kidney transplant [**2-8**] Discharge Condition: stable Discharge Instructions: Call if fevers, chills, nausea, vomiting, inability to take medications, redness/bleeding, blood sugars 200 or greater, tenderness over pancreas/kidney. Labs every Monday & Thursday for cbc, chem 7, calcium, phosphorus, ast, t.bili, amylase, lipase, albumin and trough prograf level. Check blood sugar at least every morning and evening. Call if glucose 200 or greater. keep record of blood sugars No heavy lifting Check sugars every 6 hours Followup Instructions: Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2194-9-1**] 1:10 Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2194-9-8**] 9:40 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2194-9-15**] 3:20

[ "V45.81", "238.4", "V42.0", "530.81", "401.9", "250.01" ]

icd9cm

[ [ [] ] ]

[ "00.93", "52.82" ]

icd9pcs

[ [ [] ] ]

4135, 4193

1416, 2690

358, 396

4337, 4345

4835, 5394

993, 1040

3053, 4112

4214, 4316

2716, 3030

4369, 4812

1055, 1393

274, 320

424, 542

564, 860

876, 977

6,542

117,866

14288

Discharge summary

report

Admission Date: [**2186-5-16**] Discharge Date: [**2186-5-27**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: 88 yo female sp fall on her face Major Surgical or Invasive Procedure: Open reduction/internal fixation of C2-C3 fracture dislocation with posterior segmental instrumentation and posterior arthrodesis C2-C3. History of Present Illness: She had suffered a fall resulting in a fracture dislocation of C2-C3. She had suffered some neurologic compromise, predominantly in the right side and had some difficulty breathing prior to surgery and was intubated prior to surgery. She was brought to the operating room in a hard collar. Past Medical History: PMHx: HTN, HOH, TIA x3, inc chol, stenting x 3, multiple falls last one on R shoulder has [**Month (only) **] rom R shoulder, MI [**2182**], PNA, chronic phelgm PSurgHx: stenting, c-section x2 Physical Exam: Lunga coarse b heart rrr abd soft nt nd ext exam: [**3-5**] R delt. [**4-5**] RUE, RLE. [**5-5**] LUE/LLE Pertinent Results: [**2186-5-16**] 11:22p Mg: 2.2 P: 4.0 [**2186-5-16**] 10:45p pH 7.33 pCO2 44 pO2 121 HCO3 24 BaseXS -2 Type:Art; Intubated; FiO2%:54; Rate:8/ ; TV:600 Na:142 K:3.3 Cl:110 TCO2:24 Hgb:8.4 CalcHCT:25 Glu:107 freeCa:1.01 Lactate:2.4 Other Blood Gas: Vent: Controlled [**2186-5-16**] 9:20p pH 7.32 pCO2 47 pO2 133 HCO3 25 BaseXS -2 Type:Art; Intubated; FiO2%:54 Na:142 K:3.6 Hgb:10.2 CalcHCT:31 Glu:105 freeCa:1.03 Lactate:1.9 Other Blood Gas: Vent: Controlled [**2186-5-16**] 8:03p pH 7.36 pCO2 44 pO2 157 HCO3 26 BaseXS 0 Type:Art; Intubated; FiO2%:98; AADO2:510; Req:84 Na:141 K:3.7 Hgb:8.0 CalcHCT:24 Glu:108 freeCa:1.03 Lactate:1.8 [**2186-5-16**] 5:00p pH 7.34 pCO2 42 pO2 244 HCO3 24 BaseXS -2 Type:Art Na:140 [**2186-5-16**] 4:57p SLIGHTLY HEMOLYZED 144 109 39 195 AGap=15 3.4 23 1.3 Comments: Hemolysis Falsely Elevates K Ca: 6.6 Mg: 1.7 P: 3.5 Comments: Hemolysis Falsely Elevates Mg [**2186-5-16**] 12:35p CK CPIS TNT ADDED [**5-16**] @ 15:01 139 98 39 360 AGap=25 3.5 20 1.3 CK: 120 MB: 8 Trop-*T*: <0.01 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 8.3 Mg: 2.0 P: 4.2 89 16.0 9.8 201 29.5 PT: 13.1 PTT: 25.3 INR: 1.1 [**2186-5-15**] 11:25p Trop-*T*: 0.01 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi 135 98 33 337 AGap=16 5.1 26 1.1 CK: 102 MB: 6 88 19.9 D 11.1 218 33.6 N:85 Band:4 L:7 M:3 E:1 Bas:0 Hypochr: 1+ Anisocy: 1+ Microcy: 1+ Ovalocy: OCCASIONAL Comments: MANUALLY COUNTED Plt-Est: Normal PT: 12.3 PTT: 27.2 INR: 1.1 Brief Hospital Course: suffered a fall resulting in a fracture dislocation of C2-C3. She had suffered some neurologic compromise, predominantly in the right side and had some difficulty breathing prior to surgery and was intubated prior to surgery. She was brought to the operating room in a hard collar. Halo ring was attached to patient's head using standard technique with 4 pins, anesthetizing each of the 4 pin placements. But then she was then placed prone on the operating room table with head controlled with the halo attachment to the [**Location (un) 8766**] head rest. Under fluoroscopic examination, her fracture was reduced to show alignment of the C2-C3 vertebral body. This was confirmed again on the lateral projection as well as AP projection under the fluoroscope, adn the dssition to perform a Open reduction/internal fixation of C2-C3 fracture dislocation with posterior segmental instrumentation and posterior arthrodesis C2-C3; was taken. Afer the or, patient had failute to wean form ventilator, due to age, debilitation, and generalized weakness. Pt had living will which states she would not wish to be dependent and live in n.h. & her children wanted to honor her wishes. In meeting with them and the TICU attending , the desition of extubateing the patien was taken; with a DNR DNI order. Pt deteriorating after extubation and was decided [**Last Name (un) **] made Confort esaure only. Pt expired short after. Medications on Admission: glipizide 5mg am, 2.5 pm; metoprolol 50 [**Hospital1 **], enalapril 20, lipitor 20 hs, asa 325, alphagen p gtt ou [**Hospital1 **], acuvite, MVI Discharge Disposition: Expired Discharge Diagnosis: respiratory failure Fracture dislocation at the C2-C3 level. Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2186-6-9**]

[ "250.00", "414.00", "873.8", "518.5", "272.0", "401.9", "V45.82", "E888.9", "805.08" ]

icd9cm

[ [ [] ] ]

[ "81.03", "81.62", "96.6", "03.53", "96.72", "77.79" ]

icd9pcs

[ [ [] ] ]

4256, 4265

2645, 4061

294, 433

4370, 4379

1111, 2621

4432, 4466

4286, 4349

4087, 4233

4403, 4409

985, 1092

222, 256

461, 753

775, 970

69,626

152,364

42908

Discharge summary

report

Admission Date: [**2122-11-2**] Discharge Date: [**2122-11-9**] Date of Birth: [**2038-3-29**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2122-11-2**] - Coronary artery bypass grafting x5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, sequential reverse saphenous vein graft to the first and second obtuse marginal artery and reverse saphenous vein graft to the ramus intermedius artery. [**2122-11-2**] - Cardiac Catheterization and IABP placement History of Present Illness: 84 year old male presented to [**Location (un) 620**] ED with chest pain radiating to left shoulder. Noted to have 2mm ST elevation V1-3 . Treated w/ASA nad Heparin then transferred for cardiac catheterization. Similar episode of chest pain 2 weeks ago while raking leaves-resolved w/rest. Past Medical History: Hypertension Hyperlipidemia bleeding ulcer 7 yrs ago Social History: Past smoker Family History: None Physical Exam: T 98 Pulse: 78 SR Resp:16 O2 sat: 95%-RA B/P Right: 116/60 Left: Height: 66 in Weight: 81.6 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Murmur-no Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: trace Left: trace PT [**Name (NI) 167**]: - Left: - Radial Right: 2+ Left: 2+ Carotid Bruit none Pertinent Results: Admission Labs: [**2122-11-2**] 07:45AM PT-14.4* INR(PT)-1.3* [**2122-11-2**] 08:15AM cTropnT-0.49* [**2122-11-2**] 08:15AM CK(CPK)-380* [**2122-11-2**] 09:07AM HGB-14.7 calcHCT-44 [**2122-11-2**] 12:12PM FIBRINOGE-223 [**2122-11-2**] 12:12PM PT-17.6* PTT-36.5 INR(PT)-1.7* [**2122-11-2**] 12:12PM PLT COUNT-174 [**2122-11-2**] 12:12PM WBC-20.3* RBC-3.42* HGB-9.7* HCT-29.2* MCV-85 MCH-28.3 MCHC-33.3 RDW-13.5 [**2122-11-2**] 01:04PM UREA N-14 CREAT-0.8 SODIUM-135 POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-10 Discharge Labs: [**2122-11-2**] ECHO PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The septal wall is hypertrophied. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF=40 %). with normal RV free wall contractility. The apical and mid portions of the inferior, inferoseptal walls and anteroseptal walls are hypokinetic. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. There is an intraaortic balloon pump seen in the descending aorta which extends past the subclavian takeoff and into the aortic arch. Dr. [**Last Name (STitle) **] made aware. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room. POSTBYPASS: The patient is AV paced on epinephrine and phenylephrine infusions. LV function is improved with inotropic support. LVEF now 45%. RV function is maintained. The apical and mid portions of the anterior septum & inferior septum remain hypokinetic. [**Male First Name (un) **] noticed postbypass treated w/ beta blockers & volume. The MR is now 1+, the TR is now 2+ on inotropic support. The ascending aorta and arch are intact. IABP remains in the descending aorta and distal arch. [**2122-11-2**] Cardiac Catheterization Left ventriculography revealed LVEF of 30% with anterior and inferior severe hypokinesis. Coronary angiography: co-dominant LMCA: Distal 50%, short LAD: Diffuse disease with 95% stenosis mid vessel and serial 40-50% diffuse disease LCX: Origin 430%, mid vessel 60-70% after diffusely diseased bifurcating OM1 which has origin and proximal 60% RCA: Total occlusion with collaterals from the LCA filling small PL/PDA system Other: Ramus: Proximal 60% diffuse IABP placed CT CHEST IMPRESSION: 1. Bilateral pleural effusions with loculated fluid noted in the pleural space adjacent to the pericardium on the left side and along the left horizontal fissure with no evidence for pneumonic consolidation identified. 2. Small simple fluid collection seen posterior to the sternotomy wound site in the mediastinum. Labs discharge [**2122-11-8**] 06:20AM BLOOD WBC-11.5* RBC-3.56* Hgb-10.0* Hct-30.8* MCV-86 MCH-28.1 MCHC-32.5 RDW-14.2 Plt Ct-271 [**2122-11-9**] 05:25AM BLOOD PT-16.2* INR(PT)-1.5* [**2122-11-9**] 05:25AM BLOOD UreaN-25* Creat-1.0 Na-139 K-4.2 Cl-101 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2122-11-2**] with an acute ST elevation myocardial infarction. He underwent a cardiac catheterization which revealed severe three vessel disease. An intra-aortic balloon pump (IABP) was placed and an urgent cardiac surgical consult was obtained. Given his tight left main, he was taken emergently to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative note for details. In summary he had: coronary artery bypass grafting x5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, sequential reverse saphenous vein graft to the first and second obtuse marginal artery and reverse saphenous vein graft to the ramus intermedius artery. His crossclamp time was: 73 minutes, with a cardiopulmonary bypass time of: 82 minutes. He tolerated the operation well and postoperatively he was taken to the intensive care unit for recovery. In the immediate post-op period he remained hemodynamically stable, he woke neurologically intact and was extubated. On POD1 his IABP was weaned and removed. He was noticably confused and narcotics were discontinued. He was started on diuretics and gently diuresed towards his preoperative weight. He had several brief episodes of atrial fibrillation treated with Bblockers and Amiodarone after which he converted to sinus rhythm. All tubes, lines and drains were removed per cardiac surgery guidelines. The remainder of his hospital course was uneventful. On POD3 he was transferred to the stepdown floor for continuing care. He worked with the nursing and physical therapy staff to increase strength and endurance. On POD 7 he was ready for discharge to rehab. Medications on Admission: Lisinopril 10 mg daily Amlopidine 5 mg daily Metoprolol 50 mg twice daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg once a day for 2 weeks then decrease to 200 mg daily until follow up with cardiologist. 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as needed for wheezing or SOB . 9. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (). 10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 14. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: please give 1 mg on [**11-10**] then check INR [**11-11**] for further dosing . 15. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks: continue until reevaluation in office [**11-17**] with Dr [**Last Name (STitle) **] . 16. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 17. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation four times a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: Coronary artery disease s/p CABG [**11-2**] ST elevation myocardial infarction (troponin 0.49) Post operative atrial fibrillation Hypertension Hyperlipidemia bleeding ulcer 7 yrs ago Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Tramadol Incisions: Sternal - healing well, no erythema, scant amount of serosanguous drainage from lower pole of incision Leg Left - healing well, no erythema or drainage. Edema: trace lower extremity edema 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**] **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) **] [**Name (STitle) **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] On [**2122-11-19**] 1:15 - please have xray of chest done in clinical center building [**Location (un) 470**] prior to appointment Cardiologist: Dr [**Last Name (STitle) 3142**] [**2122-12-2**] @2PM [**Telephone/Fax (1) 19980**] **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 Atrial Fibrillation Goal INR: 2.0-2.5 First draw: [**11-11**] Wednesday Please draw monday, wednesday and friday for the first two weeks for coumadin - dose to be monitored by rehab physician When discharging from rehab please contact Dr. [**Last Name (STitle) 3142**] [**Telephone/Fax (1) 19981**] to arrange for ongoing coumadin management Completed by:[**2122-11-9**]

[ "997.1", "414.01", "E878.2", "272.4", "280.0", "511.9", "410.11", "287.5", "401.9", "V12.71", "427.31", "293.0" ]

icd9cm

[ [ [] ] ]

[ "97.44", "36.14", "39.61", "88.53", "37.22", "36.15", "88.56", "37.61" ]

icd9pcs

[ [ [] ] ]

9108, 9181

5340, 7144

321, 731

9408, 9705

1810, 1810

10593, 11590

1173, 1179

7269, 9085

9202, 9387

7170, 7246

9729, 10570

2363, 5317

1194, 1791

271, 283

759, 1051

1826, 2346

1073, 1128

1144, 1157

41,518

100,991

50132

Discharge summary

report

Admission Date: [**2192-12-2**] Discharge Date: [**2192-12-10**] Date of Birth: [**2120-3-13**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 832**] Chief Complaint: Fevers, chills, cough and weakness Major Surgical or Invasive Procedure: None History of Present Illness: 72-year-old male with AChR +ve myasthenia [**Last Name (un) 2902**], Duodenal angiomas, asthma, diastolic CHF and AF who presented following a 4 day hx of fever, chills, and generalized weakness. Patient felt hot with chills past 2 nights for which he did not take his temperature but took acetamionophen for this. He noticed increasing wheeze past 2 days and did feel more SOB yesterday with no cough, sputum or hemoptysis. Since last night noted palpitations with an associated "funny feeling" in the chest. THis was a mild chest pressure which lasted 2 minutes and subsided. He had further sweating, fever, palpitations and chest discomfort (again which was self-limiting lasting 2 minutes per pt) and called an ambulance. Upon EMS arrival the patient was in a rapid AF with a heart rate about 130, O2 sat was approximately 95% on 4 L. Patient denies any chest pain, but noted mild difficulty breathing and mild nausea. Of note, he had missed his diltiazem this am. He denied emesis or abdominal pain. No recent hospital admissions. . In the ED, patient was noted to have a low grade temp 100 and was in fast AF with rate 130's and 94% 3L NC. CXR showed multifocal pneumonia. Labs demonstrated WBC 13 pt received, acetaminophen, IV levoflox/vancomycin and 2L NS and his SBP was 110's. No rate control was given. ECG showed fast AF with no ischemic changes. Vitals on transfer were 120 139/93 27-30 97% 3L NC. . Regarding myasthenic sx pt noted increased generalised weakness past 4 days with no diplopia or blurred vision and no swallowing problems. [**Name (NI) **] did not take any of his myasthenia meds until in the [**Hospital Unit Name **] which may account for his significant dysarthria although patient denies diplopia. . On arrival to the [**Hospital Unit Name 153**] vitals were T 99.6 123/91 HR 143 RR 19 sO2 97% 2.5L O2. Patient was complaining of soem SOB and mild wheeze and otherwise not disturbed by tacycardia. . ROS: The patient denies any weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: ACh R Ab +ve Myasthenia [**Last Name (un) **] on azathioprine and pyridostigmine has had for 3 years and had trouble with left ptosis 2 years. Diplopia resolved 2 years ago. Has never required ICU treatment for his MG. Colonic Polyps Duodenal angiomas (s/p thermal therapy) GI bleeding - capsule endoscopy [**10/2192**] (for guaiac +ve stools) showed mild, focal gastritis and no active bleeding sites were found. Gastritis HTN Asthma Constrictive pericarditis Chronic renal insufficiency Congestive heart failure diastolic Diverticular disease of the colon with a redundant colon Atrial fibrillation on diltiazem exudative pleural effusion . P Surgical Hx: s/p R total hip replacement S/p appendectomy . Social History: retired cab driver, ? h/o mild developmental delay, lives in [**Location (un) 453**] apt alone in [**Location (un) **] Smoking - Ex-smoker quit 16 years ago prev 2 cigars/day no ETOH, no illicits or IVDU. [**Name (NI) 1094**] brother is a retired internal med MD . Family History: Brother with DM, Mother d. 73, Father d. 73 CAD Physical Exam: On Admission: Vitals: T: 99.6 BP: 123/76 HR: 121 RR: 28 O2Sat: 95% 2.5L GEN: Tachypneic, c/o SOB. Left intermittently complete ptosis HEENT: sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2. JVP not elevated PULM: Markedly decreased BS L>R with crackles in left base and mild occasional wheeze. Generally poor air entry bilaterally. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords. Calves SNT. NEURO: alert, oriented to person, place, and time. CN II normal, complex ophthalmoplegia with significant limitation with some adduction and very limited abduction and R eye good abduction and 75% adduction with significantly limited elevation and depression of both eyes although patient cooperation was not ideal. Left complete ptosis although intermittent and weakness in eye closure bilaterally L>R but otherwise facial muscle power good. V, VIII, normal. Significant dysarthria. Good palatal movement. Somewhat impared sniff and good cough. Good tongue movement. Tone normal UL and LL. Power 4+/5 in shoulder abduction bilaterally and otherwise mild weakness in proximal muscles (Elbow F/E) bilaterally with good distal power. In LL Hip 4+/5 bilaterally with 5-/5 in hip extension and otherwise [**4-4**] in LL. Proximal weakness was fatiguable. Reflexes present and symmetrical in UL and Difficult to ellicit in the lower limb due to poor patient compliance. Plantar reflex flexor bilaterally. Coordination normal in UL. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . On Discharge: Pertinent Results: Admission labs: [**2192-12-2**] 12:20PM BLOOD WBC-13.0*# RBC-4.03* Hgb-12.3* Hct-35.2* MCV-87 MCH-30.5 MCHC-34.9 RDW-15.6* Plt Ct-270 [**2192-12-2**] 12:20PM BLOOD Neuts-90.1* Lymphs-3.6* Monos-6.2 Eos-0.1 Baso-0.1 [**2192-12-2**] 12:20PM BLOOD PT-14.4* PTT-23.7 INR(PT)-1.2* [**2192-12-2**] 12:20PM BLOOD Glucose-172* UreaN-29* Creat-1.4* Na-137 K-3.2* Cl-94* HCO3-31 AnGap-15 [**2192-12-2**] 12:20PM BLOOD cTropnT-0.01 [**2192-12-2**] 12:20PM BLOOD Calcium-9.1 Phos-2.4* Mg-2.0 [**2192-12-2**] 12:27PM BLOOD Glucose-153* Lactate-1.5 K-3.2* [**2192-12-2**] 12:27PM BLOOD Hgb-12.5* calcHCT-38 . Other labs: [**2192-12-2**] 08:04PM BLOOD Type-ART Temp-36.5 pO2-95 pCO2-43 pH-7.47* calTCO2-32* Base XS-6 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**] [**2192-12-2**] 12:27PM BLOOD Glucose-153* Lactate-1.5 K-3.2* [**2192-12-2**] 08:04PM BLOOD Lactate-1.3 [**2192-12-2**] 12:27PM BLOOD Hgb-12.5* calcHCT-38 . . Urine [**2192-12-2**] 07:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2192-12-2**] 07:33PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG [**2192-12-2**] 07:33PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2192-12-2**] 07:33PM URINE Mucous-RARE . Microbiology: BC [**12-2**] no growth to date UCx [**12-2**] negative [**2192-12-2**] Legionella Urinary Ag -ve . [**2192-12-3**] 2:49 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2192-12-3**]** GRAM STAIN (Final [**2192-12-3**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2192-12-3**]): TEST CANCELLED, PATIENT CREDITED. . . Radiology . XR CHEST (PORTABLE AP) Study Date of [**2192-12-2**] 12:25 PM FINDINGS: There is a rounded opacity in the right upper lobe. There is left basilar atelectasis. Lung volumes are slightly low. The cardiac silhouette, hilar and mediastinal contours appear within normal limits. There is no pneumothorax or pleural effusion. IMPRESSION: Right upper lobe consolidative opacity worrisome for pneumonia. Recommend repeat chest radiograph after appropriate treatment to assess for resolution. Left basilar atelectasis. . XR CHEST (PORTABLE AP) Study Date of [**2192-12-3**] 5:07 AM Portable AP chest radiograph was reviewed in comparison to [**2192-12-2**]. The right upper lobe rounded opacity appears to be slightly bigger than on the prior study and might be consistent with gradual progression of infectious process. Left retrocardiac consolidation is unchanged. Right basal atelectasis is unchanged. Cardiomediastinal silhouette is stable. Followup of the right upper lobe consolidation to complete resolution is mandatory. . [**2192-12-6**]: MRI BRAIN WITHOUT IV CONTRAST: The study is very limited, with incomplete diffusion imaging. Within the limitations of obtaining only the directional sequence of the diffusion study, there is no evidence of acute infarction. Non-contrast sagittal T1-weighted images show no mass effect or hematoma. IMPRESSIONS: Very limited study due to early termination shows no evidence of acute infarction, mass effect, or hematoma. Brief Hospital Course: 72-year-old male with AChR +ve myasthenia [**Last Name (un) 2902**], Duodenal angiomas, asthma, diastolic CHF and AF presents with fevers, chills and SOB and was found to be in fast AF with evidence of multifocal pneumonia on CXR. Considerable myasthenic sx (not affecting respiratory muscles but had mild proximal fatiguable weakness) on admission but now improving with persistent eye signs. . # Multi-lobar Pneumonia with acute respiratory failure: Evidence of predominantly RUL consolidation but also left base changes in context of fevers, chills and worsening SOB. Patient started on Levofloxacin and Ceftriaxone for CAP and given potential for worsening MG with levofloxacin this was changed to azithromycin. BCs, Sputum cultures, Urine legionella Ag was negative. WBC downtrending on hospital day 2 but CXR ppeared slightly worse with evidence of left base consolidation. He was treated with PRN nebs. He symptomaticlly improved, and was discharged to complete a total of 14 days of treatment on cefpodoxime (already completed 1 week of azithromycin). He will need a repeat CXR in [**3-6**] weeks to monitor for resolution. . # Rapid Atrial Fibrillation: On home maintained on diltiazem 240mg [**Hospital1 **]. Noted to have rate 130 at EMS and rate in ICU 100s-140s however had not received daily nodal agents. On evening of admission received 120mg of diltiazem. On morning of hospital day 2 resumed full home dose diltiazem 240mg [**Hospital1 **]. He was changed to short acting diltiazem 90mg Q6 on [**12-3**] as rate was still high. Regarding anticoagulation, patient not anticoagulated as an outpatient. Started on ASA 325mg which was discontinued in the setting of GI bleeding. He was discharged from the ICU on [**12-3**] and his HR was 90s-100s. On diltiazem 240 mg po bid he had HR in the 80's on the day of discharge. . # AChR +ve Myasthenia: Sees O/P neurologist. Usually on regular pyridostigmine and azathioprine. Current significant symptoms with complex ophthalmoplegia, ptosis and fatiguable proximal weakness with dysarthria. Generally poor chest wall movement. Baseline ABG obtained which was reassuring for intact respiratory status and showed respiratory alkalosis. Patient was unable to cooperate with FVC. Patient continued on azathioprine 150mg and pyridostigmine 90mg qid and glycopyrrolate. By Day 2 he had improved - no longer had proximal weakness but had persistent ocular symptosm with partial ptosis on left and very limited eye movement on the left especially in adduction and upgaze bilaterally. Neurology were consulted and followed. He eventually stabilized on his home doses of pyridostigmine and azathioprine, as well as glycopyrollate. . # Gait ataxia. He exhibited gait ataxian on hospital day 3. This improved slowly with increased ambulation. A partial MRI was completed, which showed no acute infarcts. He will be discharged with home PT and a walker. . # HTN: On admission relatively hypotensive systolic pressures improved in [**Hospital Unit Name 153**]. Held furosemide in setting of presenting hypotension thoguh this was restarted prior to discharge. . # Hx dCHF: furosemide was held during admission, with no signs of volume overload. Furosemide 80 mg po daily was restarted at discharge. . # Asthma: No further significant wheeze. He was given PRN Xopenex nebs . # Gastrointestinal bleeding, with history of angiomas. He was started on heparin SC and aspirin 325, then 81. On hospital day 4, he developed guaic positive stool. Prilosec was increased to 40 mg po bid, and heparin and aspirin were discontinued. He had a slow drift down in his hematocrit. He will follow up with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1940**], his primary gastroenterologist for an enteroscopy in the next 4-6 weeks. . # Diarrhea. The patient developed diarrhea occurring 3 times daily at the time of discharge. C Diff testing was negative. It is most likely that this represents a mediation side effect potentially from glycopyrollate. He will follow-up as an outpatient for further management of this issue. . Key follow up: Repeat CXR 4-6 weeks Medications on Admission: Calcitriol 0.25 mcg PO DAILY Xopenex Neb *NF* 1.25 mg/3 mL Inhalation q4 SOB Simvastatin 20 mg PO/NG DAILY Vitamin D 1000 UNIT PO/NG DAILY Ferrous Sulfate 325 mg PO/NG DAILY Citalopram 10 mg PO/NG DAILY Omeprazole 20 mg PO BID Diltiazem Extended-Release 240 mg PO Q12H Glycopyrrolate 1 mg PO/NG QHS Azathioprine 50 mg am 100mg pm Pyridostigmine Bromide 90 mg PO/NG Q6H Furosemide 80mg am 40mg pm Potassium chloride 20mEq [**Hospital1 **] FeSO4 325mg qd Discharge Medications: 1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. glycopyrrolate 1 mg Tablet Sig: One (1) Tablet PO four times a day: with pyridostigmine. 5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation q6 prn () as needed for SOB. 13. diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 14. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: ## Gastrointestinal bleeding ## Multifocal community acquired pneumonia with acute respiratory failure ## Myasthenia [**Last Name (un) 2902**] with chronic ptosis of left eye, and weakness in setting of illness. ## Gait ataxia, ## Chronic diastolic CHF without acute exacerbation ## Atrial fibrillation with RVR, ## Stage II CKD, at baseline ## Chronic asthma without acute exacerbation. 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 with pneumonia and an exacerbation of your myasthenia. You were initially admitted to the ICU and then transferred to the floor. The neurology team saw you, and you did not have any respiratory failure due to your myasthenia [**Last Name (un) 2902**]. You improved with antibiotics. You also developed gastrointestinal bleeding likely due to your angiomas, while on heparin shots and aspirin. These were stopped and your prilosec was increased. With these changes, your bleeding stopped. . Medication changes: Complete 6 more days of CEFPODOXIME 200 mg po twice daily Increase PRILOSEC to 40 mg po twice daily Followup Instructions: Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA Specialty: Primary Care Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3530**] When: [**Last Name (LF) 2974**], [**12-14**] at 11:30am . Please also call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to schedule a follow-up appointment in the next 1-2 weeks.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14611, 14669

8760, 12847

327, 334

15101, 15101

5403, 5403

15943, 16403

3635, 3684

13385, 14588

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362, 2606

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15116, 15260

2628, 3335

3351, 3619

6010, 8737

14,953

165,616

48724

Discharge summary

report

Admission Date: [**2116-10-31**] Discharge Date: [**2116-11-1**] Date of Birth: [**2060-8-8**] Sex: F Service: MEDICINE Allergies: Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime / Vancomycin / Cephalosporins / Infliximab / Mercaptopurine / Mesalamine / Heparin Agents / Fluconazole / Meropenem / Tizanidine / Ativan / Loperamide / Iodine Containing Agents Classifier / Feraheme / Naltrexone Attending:[**First Name3 (LF) 338**] Chief Complaint: RUE hematoma, abdominal pain Major Surgical or Invasive Procedure: 1. Nasogastric tube placement (self placed). History of Present Illness: Ms. [**Known lastname 1007**] is a 56 year old woman with history of Crohn's disease c/b rectovaginal fistula and multiple small bowel resections, h/o SVC syndrome s/p angioplasty on fondaparinux, (h/o HIT), h/o parathyroid adenoma who presents with progressive RUE pain and developing hematoma, as well as subacute onset of lower abdominal pain. She had blood drawn on Monday from her right arm to check her labs. The following day, the patient reported worsening right upper extremity pain and a large developing hematoma. She presented to the ED on Wednesday where an ultrasound did not show evidence of clot, but did show large hematoma. She subsequently saw her PCP the following day where her hematoma was marked out. Yesterday, the patient bumped her arm during a fall and had acute severe pain. In addition, for the preceding 24 hours, she reports progressive abdominal distension, and decreased passage of bowel movements. She usually passes 5 loose stools per day. She has vomited about once per day for the past week she reports as "bilious." Patient does have long standing history of vomiting per pt, and reports worse after methotrexate which she had on Monday. She subsequently came into the ED for evaluation. She complains of low grade fevers ~100 since Tuesday. In the ED, she was told that she had a pneumonia based on CXR. She denies any cough, bloody stools/emesis, chest pain, or shortness of breath. Of note according to GI, she has been on many regimens for her Crohn's disease. Remicade was complicated by Serum Sickness, 6-MP led to leukopenia, and prednisone was complicated by psychosis. In [**Month (only) 205**], she was started on Methotrexate, which she thinks helped her Crohn's symptoms. She was seen in clinic by Dr. [**Last Name (STitle) 79**] on [**10-26**] where she wascomplaining of abdominal pain and diarrhea. At that time, she was started on Entocort at 9mg, as well as Methotrexate. She was also started on Hydromorphone for control of severe pain. Of note, she was admitted in [**8-13**] with a low hematocrit to 23.1. At that time, she was complaining of intermittent bright red blood per stool for several weeks. At that hospitalization, a flex sig was normal to the splenic flexure. In the ED, initial VS were: 98 110 81/58 18 98%RA. On arrival to the MICU, vital signs were T 98.2 HR 99 BP 118/72 RR 11 O2 sat 98% RA patient reported the history above and complained of severe pain in the right arm and mild abdominal pain and distension. She notes that she has not had a bowel movement since Thursday, but has been passing flatus. Review of systems: negative except for above. Past Medical History: 1. Crohn's disease: - Diagnosed [**2079**] - S/p ~13 surgeries including transverse / ascending colectomy - Rectovaginal fistula 2. Short bowel syndrome 3. History of multiple SBOs 4. SVC syndrome s/p angioplasty - ~[**2101**]: episode of facial and neck swelling; noted to have stenoses of right subclavian and SVC - Angioplasty by IR 5. HIT+ Ab: s/p 30 days treatment with Fondaparinux 6. Mediastinal lymphadenopathy NOS: followed by Dr. [**Last Name (STitle) 575**] 7. Pulmonary nodules 8. Hypothyroidism 9. Parathyroid adenoma s/p removal 10. PTSD, particularly active when in hospital setting due to prior assault in hospital setting many years ago 11. Depression & Anxiety 12. Fibromyalgia 13. History of gastric dysmotility; has been on TPN in past 14. History of line/portocath infections (partic w/ coag neg staph) 15. Fatty liver with mildly elevated LFTs at baseline 16. Anemia, iron deficiency 17. S/p TAH BSO 18. S/p cholecystectomy [**23**]. S/p Right knee meniscal surgery [**3-/2114**] 20. S/p Left knee meniscal surgery [**4-/2114**] 21. nephrolithiasis Social History: The patient lives with her husband and she has 5 children (3 biologic, 2 step). She is currently disabled. Used to work as pre-school and kindergarten teacher. Denies any history of tobacco, ETOH or illicit drugs. Family History: Significant for family history of Crohn's disease and osteoarthritis. No reported family history of CAD or DM. Physical Exam: Admission Physical exam: Vitals: T 98.2 HR 99 BP 118/72 RR 11 O2 sat 98% RA Gen: NAD Neck: no masses CV: NR, RR, no murmurs Pulm: CTAB, good air movement, no coughing Abd: distended, soft, +BS Ext: right arm ecchymosis encompassing most of her upper arm, soft, no swelling, no lower extremity edema, Rectal: in ED: guiaic negative Discharge Physical Exam: Vitals: T 98.2 HR 72 BP 120/69 RR 24 O2 sat 100% RA Gen: NAD Neck: no masses, JVP not elevated CV: RRR, no murmurs Pulm: CTAB, good air movement, no coughing Abd: distended, soft, minimally tender to palpation, +BS Ext: right arm ecchymosis encompassing most of her upper arm, soft, no lower extremity edema, full range of motion of elbow and fingers, no numbness Pertinent Results: Admission labs: [**2116-10-31**] 04:30AM BLOOD WBC-4.8 RBC-3.23*# Hgb-8.2*# Hct-24.3*# MCV-75* MCH-25.4* MCHC-33.7 RDW-19.8* Plt Ct-266 [**2116-10-31**] 10:05PM BLOOD WBC-3.9* RBC-3.29* Hgb-8.1* Hct-24.6* MCV-75* MCH-24.6* MCHC-32.8 RDW-20.5* Plt Ct-162 [**2116-10-31**] 04:30AM BLOOD Neuts-77.4* Lymphs-17.3* Monos-2.4 Eos-2.3 Baso-0.5 [**2116-10-31**] 04:30AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-139 K-2.9* Cl-98 HCO3-31 AnGap-13 [**2116-10-31**] 04:30AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.2# Mg-1.7 [**2116-10-31**] 04:30AM BLOOD ALT-17 AST-20 AlkPhos-121* TotBili-0.4 [**2116-10-31**] 05:07AM BLOOD Lactate-1.7 Discharge labs: Team recommended following hematocrit to ensure continued stability, but patient declined due to psychological stressors (see hospital course). Studies: [**2116-10-31**] CXR PA/Lat: 1. Hazy opacity in the right upper lung field is not significantly changed and likely represent an area of chronic airspace disease. Overlying infection cannot be excluded. 2. Nasogastric tube with both side port and the tip above the gastroesophageal junction raised increased risk for aspiration. The tube should be advanced at least 12 cm. [**2116-10-31**] CT Abd/Pelv: There is no retroperitoneal bleed. There is no free air or free fluid. [**2116-10-31**] X-ray shoulder and elbow: No specific radiographic evidence of displaced fracture or dislocation of the right elbow and right shoulder. Soft tissue contusion overlying the right elbow. [**2116-10-31**] KUB 1. Multiple air-fluid levels with dilated loops of bowel suggest small-bowel obstruction. 2. NG tube with both tip and side port above the GE junction should be advanced at least 12 cm. Micro: None Brief Hospital Course: Ms. [**Known lastname 1007**] is a 56 year old woman with Crohn's disease complicated by rectovaginal fistula and multiple SBOs s/p multiple abdominal surgeries, also with prior SVC surgery now on fondaparinux, who was transferred to ICU from ED for hypotension and HCT drop of 15 in past 4 days likely due to her right upper extremity hematoma. # Acute blood loss anemia: Patient had 14 point Hct drop over the course of 5 days (38.7 on [**2116-10-26**] to 24.3 on [**2116-10-31**]). The most likely source of this anemia is acute blood loss from large hematoma in RUE (below) thought to be related to trauma from venipuncture on routine outpatient lab work in the setting of her anticoagulation with fondaparinux. Patient also noted a fall onto right arm as well, which also could have contributed to the large hematoma. Other possible causes of anemia were considered including retroperitoneal bleed, GI losses, or hemolysis, but there was no evidence of RP bleed on CT, NG lavage and guaiac were negative in the ED, and Tbili was normal. Her fondaparinux was discontinued by her PCP on Thursday [**10-30**]. Her hematocrit remained stable at 12 hours (24.6, up from 24.3) and the arm ecchymosis appeard to be resolving. The team recommended trending the hematocrit the following morning to evaluate for continued stability, especially since she would be restarting fondaparinux. Due to the patients psychological stressors from being in the hospital, she declined further lab draws. She understood the risks of declining the lab draw, including the risk of a continued bleed and even death, and she accepted these risks. She did agree to have her blood drawn the following day as an outpatient and to return to the hospital if she experienced any concerning symptoms. # Right Upper Ext Hematoma: Likely due to deep stick in right antecubital fossa on Monday while on fondaparinux for her SVC surgery in [**2115**]. Patient stopped her fondaparinux Thursday per PCP. [**Name10 (NameIs) **] evidence of compartment syndrome on exam and she remained neurovascularly intact. The ecchymosis had spread far beyond the markings drawn by PCP, [**Name10 (NameIs) **] hematocrit remained stable (24.3 on admission to 24.6 approx 12 hours later), and the ecchymosis improved while hospitalized. She was seen by vascular surgery who felt she should restart her fondaparinux on Sunday [**11-1**] given that there was no longer evidence of active bleeding. She declined further lab draws (as above), but agreed to have blood drawn as outpatient within 1-3 days. # Partial SBO: Patient has history of Crohn's disease and has had multiple bowel obstructions and surgeries. Last abdominal surgery was [**2112**] per pt. One day prior to admission patient reported progressive abdominal distension and decreased passage of bowel movements. Patient self placed an NGT on arrival to the ED. KUB showed distended loops and air fluid levels concerning for obstruction, and CT revealed large amount of stool in the colon with no evidence of free air or transition point. She was passing flatus throught. Surgery was consulted and felt that no surgical intervention was indicated. Of note, patient ate solid foods including a hamburger in the ED and oatmeal for breakfast the following morning while advised to be NPO. She self-discontinued her NGT after having a bowel movement. # Hypotension: Patient had isolated blood pressure [**Location (un) 1131**] in the 80s systolic, otherwise remained in the 90s-100s. The most likely source of her hypotension is poor po intake in the setting of vomiting and diarrhea. On the differential would be hypovolemia secondary to acute blood loss from hematoma in arm (above). Sepsis is unlikely given that she has afebrile without leukocytosis, and her BPs have stabilized and the remainder of her vitals are normal. She responded well to IV fluids and did not require pressors. Her home antihypertensives were held on admission and restarted on discharge. # Right apical lung opacity: Patient with RUL opacity on CXR in ED. This has been noted on multiple prior CXRs and CTA on [**2116-8-12**]. She was given one dose of levofloxacin emperically in the ED, but there was no concern for infection on the floor and this was discontinued. This opacity has been followed by Dr. [**Last Name (STitle) 575**] and dates back to at least [**2110**]. CT stability documented and there is no acute change to suggest infection or malignancy. This can be followed by xray only unless change or symptoms are noted. # Pain Management: Patient's home pain regimen had been escalated by PCP given pain from hematoma (above) to 4-8 mg dilaudid PO Q4H prior to admission. Of note, she is on a narcotics contract with her PCP. [**Name10 (NameIs) **] was transitioned to IV dilaudid while in house given the partial bowel obstruction (above) and also requested 50 mg IV benadryl for itching. When her partial bowel obstruction resolved and she self-discontinued her NGT, she was transitioned back to PO pain medications. # Crohn's disease: Diagnosed [**2079**]. S/p ~13 surgeries including transverse / ascending colectomy with ostomy reversal in [**2096**]. History of rectovaginal fistula and short bowel syndrome. She is currently on methotrexate and Entocort. Initially complianing of abdominal pain and distension on admission with KUB concerning for obstruction. Patient symptoms resolved the morning after admission following a bowel movement. # SVC syndrome s/p angioplasty: Patient noticed episodes of facial and neck swelling in [**2101**]. She was noted to have stenoses of right subclavian and SVC and underwent angioplasty by IR in [**2115**]. She has been anticoagulated as outpatient on fondaparinux, though this was held by PCP two days prior to admission. She was seen by vascular surgery while in house and they recommended restarting fondaparinux on Sunday [**11-1**] given apparent stability of RUE hematoma. # Hypothyroidism: Stable. Euthyroid on exam, home levothyroxine 50mcg po daily was continued. # Hypertension: Home antihypertensives were held on admission given transient hypotension (above) and were restarted on discharge. # Depression/Anxiety/PTSD # Fibromyalgia: Stable. # Poor IV access: Unable to have central line. Her only access on admission was a 20G peripheral in R axilla. If she needs emergency access, she will require intraosseous access. # Hx HIT: Avoid all heparin products. # Transitional issues: - Patient should have hematocrit checked within 1-3 days of discharge to monitor for stability (last hct 24.6) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**]. 1. Ondansetron 8 mg PO BID:PRN nausea 2. Budesonide 3 mg PO DAILY 3. Magnesium Oxide 500 mg PO ONCE Duration: 1 Doses 4. Methotrexate Sodium P.F. 25 mg IT 1X/WEEK (MO) Duration: 1 Doses 5. Oxazepam 30 mg PO HS:PRN anxiety, insomnia 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm, not with narcotics/sedating meds 8. Amlodipine 2.5 mg PO DAILY 9. Fondaparinux Sodium 7.5 mg SC DAILY 10. HYDROmorphone (Dilaudid) 4-8 mg PO Q4H:PRN pain 11. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain 12. Promethazine 25 mg PO BID:PRN nausea 13. Nystatin Oral Suspension 5 mL PO TID:PRN thrush swish and swallow 14. Potassium Chloride 20 mEq PO BID Duration: 24 Hours Hold for K >4 15. Duloxetine 60 mg PO DAILY 16. Hydrochlorothiazide 12.5 mg PO QAM 17. Levothyroxine Sodium 50 mcg PO DAILY 18. Vitamin D 1000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Budesonide 3 mg PO DAILY 2. Duloxetine 60 mg PO DAILY 3. Fondaparinux Sodium 7.5 mg SC DAILY 4. HYDROmorphone (Dilaudid) 4-8 mg PO Q4H:PRN pain 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Oxazepam 30 mg PO HS:PRN anxiety, insomnia 7. Amlodipine 2.5 mg PO DAILY 8. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm, not with narcotics/sedating meds 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Hydrochlorothiazide 12.5 mg PO QAM 11. Nystatin Oral Suspension 5 mL PO TID:PRN thrush swish and swallow 12. Ondansetron 8 mg PO BID:PRN nausea 13. Promethazine 25 mg PO BID:PRN nausea 14. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain 15. Vitamin D 1000 UNIT PO 1X/WEEK (MO) 16. Cyanocobalamin 500 mcg PO QWEEK 17. FoLIC Acid 1 mg PO DAILY 18. Magnesium Oxide 500 mg PO DAILY 19. Methotrexate Sodium P.F. 25 mg IT 1X/WEEK (MO) Duration: 1 Doses 20. Potassium Chloride 20 mEq PO BID Duration: 24 Hours Hold for K >4 21. Outpatient Lab Work Please draw hematocrit and have result faxed to Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3382**]. ICD9 = 285.9. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Right upper extremity hematoma, Partial small bowel obstruction, Secondary diagnosis: Crohn's disease, Heparin induced thrombocytopenia, SVC syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to take care of during your stay at [**Hospital1 18**]. You were admitted for a collection of blood in your right arm. Your fondaparinaux was temporarily stopped while your blood levels stabilized. The fondaparinaux was then resumed. Please keep your arm elevated and have your blood levels drawn tomorrow at [**Hospital1 **]. In addition, your bowels slowed down and caused you to have a partial obstruction. You placed a nasogastric tube to help relieve the pressure and were able to have a bowel movement. You tolerated a diet prior to discharge. There were no changes made to your medication regimen. Followup Instructions: Please have your labs drawn tomorrow to check your blood level. Please follow up with your primary care physician within one week. Please follow up with your gastroenterologist, Dr. [**Last Name (STitle) 79**].

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4504

Discharge summary

report

Admission Date: [**2105-4-8**] Discharge Date: [**2105-5-1**] Service: MEDICINE Allergies: Doxycycline Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. intubation 2. Tracheostomy 3. PEG tube placement History of Present Illness: [**Age over 90 **]y/o F with h/o COPD on home O2 presents with acute SOB, hypercarbia requiring intubation. Per son, was doing ok at baseline (never leaves house, on 3L NC, on nebs) until 2-3 days ago, when she developed worsening SOB. No cough or fever. No chest pain or URI symptoms. On transfer, was breathing at 40, BiPAP attempted with sats in 90s. Initial ABG 7.28/85/449 (on BiPAP), decision made to intubate. Started on propofol and SBP dropped to 50s systolic - D/C'ed propofol and gave fluid bolus, pressures improved. Pt switched to fentanyl/versed. Also given IV solumedrol. Fem TLC placed. Past Medical History: 1. COPD on home O2 (3L NC); [**1-8**] PFTs FEV1 0.64, FVC 0.74, FEV1/FVC 86 2. hypertension 3. colon ca s/p resection [**2097**] 4. seizure secondary to SIADH 5. dementia 6. anxiety 7. DJD 8. iron deficiency anemia 9. echo [**1-9**] - EF nl, mod PA HTN, TR AR Social History: Lives with children, son is health care proxy. 20 p/y history of tobacco. Denies alcohol/drugs. Very inactive - baseline is that does not leave house. Family History: Notable for tuberculosis and lung cancer (per prior discharge summaries). Physical Exam: On admission: T 99.9 105/42 109 14 99% on AC 500x14 PEEP 5 50% Gen: sedated, intubated HEENT: PERRL, EOMI CV: RRR, nl S1/S2, no murmurs, JVP not elevated Pulm: CTAB Abd: soft, NT/ND, +BS Ext: trace edema, R > L, new fem line Neuro: sedated Pertinent Results: [**2105-4-8**] 12:40PM PT-12.2 PTT-25.3 INR(PT)-0.9 [**2105-4-8**] 12:40PM PLT COUNT-348 PLTCLM-1+ [**2105-4-8**] 12:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2105-4-8**] 12:40PM NEUTS-84* BANDS-7* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2105-4-8**] 12:40PM WBC-25.8*# RBC-4.27 HGB-12.7 HCT-38.8 MCV-91 MCH-29.8 MCHC-32.8 RDW-12.9 [**2105-4-8**] 12:40PM OSMOLAL-281 [**2105-4-8**] 12:40PM CALCIUM-10.1 PHOSPHATE-4.5 MAGNESIUM-1.7 [**2105-4-8**] 12:40PM CK-MB-5 [**2105-4-8**] 12:40PM cTropnT-0.01 [**2105-4-8**] 12:40PM CK(CPK)-103 [**2105-4-8**] 12:40PM GLUCOSE-169* UREA N-16 CREAT-0.6 SODIUM-130* POTASSIUM-5.0 CHLORIDE-86* TOTAL CO2-38* ANION GAP-11 [**2105-4-8**] 12:56PM PO2-449* PCO2-85* PH-7.28* TOTAL CO2-42* BASE XS-9 [**2105-4-8**] 02:02PM LACTATE-2.2* [**2105-4-8**] 02:50PM URINE MUCOUS-MOD [**2105-4-8**] 02:50PM URINE AMORPH-MANY [**2105-4-8**] 02:50PM URINE RBC-[**7-17**]* WBC-[**4-11**] BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-0-2 RENAL EPI-0-2 [**2105-4-8**] 02:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2105-4-8**] 02:50PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2105-4-8**] 05:18PM O2 SAT-98 [**2105-4-8**] 05:18PM LACTATE-1.1 [**2105-4-8**] 05:18PM TYPE-ART PO2-157* PCO2-56* PH-7.39 TOTAL CO2-35* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED [**2105-4-8**] 07:15PM URINE AMORPH-OCC [**2105-4-8**] 07:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2105-4-8**] 07:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2105-4-8**] 07:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2105-4-8**] 07:15PM URINE OSMOLAL-424 [**2105-4-8**] 07:15PM URINE HOURS-RANDOM CREAT-16 SODIUM-88 [**2105-4-8**] 07:16PM PLT COUNT-237 [**2105-4-8**] 07:16PM NEUTS-95.8* BANDS-0 LYMPHS-2.1* MONOS-1.9* EOS-0 BASOS-0.1 [**2105-4-8**] 07:16PM WBC-21.9* RBC-3.38* HGB-9.9* HCT-30.4* MCV-90 MCH-29.2 MCHC-32.5 RDW-12.8 [**2105-4-8**] 07:16PM CALCIUM-8.1* PHOSPHATE-2.9# MAGNESIUM-1.4* [**2105-4-8**] 07:16PM GLUCOSE-226* UREA N-13 CREAT-0.7 SODIUM-132* POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-35* ANION GAP-7* [**2105-4-8**] 09:07PM LACTATE-1.4 [**2105-4-8**] 09:07PM TYPE-ART PO2-138* PCO2-47* PH-7.44 TOTAL CO2-33* BASE XS-7 INTUBATED-INTUBATED [**2105-4-8**] 11:50PM LACTATE-1.5 [**2105-4-8**] 11:50PM TYPE-ART RATES-/12 TIDAL VOL-500 O2-40 PO2-130* PCO2-51* PH-7.42 TOTAL CO2-34* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED CT Abdomen ([**4-17**]) - CT of the abdomen with contrast: There are emphysematous changes at both lung bases. There are small bilateral pleural effusions and bibasilar dependent atelectasis. The liver and spleen are normal. The pancreas and adrenal glands are normal. Both kidneys and ureters are normal. There is stable dilatation of the extrahepatic bile ducts and common bile duct. There are multiple lymph nodes in the mesentery, not meeting pathologic criteria and size. There are atherosclerotic calcifications of the aorta and its branches. The loops of small bowel are distended, but do not display wall thickening or transition point. There is diastasis of the anterior abdominal musculature, but no definite hernia. The colon is markedly abnormal. The most prominent abnormality is seen within the cecum and ascending colon with marked wall thickening, edema, and adjacent stranding. There is also free fluid adjacent to the right colon. There is a normal appearing hepatic flexure. The rest of the transverse colon also displays wall thickening, however. The descending colon is also abnormal, but to a lesser degree with less wall thickening and adjacent free fluid. The terminal ileum is relatively spared. The SMA, celiac axis, are normal. The [**Female First Name (un) 899**] is not discretely identified. There may be some air within the wall of the right colon, but this is difficult to definitively assess. No free air within the abdomen. No portal venous air. CT of the pelvis with contrast: There is free fluid within the pelvis. There is a rectal tube and a Foley catheter. The uterus and adnexa are normal. No inguinal lymphadenopathy. CTA Chest ([**2105-4-8**]) - CT OF THE CHEST: There are no significant axillary or mediastinal lymph nodes. There are enlarged hilar lymph nodes bilaterally. The largest one on the right side measures 2.2 x 1.3 cm. Evaluation of the pulmonary arteries was optimal. There is a single filling defect in the subsegmental branch going to the apical segment of the right upper lobe. This finding is consistent with a tiny pulmonary embolism. No other filling defects were seen. There is no CT evidence of pulmonary artery hypertension. Lung windows demonstrate severe emphysematous changes with bullae of varying sizes. There are lung nodules. One is 6 mm and is located in association with an area of pleural thickening. There are multiple calcified granulomas throughout the lungs. Another small noncalcified opacity in the right upper lobe measures 2 x 6 mm (series 2 image 31). Another noncalcified pleural based opacity is seen on series 2 image 131 and measures 6 mm. Another noncalcified opacity in the lingula measures 6 mm (series 2B image 39). Another noncalcified pleural based opacity (series 3 image 48) measures 6 x 9 mm. Although this most likely represents granulomatous changes follow-up is recommended. There are areas of septal thickening in the left lower lobe which are slightly nodular and could represent lymphangitic spread of tumor or an acute infection. Follow-up is definitely recommended. Below this area there is a patchy area of air space disease that may represent an acute infectious process. However, follow-up is also recommended for this area. Brief Hospital Course: ## hypercarbic respiratory failure - pt's respiratory failure was thought to be likely due to COPD exacerbation. Underlying precipitant was most likely pneumonia, as pt had a retrocardiac opacity on CXR. Pt was ruled out for influenza with a negative DFA. She was started on ceftriaxone/azithromycin. Sputum cultures grew out Moraxella catarrhalis. Due to her respiratory failure, she was intubated in the ED and admitted to the [**Hospital Unit Name 153**]. She was continued on the above antibiotics for total 8 day course, as well as IV solumedrol, after which she was changed to a po prednisone taper via her OG tube. Patient was kept on standing 10mg IV solumedrol after she was made NPO for colitis, and eventually 10mg prednisone per PEG tube. She was placed on standing albuterol and atrovent nebs. Pt initially had a respiratory alkalosis, which was concerning given that she is a CO2 retainer at baseline (bicarb 38 at baseline). Her RR was decreased to 10, and she was kept mainly on AC 500x10 PEEP 5 FIO2 40%. It was somewhat difficult to wean her, patient improved and was eventually weaned to PS. Patient was exubated and initially did well however throughout the day patient with poor ventilation and (after discussion with son) was re-intubated. It was felt that patient failed exuabtion secondary to fatigue and muscle weakness. Initially the family did not want the patient to get a tracheostomy. However after having a family meeting and explaination that it would be very difficult to wean off patient without tracheostomy the patient and family agreed to have both tracheostomy and PEG tube. After tracheostomy patient continued to do very well on pressure support which was slowly weaned down as tolerated. Patient also was also fitted for passy-muir valve. It is recommended that patient have follow up CT scan of chest to assess any change in calcified lesions seen on CTA done on [**2105-4-8**] ## Colitis - Patient during ICU course developed abdominal distension. A KUB was performed which showed dialated large bowel upto rectum full of air. Patient was disempacted and GI was consulted. Patient had a CT abdomen which showed colonic thickening in ascending/transverse colon with stranding, pelvic fluid, and possible air in wall of gut. Surgery was notified and stated that surgery was not indicated based on CT results. GI stated to medically treat patient for C. diff. Patient was started on IV flagyl and PO vanc for empiric C. diff colitis as well as levo for coverage of other gut flora. Patient's WBC count continued to rise as high as 49K but trended back down once started on abx. Patient's tube feeds and bowel regimine were stopped and TPN initiated. Patient's C. diff toxin came back negative however given high WBC, CT findings, and previous abx course for PNA felt that patient had C. diff colitis. She contiued to improve while on 14 day course of antibiotics however continued to have diarrhea. After PEG tube was placed patient developed guiac postive stools, and her Hct continued to trend down. GI was consulted who recommended to follow serial Hct and transfuse as neccessary. Patient responded appropriately to blood transfusions. Patient will need an outpatient colonoscopy in the near future. ## Pulmonary embolus - A small subsegmental PE was noted on CT angio performed in the ED. This was thought to be unlikely to be a major contributor to pt's respiratory status, as it was small in size. Nonetheless, she was started on heparin, and initially begun on po coumadin. It was decided, however, that due to the small size of her PE, and the risks of lifelong anticoagulation in this elderly female with some risk to fall, that we would treat her PE with 10 days of heparin and not anticoagulate her orally with coumadin. Patient recieved a total of 8 days of anit-coagulation that was discontinued early secondary to colitis and drop in Hct. ## Glycemic control - Pt's fingersticks were checked 4x/day. She was noted to be hyperglycemic, and 8 units of glargine was added to her regimen, her glargine was gradually increased as needed since her blood sugars remained high even though her steroids were tapered. ## FEN - An OG tube was placed. Tube feeds were begun for nutrition. Once patient developed abdominal distention and concern for colitis she was switched to TPN. After the PEG tube was placed tube feeds were again initiated. ## Code - DNR. Code discussion was had with family, as she was not as easily extubatable as she had been during previous admissions. It was conveyed to the family that her lung disease was severe, and family agreed to a DNR code. ## Communication - with son, health care proxy Medications on Admission: prednisone 20mg po daily ditropan protonix 40mg po daily combivent inhaler albuterol nebs atrovent nebs advair lorazepam Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours). 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous once a day. 9. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1) PO twice a day. 10. Fluticasone Propionate 220 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: COPD Pnuemonia C. diff colitis Discharge Condition: Stable - Patient still on ventilator however improving as patient getting stronger. Patient with recovering colitis, still with loose stools, however improving. Discharge Instructions: Please follow up with your primary care doctor 1-2 weeks after discharge from rehabilitation facility Followup Instructions: Please setup appointment with [**Hospital1 18**] Gastroenterology to have outpatient colonoscopy performed in the near future. ([**Telephone/Fax (1) 19233**] Please follow up with your primary care doctor soon after discharge from rehab facility. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V15.82", "294.8", "486", "276.1", "008.45", "458.9", "560.39", "300.00", "556.9", "415.19", "518.81", "280.9", "428.0", "280.0", "V10.06", "578.9", "491.21", "401.9" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.38", "38.91", "96.6", "43.11", "88.43", "99.15", "38.93", "99.04", "96.05", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

13497, 13576

7698, 12415

244, 297

13651, 13814

1775, 7675

13965, 14352

1416, 1491

12586, 13474

13597, 13630

12441, 12563

13838, 13942

1506, 1506

185, 206

325, 938

1520, 1756

960, 1229

1245, 1400

16,881

118,527

3716+3717

Discharge summary

report+report

Admission Date: [**2164-10-5**] Discharge Date: [**2164-10-10**] Date of Birth: [**2091-1-9**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male who presented with recurrent right renal cancer. PAST MEDICAL/SURGICAL HISTORY: Included coronary artery disease, an MI in [**2158**], end stage renal disease, left nephrectomy for a right cell cancer with mets to the abdomen with post chemotherapy. A CABG in [**2163-3-30**], non-insulin dependent diabetes mellitus, hypercholesterolemia, GERD and a heart cath in [**7-29**] of two vessel disease preoperatively. In [**2158**] he had a penile tumor and in [**2158**] he had an upper GI bleed. MEDICATIONS: At home include Aspirin, Lipitor 20 mg once a day, Nephrocaps one capsule once a day, Glyburide 2.5 mg once a day, Plavix 75 mg once a day, Protonix 40 mg once a day, Ativan 1 mg q h.s. prn, Coreg 6.5 mg [**Hospital1 **], Periostat 20 mg [**Hospital1 **] and TUMS 500 mg [**Hospital1 **]. ALLERGIES: CT contrast and Morphine. LABORATORY DATA: Preoperative labs were a BMP of 131, 5.9, 88, 20, 84, 9.2 and 92. CBC 5.5, 38.6 and 174 and 721, coag profile with PT 13, PTT 27.2 with INR of 1.1. EKG revealed sinus rhythm with evidence of an old inferolateral infarct with a normal QT interval. HOSPITAL COURSE: The patient was brought in for same day surgery under Dr.[**Name (NI) 6444**] service in neurology, [**2164-10-5**] for a right nephrectomy. During the course of the operation he received 6000 crystalloid and 2 units of packed red blood cells. He stayed in the PACU and the ICU until [**2164-10-6**] and on [**10-7**] he was transferred back to the floor. Pre-operatively nephrology and dialysis were alerted of his presence so that dialysis could begin in the hospital. Dialysis was begun three days a week, Tuesday, Thursday and Saturday. His potassium drawn just before the operation was 5.6. During the rest of his hospital course the potassium was never above 5 while on dialysis. Patient did well postoperatively and was given three doses of Ancef perioperatively. His medications during his hospital stay will be stated at the end of the dictation. He was transferred from the PACU to the ICU and then transferred back to the dialysis floor on [**5-5**]. His labs were stable and he was slowly advanced over the course of his admission to a renal [**Doctor First Name **] 2100 calorie diet which he tolerated well. He started to pass flatus on postoperative day #3. He remained afebrile for the course of his admission and no distress whatsoever and dialysis was instrumental in helping us to care for him. His medications during his stay here were Zofran 4 mg IV q 4 hours prn, Ancef three doses periodically, 1 gm q 6-8 hours, sliding scale insulin, Droperidol .625 mg IV q 4-6 hours prn, Ativan 1 mg q h.s., Lipitor 20 mg once a day, Coreg 6.25 mg [**Hospital1 **], Nephrocaps one once a day, Captopril 12.5 mg tid, Prevacid 15 mg once a day, Percocet and Colace. The patient was discharged on [**10-9**]. The patient did not desire any pain medications despite an offer for Percocet at home. The patient is to follow-up with Dr. [**Last Name (STitle) 365**] in clinic as well as nephrology for his dialysis and treatment. DISCHARGE MEDICATIONS: Patient was discharged home to resume his medications same as preoperatively. The patient refused any narcotic pain killers to take home. He claimed he had Percocet at home with Colace. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 12485**], MD [**MD Number(1) 12486**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2164-10-9**] 08:12 T: [**2164-10-11**] 20:46 JOB#: [**Job Number 16759**] & [**Numeric Identifier 16760**] Admission Date: [**2164-10-5**] Discharge Date: [**2164-10-10**] Date of Birth: [**2091-1-9**] Sex: M Service: SECOND ADDENDUM: Patient was kept until [**2164-10-10**] for additional Dialysis this a.m. Discharged and follow-up with Urology and Nephrology. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 12485**], MD [**MD Number(1) 12486**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2164-10-13**] 20:48 T: [**2164-10-13**] 20:48 JOB#: [**Job Number 16761**]

[ "272.0", "189.0", "416.0", "250.00", "585", "V45.81", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95", "55.51" ]

icd9pcs

[ [ [] ] ]

3292, 4331

1318, 3268

156, 1300

9,030

166,387

3724

Discharge summary

report

Admission Date: [**2128-4-11**] Discharge Date: [**2128-4-16**] Date of Birth: [**2068-7-14**] Sex: M Service: MEDICINE Allergies: Oxycodone / Zanaflex Attending:[**First Name3 (LF) 2387**] Chief Complaint: s/p fall with loss-of-consciousness. Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: This is a 59 year-old male with a history of CAD, seizure disorder, remote PE off of anticoagulation, peripheral [**First Name3 (LF) 1106**] disease with left BKA, Interstitial lung disease NOS with radiographic evidence of emphysema and is on 2L Home O2, who presents with fall with resultant head injury and loss-of-consciousness, followed by chest discomfort upon regaining consciousness. Patient was in usual state of health until 17:00 on [**2128-4-10**] when he was reaching toward a top shelf in his apartment, states he lost his balance, and fell, remembers landing on his left lower extremity stump, remembers hitting his head, and losing consciousness. Prior to loss-of-consciousness, patient denied any presyncope/lightheadedness, palpitations, shortness of breath, or chest discomfort. He awoke spontaneously approximately at 19:15 and noticed a sharp epigastric discomfort, [**5-25**], non-radiating, associated with nausea and shortness of breath, that was relieved 30 minutes later after taking 1 sublingual nitroglycerin. Patient continued to have severe pain in his left-lower extremity stump. He had another episode of chest discomfort at 03:00 on [**2128-4-11**] that resolved in 45 minutes with 3 sublingual nitroglycerin. Subsequently, this morning, because the pain in his left-lower extremity continued to persist and was severe, patient called his brother who [**Name2 (NI) 4662**] him to the emergency room. . In the ED, initial vitals were T:98.9, BP:79/48, HR:90, RR:14, O2Sat:93% on 4L. He was found to have acute renal failure, creatinine 0.9=>3.6 and was given 2 litres of normal saline. Given the head trauma, CT head showed no acute intracranial pathology. Also, patient had transaminitis and gall bladder ultrasound was performed. VQ scan was performed given history of PE and inability to perform CTA due to renal insufficiency. Left knee plain film was also obtained. Given elevation of troponin and Creatinine Kinase, outpatient cardiology coverage for Dr. [**Last Name (STitle) **] (Dr. [**Last Name (STitle) 16801**] was notified and advised against initiating heparin at this time given marked impairment in renal function making troponin unreliable, and small MB index despite large CK elevation, suggesting against cardiac aetiology of biomarker elevation. Patient's lactate was checked in the ED and came down from 4.1=>2.6 after 2 litres of fluid. He was given 1 dose of levofloxacin 750mg for possible infiltrate on chest x-ray. Also given ASA 325 mg PO x1 and Morphine 2 mg IV x1. SBP improved to 110-140 after 2 L NS. He was noted to be guaiac positive. . He reports that he has had no chest pain since [**4-10**]. He denies SOB but does report DOE after [**12-17**] blocks. He denies PND and orthopnea (but chronically useas 2 pillow at night). He denies ankle edema. He reports pain in his L BKA. . ROS: The patient denies any fevers, chills, weight change, vomiting, diarrhea, constipation, melena, hematochezia, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, vision changes, headache, rash or skin changes. Past Medical History: #. ? Interstitial lung disease - Per [**5-/2127**] discharge summary, clinically diagnosed due to persistent hypoxia. No biopsy has been performed. On O2 at night since [**5-22**]. #. CAD - s/p 1v CABG in [**2111**] (SVG -> RCA), occluded RCA and SVG->RCA graft on Cath in [**1-20**] and RCA fills w/ collaterals - PCI to LAD(3.0x23 Cypher) in [**8-20**] and OM1(2.5x15 Vision-BMS) in [**5-/2127**] #. PVD s/p Right femoral to dorsalis pedis vein graft, L. femoral-peroneal bypass, right femoral-DP vein graft bypass, and left BKA, Excision of vein graft and aneurysm of the right common femoral artery with proximal vein bypass with interposition segment of nonreversed right basilic vein. Cath [**8-20**] showed LSFA stents were totally occluded with collaterals supplying the distal extremity via the LPFA which was diffusely diseased, s/p successful PTCA and rheolytic thrombectomy of the left popliteal and s/p successful stenting of the proximal left peroneal artery with a 3.5 x 23 mm cypher DES in [**9-18**], s/p successful stenting of the [**Female First Name (un) 7195**] with a 9.0 x 38 mm Dynalink self-expanding stent post-dilated with a 8.0 mm balloon. #. h/o CVA with mild R sided weakness, which has resolved with occlusion of the right distal carotid. #. Emphysema on chest CT, no PFTs on record #. Hypercholesterolemia #. Total thyroidectomy for thyroid CA with resultant hypothyroidism #. Bilateral inguinal hernia repair #. History of seizures #. PE [**11-20**] on coumadin ->on oxygen at night since then, baseline 2-4 L NC #. History of stroke in [**2116**] with left-sided weakness, which has resolved with occlusion of the right distal carotid. #. Seizure disorder #. H/o SVT, s/p ablation #. Ischemic neuropathy Social History: He denies alcohol use. He smoked 1 ppd for 20 years but quit in [**2126**]. Lives alone with multiple family members living nearby. Formerly worked as a computer systems engineer but had to retire in [**2109**] due to multiple surgeries and medical problems. Currently on disability. Reports asbestos exposure for 7 years at a building he worked at. Family History: Noncontributory, sister with history of ruptured cerebral aneurysm at age 48. Physical Exam: Vitals: T:98.8 BP:107/70 HR:86 RR:12 O2Sat:92% on 5L NC GEN: Chronically ill-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, TTP in epigastrium, +BS, no HSM, no masses EXT: left BKA stump markedly tender, no oedema, warm, good capillary refill. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: LABS: [**2128-4-11**] 11:05AM BLOOD WBC-10.4 RBC-5.43# Hgb-16.7# Hct-48.6# MCV-89 MCH-30.8 MCHC-34.5 RDW-16.3* Plt Ct-120*# [**2128-4-16**] 07:40AM BLOOD WBC-6.2 RBC-4.58* Hgb-14.1 Hct-42.2 MCV-92 MCH-30.7 MCHC-33.3 RDW-16.1* Plt Ct-112* [**2128-4-11**] 11:05AM BLOOD Neuts-81.8* Lymphs-13.6* Monos-4.4 Eos-0.1 Baso-0.1 [**2128-4-11**] 11:05AM BLOOD PT-28.3* PTT-39.8* INR(PT)-2.8* [**2128-4-16**] 07:40AM BLOOD PT-13.5* PTT-33.0 INR(PT)-1.2* [**2128-4-11**] 10:54AM BLOOD Glucose-104 UreaN-33* Creat-3.6*# Na-141 K-5.4* Cl-97 HCO3-19* AnGap-30* [**2128-4-16**] 07:40AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-140 K-3.9 Cl-96 HCO3-35* AnGap-13 [**2128-4-11**] 11:05AM BLOOD ALT-2704* AST-4145* CK(CPK)-1427* AlkPhos-142* TotBili-1.7* [**2128-4-11**] 07:02PM BLOOD ALT-2888* AST-4099* LD(LDH)-3344* CK(CPK)-1224* AlkPhos-119* TotBili-1.4 DirBili-0.6* IndBili-0.8 [**2128-4-16**] 07:40AM BLOOD ALT-546* AST-96* CK(CPK)-83 AlkPhos-98 TotBili-1.4 [**2128-4-11**] 11:05AM BLOOD Lipase-168* [**2128-4-12**] 04:16AM BLOOD Lipase-89* [**2128-4-11**] 11:05AM BLOOD CK-MB-51* MB Indx-3.6 proBNP-[**Numeric Identifier 16802**]* [**2128-4-11**] 11:05AM BLOOD cTropnT-2.96* [**2128-4-11**] 07:02PM BLOOD CK-MB-47* MB Indx-3.8 cTropnT-3.41* [**2128-4-12**] 04:16AM BLOOD CK-MB-34* MB Indx-3.8 cTropnT-2.57* [**2128-4-13**] 05:14AM BLOOD CK-MB-11* MB Indx-5.3 cTropnT-1.85* [**2128-4-14**] 03:42AM BLOOD CK-MB-NotDone cTropnT-2.14* [**2128-4-15**] 04:26AM BLOOD CK-MB-NotDone cTropnT-2.15* [**2128-4-16**] 07:40AM BLOOD CK-MB-NotDone cTropnT-1.45* [**2128-4-11**] 11:05AM BLOOD Calcium-8.2* Phos-6.7*# Mg-2.2 [**2128-4-15**] 04:26AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.2 [**2128-4-11**] 07:02PM BLOOD VitB12-GREATER TH Hapto-137 [**2128-4-11**] 07:02PM BLOOD TSH-0.024* [**2128-4-11**] 07:02PM BLOOD T3-61* Free T4-1.7 [**2128-4-12**] 04:16AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2128-4-11**] 11:05AM BLOOD Osmolal-301 [**2128-4-11**] 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2128-4-12**] 04:16AM BLOOD HCV Ab-NEGATIVE [**2128-4-11**] 11:54AM BLOOD Lactate-4.1* [**2128-4-12**] 04:53AM BLOOD Lactate-1.2 [**2128-4-11**] 01:10PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2128-4-11**] 01:10PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [**2128-4-11**] 01:10PM URINE RBC-<1 WBC-[**2-18**] Bacteri-OCC Yeast-NONE Epi-[**2-18**] [**2128-4-11**] 01:10PM URINE CastGr-0-2 CastHy-0-2 [**2128-4-11**] 01:10PM URINE Eos-NEGATIVE [**2128-4-11**] 01:10PM URINE Hours-RANDOM UreaN-232 Creat-178 Na-46 K-49 Cl-25 [**2128-4-11**] 01:10PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . MICRO: Blood Culture ([**4-11**]): No Growth x2 . IMAGING: ECG: Sinus rhythm at 94 bpm, normal axis and intervals, normal R-wave progression, Q-waves in inferior leads, Biphasic T-waves in precordial leads same compared to prior dated [**2127-10-22**]. . CXR Portable ([**2128-4-11**]): IMPRESSION: 1. Diffuse reticular density at both lung bases which might represent interstitial lung disease. No focal consolidation is noted. 2. Lingular atelectasis is unchanged. . VQ Scan ([**2128-4-11**]): IMPRESSION: In absence of ventilation imaging and known chest radiograph findings the perfusion abnormalities are indeterminate/intermediate probability for PE. . Head CT ([**2128-4-11**]): IMPRESSION: No acute intracranial pathology. . RUQ Ultrasound ([**2128-4-11**]): IMPRESSION: 1. Unremarkable right upper quadrant ultrasound with no focal hepatic lesions or fatty infiltration identified. 2. Mild splenomegaly, unchanged. . L Knee Films ([**4-11**]): IMPRESSION: Little change in the below-the-knee amputation with patchy demineralization about the knee. . EEG ([**4-12**]): IMPRESSION: This is an abnormal portable EEG due to the slow and disorganized background admixed with bursts of generalized delta frequency slowing. This constellation of findings is consistent with a mild to moderate encephalopathy suggesting dysfunction of bilateral subcortical or deep 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. . TTE ([**4-12**]): The left atrium is 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. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal images. Unable to adequately assess for source of embolism. Bubble study could not be interpreted due to poor windows. LV systolic function appears grossly normal. The right ventricle is dilated and hypokinetic. No significant valvular abnormality seen. . MRI Head/MRA Brain ([**4-12**]): 1. No evidence of acute infarct. 2. Chronic right ICA occlusion, level unknown. The right MCA is patent, filling through the anterior and posterior communicating arteries. 3. Multiple periventricular FLAIR hyperintensities, for which the differential diagnosis is broad. In a large percentage of these patients, no cause is identified for these abnormalities. They can also be due to small vessel infarction, demyelinating disease, infection including Lyme disease, and occasionally seen in patients with migraine headaches. . Renal Ultrasound ([**4-12**]): 1. No renal mass lesion or hydronephrosis. 2. Cholelithiasis. . CT Left Lower Extremity ([**4-12**]):IMPRESSION: 1. Findings most consistent with diffuse osteopenia in this patient status post below-the-knee amputation. No displaced fracture. 2. Mild patellofemoral compartment osteoarthritic change. 3. Small joint effusion. . Cardiac Catheterization ([**4-13**]): COMMENTS: 1. Coronary angiography of this right dominant system revealed minimal disease of the LMCA, widely patent prior LAD stents, mild restenosis of OM1, and 100% occluded RCA that fills via LCx collaterals. 2. Arterial bypass angiography revealed 100% occluded SVG->R-PDA. 3. Resting hemodynamics revealed elevated and equalized right and left sided filling pressures with RVEDP, mean PCWP, and LVEDP of 20 mm Hg. PASP was severely elevated at 71 mm Hg. Systemic arterial pressure was moderately elevated. Cardiac index was preserved at 2.7 l/min/m2. 4. Left ventriculography revealed 1+ mitral regurgitation and LVEF of 50% with inferior hypokinesis. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent prior LAD stent, mild restenosis of OM1 stent. 3. Occluded SVG-->R-PDA. 4. Severely elevated right heart pressures and pulmonary hypertension. 5. Equalization of left and right sided filling pressures with possible restrictive vs. constrictive physiology. . CTA Chest ([**4-15**]): IMPRESSION: 1. No pulmonary embolism. 2. Left lower lobe pneumonia. 3. Mild pulmonary edema. 4. Spiculated nodule in the superior segment of the left lower lobe, with interval growth. This is concerning in the background of centrilobular emphysema and is too small to biopsy. A short interval followup is recommended. . TTE ([**4-16**]): The left atrium is normal in size. 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 grossly normal (LVEF 60%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. 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. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. An atrial septal defect (or any intracardiac or extracardiac shunt) cannot be excluded on the basis of this study due to the technically suboptimal nature of the images. A transesophageal echocardiogram is recommended if exclusion of a shunt is required. Brief Hospital Course: # Fall/Loss of consciouness: The patient reported that he fell at home when reaching toward a top shelf in his apartment, and it sounded to be mechanical. Head CT showed no acute intracranial pathology, MRI/MRA Head showed no evidence of acute infarct but did show multiple periventricular FLAIR hyperintensities, for which the differential diagnosis is broad (no cause, small vessel infarction, demyelinating disease, infection including Lyme disease, and occasionally seen in patients with migraine headaches). There were no events on telemetry to suggest an arrhythmia. EEG was negative for seizure activity, but did show slow and disorganized background admixed with bursts of generalized delta frequency slowing consistent with a mild to moderate encephalopathy suggesting dysfunction of bilateral subcortical or deep midline structures (Ddx: medications, metabolic disturbances, and infection). TTE attempted twice, but quality was suboptimal: bubble study could not be interpreted due to poor windows, LV systolic function appears grossly normal (LVEF >55%), RV is dilated and hypokinetic, no significant valvular abnormality seen. Physical therapy was consulted and recommended he go home with PT. Social work was consulted and recommended a home safety evaluation. . # Hypotension: The patient had a blood pressure of 79/48 on admission, which improved to SBP 110-140 after 2L NS in the ED. He again had hypotension in the MICU after aggressive diuresis with SBP down to 60-70 but asymptomatic. He remained normotensive since he was called out to the medical floor. There was no evidence of bleeding and no localizing signs or symptoms of infection. His WBC ranged 5.4-10.4, and his blood cultures showed no growth. . # Fluid overload: The patient had a proBNP of [**Numeric Identifier 16802**] on admission from previously 3000-8000. He then developed further volume overload likely from aggressive volume resucitation given his hypotension on admission. TTE [**2128-4-12**] did not show evidence of systolic or diastolic heart failure, LVEF >55%. Cardiac Catheterization showed possible restrictive/constrictive physiology. He appeared to be auto-diuresing, and the patient seemed euvolemic on discharge. His Lasix was held during this admission because of his hypotension, and he was instructed to follow up with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] about when this should be restarted. . # Emphysema/Pulmonary Hypertension: The patient reported he is on 3L home oxygen at night. He has a history of asbestos exposure and a history of possible interstitial lung disease, however there was no evidence of interstitial lung disease on Chest CT [**10-22**]. V/Q scan on admission was indeterminate/intermediate probability for PE. CTA chest was initially deferred given his ARF and recent contrast load with catheterization. In the MICU, he would desaturate overnight requiring a face mask, likely due to central apnea. He was intermittently hypoxic to 80s but asymptomatic during the day. Cardiac catheterization showed severe pulmonary hypertension (mean PA pressure 51, mean PCWP 20), possible restrictive/constrictive physiology. TTE showed TR gradient elevated to 42 mm Hg. CTA Chest on [**2128-4-15**] showed no pulmonary embolism, left lower lobe pneumonia, mild pulmonary edema, and spiculated nodule in the superior segment of the left lower lobe, with interval growth. The patient remained afebrile with no leukocytosis and no evidence of infiltrate on CXR, so the team elected not to treat the possible PNA on CTA chest. He was continued on fluticasone/salmeterol and tiotropium. He was continued on supplemental O2 for a goal SaO2 88-93% due to CO2 retention if higher than 93%. He was scheduled for a repeat Chest CT in 1 month to evaluate the spiculated nodule. . # NSTEMI: The patient has a history of CAD s/p 1v CABG in [**2111**] (SVG -> RCA), known occluded RCA and SVG->RCA graft on Cath in [**1-20**] and RCA fills with collaterals, and s/p PCI to LAD (3.0x23 Cypher) in [**8-20**] and OM1 (2.5x15 Vision-BMS) in [**5-22**]. He reported some chest discomfort around the time of his fall at home. His CK peaked at 1427, troponin peaked at 3.41 on [**4-11**]. The patient had a cardiac catheterization on [**2128-4-13**] which showed patent prior LAD stent, mild restenosis of OM1 stent, and 100% occluded SVG->R-PDA and RCA. He had a bump in troponin from 1.85->2.14 after the catherization but his CK remained normal (69-84). He was continued on ASA 325 mg daily, Plavix 75 mg daily, and Metoprolol 25 tid. His Atorvastatin was held in the setting of transaminitis. . # Acute renal failure/Rhabdomyolysis: The patient's Cr was up to 3.6 on admission from a baseline of 0.6-0.8. His FeUrea was 14%, and this was thought to be prerenal renal failure with a likely component of contrast nephropathy. His initial CK was up to 1427, and he may have also had component of rhabdomyolysis. Renal ultrasound showed no renal mass lesion or hydronephrosis. He received Mucomyst and NaHCO3 pre-catheterization. He was given IVF with improvement of Cr to 0.8 at the time of discharge. . # Left Femur fracture: The patient presented with a mechanical fall at home in which he landed on his left BKA. Left knee films showed little change in the below-the-knee amputation with patchy demineralization about the knee. CT of the LLE showed diffuse osteopenia status post below-the-knee amputation, no displaced fracture, mild patellofemoral compartment osteoarthritic change, and small joint effusion. Orthopedics was consulted and determined that the patient had a nondisplaced lateral cortex supracondylar femur fracture that was not operable. Orthopedics determined that the team should hold off joint aspiration as it would likely reaccumulate. The patient was instructed to be NWB x4-6 weeks, and to avoid his prosthesis. There was difficulty controlling the patient's pain, as he became somnolent on some of the long-acting pain medications. The chronic pain service was consulted. He was continued on Gabapentin 800 mg q8hr and prescribed a Lidocaine patch to his left BKA. The patient will follow up with Dr. [**Last Name (STitle) **] in 2 weeks with repeat Xrays. Physical therapy was consulted and recommended home PT. . # Transaminitis: The patient presented with transaminitis, and peak enzymes were ALT 2888, AST 4099, LDH 3344. This was thought to be secondary to shock liver. A Hepatitis panel was negative for A, B, C. His LFTs were trending down at the time of discharge. His Atorvastatin was held during this admission, and he was instructed to have his LFTs rechecked as an outpatient for consideration of restarting the Atorvastatin. . # Seizure disorder: The patient had an EEG which showed no clearly epileptiform features and no electrographic seizure activity was noted. He was continued on Keppra 1500 PO bid. . # Psych: The patient was continued on Clonazepam 1 mg tid. He was instructed to follow up with behavioral neurology as an outpatient. Social Work was consulted to help the patient with coping and compliance. . # Peripheral neuropathy: He was continued on his home dose of Gabapentin 800 mg tid. . # Hypothyroidism: His TFTs showed TSH 0.024 (low), Free T4 1.7, T3 61 (low). His Levothyroxine was decreased from 150 mcg to 125 mcg daily. He was instructed to have his TFTs rechecked in 1 month. Medications on Admission: #. Atorvastatin 20mg qAM #. Clonazepam 1mg TID #. Clopidogrel 75mg daily #. Fluticasone-Salmeterol 250/50 1 inh [**Hospital1 **] #. Furosemide 20mg qAM #. Gabapentin 800mg TID #. Hydroxyzine 25mg q4-6H PRN itch #. Levetiracetam 1500mg [**Hospital1 **] #. Levothyroxine 150mcg daily #. Metoprolol tartrate 25mg TID #. Nitroglycerin 0.3 mg tab SL PRN #. Tiotropium 18 mcg capsule, 1 cap inh daily #. ASA 325mg daily #. Calcium carbonate 500 mg (1250mg) tablet, chewable, 1 tab daily #. Cholecalciferol 400 U tablet daily #. Pyridoxine 50mg daily . Allergies: Oxycodone / Zanaflex Discharge Medications: 1. Outpatient Lab Work You should have your LFTs (ALT, AST, alk phos, LDH, T bili) rechecked in 2 weeks ([**Date range (1) 16803**]), and faxed to Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] in the [**Hospital 191**] clinic [**Telephone/Fax (1) 16804**] 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inh Inhalation [**Hospital1 **] (2 times a day). 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every [**3-21**] hours as needed for itching. 7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (3) **]:*30 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual as directed: Take 1 tab under the tonuge every 5 minutes for chest pain. If taking 3 tabs, call 911. 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 (). [**Month/Day (3) **]:*30 Adhesive Patch, Medicated(s)* Refills:*2* 17. Outpatient Lab Work You should have TSH and Free T4 rechecked in 4 weeks ([**Date range (1) 16805**]). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY: Mechanical Fall NSTEMI Acute Renal Failure Shock Liver Acute on Chronic Heart Failure Left Femur Fracture Emphysema Pulmonary Hypertension Hypothyroidism . SECONDARY: PVD Seizure disorder Peripheral Neuropathy Discharge Condition: Stable Discharge Instructions: 1. If you develop chest pain, shortness of breath, palpitations, lightheadedness/dizziness, weakness or numbness, difficulty speaking or swallowing, fever >101.5, or any other symptoms that concern you call your primary care physician or return to the ED. 2. We are holding your Atorvastatin, because your liver enzymes were elevated on admission. You should have your liver enzymes rechecked as an outpatient, and then consider restarted your Atorvastatin. 3. Your Levothyroxine was decreased to 125 mcg daily. You should have your thyroid function tests rechecked in 4 weeks on this new dose. 4. Your Lasix was held during this admission because of low blood pressure. You should follow up with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] about when this should be restarted. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] in Cardiology ([**Telephone/Fax (1) 7960**]) on [**2128-4-21**] at 12:15 pm on [**Last Name (NamePattern1) **], Fog 430, [**Location (un) 86**], MA. . You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] in Neurology ([**Telephone/Fax (1) 541**]) on [**2128-5-3**] at 3:00 in the [**Hospital Ward Name **] CENTER, [**Location (un) **] NEUROLOGY UNIT. . You have a repeat X-ray of your Left Femur on [**2128-5-6**] at 12:00 in the [**Hospital Ward Name 23**] Building, [**Location (un) 551**]. You then have a follow up appointment with Dr. [**Last Name (STitle) **] in Orthopedics ([**Telephone/Fax (1) 1228**]) on [**2128-5-6**] at 12:20 in the [**Hospital Ward Name 23**] Building, [**Location (un) 551**]. . You have a follow up CT Chest on [**2128-5-12**] at 1:00 in the [**Hospital Unit Name 1824**] at 1:00. You should not eat or drink anything for 3 hours prior to this procedure. . You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16800**] in Primary Care ([**Telephone/Fax (1) 250**]) on [**2128-5-12**] at 3:30 in the [**Hospital Ward Name **] CENTER, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT. . You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Behavioral Neurology ([**Telephone/Fax (1) 1690**]) on [**2128-7-2**] in 9:30 am [**Hospital Ward Name 860**] [**Doctor Last Name **], [**Location (un) 551**], [**Apartment Address(1) 16806**].

[ "E888.1", "570", "V45.82", "733.90", "790.92", "E947.8", "V45.89", "V49.75", "518.89", "584.9", "276.4", "V12.54", "443.9", "414.02", "V10.87", "458.9", "728.88", "719.06", "414.01", "428.0", "338.29", "V12.51", "959.01", "244.8", "V46.2", "574.20", "410.71", "272.0", "492.8", "276.51", "515", "355.8", "416.0", "821.23", "345.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

25382, 25440

15510, 22882

318, 344

25703, 25712

6388, 13774

26557, 28167

5629, 5708

23510, 25359

25461, 25682

22908, 23487

13791, 15487

25736, 26534

5723, 6369

242, 280

372, 3484

3506, 5246

5262, 5613

10,246

112,882

2729

Discharge summary

report

Admission Date: [**2163-5-3**] Discharge Date: [**2163-5-6**] Date of Birth: Sex: F Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: A 41-year-old female with a history of coronary artery bypass graft x3 in [**2156**] who has experienced substernal chest pain over the past two days. Patient initially attributed her discomfort to a cold. This afternoon pain worsened then spread to her arms and neck. She planned to see her doctor tomorrow, but due to this worsening of the pain, the patient decided to come to the Emergency Department. At [**Hospital1 69**], the patient was brought to the Catheterization Laboratory. At cardiac catheterization, patient was found to have three vessel coronary artery disease. The LMCA had a distal 50% stenosis. The left anterior descending artery was totally occluded after giving off S1 and D1. The distal left anterior descending artery stent refilled via the left collaterals. The left LCA was totally occluded proximally. The right coronary artery was severely diffusely diseased proximally and totally occluded in its mid segment. Selective graft vessel angiography revealed a totally occluded saphenous vein graft to OM after giving off the free LIMA to distal left anterior descending artery. The distal left anterior descending artery supplied by the LIMA graft had mild-to-moderate diffuse disease, but had no flow limiting lesions. The saphenous vein graft to distal RVA was widely patent, but with TIMI-I flow and injection, and supplied diminutive distal right coronary artery. Resting hemodynamics revealed elevated right and left sided filling pressures. There was mild pulmonary hypertension. Cardiac index is mildly reduced at 2.2. The distal right coronary artery occlusion just beyond the saphenous vein graft, right coronary artery anastomosis was successfully treated by thrombectomy, angioplasty, and stenting with no residual stenosis, no intergraphic evidence of dissection, and TIMI-III flow. During procedure, the patient required administration of dopamine due to systolic blood pressures in the 70's. She was transferred to the CCU for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft x3 in [**2156**]: LIMA to LAD, saphenous vein graft to OM, saphenous vein graft to PDA. 2. Sternal wound infection. 3. Hypothyroidism. 4. Nephrolithiasis. 5. Obesity. 6. Anemia. 7. Depression. 8. Gestational diabetes. 9. Repair of triple hernia. ALLERGIES: Penicillin, succinylcholine, and sulfa. MEDICATIONS: 1. Hydrochlorothiazide 25 mg po q day. 2. Triamterene 37.5 mg po q day. 3. Lasix 40. 4. Levoxyl 50. 5. Omeprazole 20. 6. Folic acid 1. SOCIAL HISTORY: The patient lives in [**Location 4288**] with her husband. She smokes half a pack a day. She is currently not employed. FAMILY HISTORY: Mother died at age 50 of a myocardial infarction. Multiple family members on her mother's side died in their 50's of coronary artery disease. Father has diabetes mellitus. PHYSICAL EXAMINATION: General: Obese female lying in bed in no apparent distress. Vital signs: Temperature 96.9, blood pressure 120/79, heart rate 74, respiratory rate 24, and O2 saturation 98% on 2 liters. Weight 104.3 kg. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mucous membranes moist. Oropharynx clear. Neck is supple, difficult to assess jugular venous distention. Heart: Regular, rate, and rhythm, S1, S2, no murmurs, rubs, or gallops. Chest: Sternotomy scar present. Lungs are clear to auscultation anteriorly. Abdomen is soft, nontender, nondistended, positive bowel sounds. Midline abdominal scar. Extremities: Lower leg scar from SV harvest site. Neurologic is alert and oriented times three. Cranial nerves II through XII are grossly intact. Examination is otherwise negative. LABORATORY DATA: White count was 8.1, hematocrit 46.2. Chemistries were significant for a potassium of 3.3 and a magnesium of 1.4. ALT was elevated at 58, AST was elevated at 86, alkaline phosphatase, and total bilirubin were within normal limits. Initial CK was 94 with a troponin of 18.2, second CK was 399 with a troponin of 16.5, third CK was 910. ELECTROCARDIOGRAM: Normal sinus rhythm at 80 beats per minute, normal intervals, right axis deviation, 2 mm ST segment elevation in II, 1 mm ST segment elevation in lead III, 2 mm ST segment elevation in aVF, Q's in I and II, right sided leads, no ST elevation in V4 R. CHEST X-RAY: Probable mild fluid overload, no evidence for pneumonia. IMPRESSION: A 41-year-old female with history of CABG x3 in [**2156**] and a strong family history of coronary artery disease admitted with chest pain and electrocardiogram changes consistent with inferior myocardial infarction. Patient is status post Angio-Jet thrombectomy to distal right coronary artery with placement of stent to right coronary artery beyond PDA. The patient is admitted to the CCU for further management. HOSPITAL COURSE: The patient was maintained on beta blocker, aspirin, Plavix in the CCU. She was also administered Integrilin for 18 hours. Her homocysteine level was sent off to workup patient's workup etiology of coronary artery disease in this young woman. Creatinine kinase was followed and was noted to be peak at 910. The patient remained in normal sinus rhythm and was monitored on Telemetry. ACE inhibitor was titrated up as patient tolerated. Patient remained chest pain free during her hospital stay. On [**5-5**] she underwent echocardiogram which disclosed the following: 1) Mild dilatation of the left atrium, 2) left ventricular cavity size is normal, overall left ventricular systolic function is mildly depressed, inferior akinesis is present, 3) trace aortic regurgitation is seen, 4) the mitral valve leaflets were mildly thickened, 5) trivial mitral regurgitation is seen. During hospital stay, it was emphasized to this patient that she must quit smoking. The patient was administered nicotine patch and gum during her hospital stay. The patient expressed a desire to quit smoking. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease. 2. Occluded saphenous vein graft to obtuse marginal. 3. Mild systolic and diastolic left ventricular dysfunction. 4. Acute inferior myocardial infarction managed by acute PTCA. 5. Successful Angio-Jet and stenting of the distal right coronary artery beyond the saphenous vein graft-right coronary artery anastomosis. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Atenolol 25 mg po q day. 3. Plavix 75 mg po q day. 4. Folic acid 1 mg po q day. 5. Protonix 40 mg po q day. 6. Levothyroxine 50 mcg po q day. 7. Pravastatin 20 mg po q day. 8. Lisinopril 5 mg po q day. 9. Nicotine gum 2 mg one gum q1h as needed. 10. Nicotine patch 7 mg. DISCHARGE INSTRUCTIONS: Patient instructed to followup with her primary care physician. DR.[**Last Name (STitle) **],[**First Name3 (LF) 2064**] 12-ABZ Dictated By:[**Dictator Info 13504**] MEDQUIST36 D: [**2163-5-9**] 15:45 T: [**2163-5-11**] 05:42 JOB#: [**Job Number 13505**]

[ "427.89", "244.9", "997.1", "410.41", "V45.81", "414.01", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "37.78", "99.20", "37.23", "36.06", "36.01", "88.56" ]

icd9pcs

[ [ [] ] ]

6210, 6217

2884, 3059

6238, 6597

6620, 6923

5092, 6188

6948, 7235

3082, 5074

143, 156

185, 2187

2209, 2727

2744, 2867

2,061

174,783

24518

Discharge summary

report

Admission Date: [**2107-1-5**] Discharge Date: [**2107-1-30**] Service: VSU PRINCIPAL DIAGNOSIS: Right foot ischemia and right great toe ulcer, left third toe ulcer. PRINCIPAL PROCEDURE: Right below knee popliteal with DP bypass graft, left vein patch angioplasty graft to PT. PAST MEDICAL HISTORY: Significant for diabetes, hypertension, coronary artery disease, congestive heart failure, end stage renal disease, neuropathy, Paget's disease, HOSPITAL COURSE: Mr. [**Known lastname 61975**] is an 83-year-old gentleman who was admitted on [**2107-1-5**], with right foot ischemia and right toe ulcer as well as left third toe ulcer. He was started on IV antibiotics including Cipro and Flagyl and Vancomycin preoperatively. On [**2107-1-5**], he had an angio which showed an occluded right fem [**Doctor Last Name **] and left fem [**Doctor Last Name **], but PDA was patent, as well as stenosis in his left PT. On [**1-6**] he got a CT angiogram that showed bilateral pleural effusions however no signs of PE. On [**1-7**] he had vein mapping as well as PVRs as part of his preoperative work up. He also had a cardiology evaluation. He was taken to the operating room on [**2107-1-14**], for a right double below knee popliteal to DP bypass graft with a left vein patch angioplasty. Postoperatively he did well. On postoperative day 1, he underwent dialysis. He was in the vascular intensive care unit for monitoring. After dialysis he was noted to be somewhat hypotensive. The health officer was called to evaluate him and noted that he had some mental status changes as well as hypotension. He was immediately transferred to the intensive care unit where upon evaluation of the blood gases and mental status changes, he was electively intubated and started on Neo-Synephrine and Levophed for his blood pressure. At this point a cardiology evaluation was obtained in order to help evaluate the etiology for his hypotension. He was empirically started on a heparin drip and per cardiology there are no plans for catheterization. His pressures stabilized on Neo-Synephrine and Levophed. He self extubated himself that evening and was stable on nasal cannula. His mental status improved and he was alert, oriented and following commands. On [**1-17**], he got an echocardiogram which showed dilated left atrium, low to normal left ventricular function and elevated right ventricular pressure with systolic hypertension. Cardiology continued to follow him during this time. He continued to have increased pressor requirement without any clear etiology. He had a full set of blood cultures which were all negative. He was empirically started on broad spectrum antibiotics. There was some concern because of his right ventricular increased filling pressure of pulmonary embolus. He had a CT of the chest on [**1-19**] that confirmed no sign of any sort of pulmonary embolus. At this point his heparin drip was stopped. He continued to be sort of stable on pressors, however we were unable to wean his pressors. We were treating him as if he was having a septic physiology as well as possible congestive heart failure. He remained stable on pressors and alert and oriented, however on the evening of [**1-26**] he complained of some back pain and discomfort and some increased shortness of breath. At that morning he was intubated for increased work of breathing. He had CTA of his chest and abdomen. CT of his chest showed new pulmonary infiltrate and CT of his abdomen showed some abdominal ascites, however there were no signs of any intraabdominal process that would be concerning. He had a repeat echocardiogram on [**1-27**] that did not show any significant change since his previous echo on [**1-17**], however he did continue over the course of next few days to have increasing pressor requirement and was intermittently started on a vasopressor, maxing on his Levophed and Neo-Synephrine. On the morning of [**1-29**], he was maxed out on both Neo-Synephrine, vasopressor and Levophed with hypotension, systolic pressures in the 70s. No secrecy concern that he had not been improving without any clear etiology. It was determined to repeat his accuracy with some changes in his cardiac function however at this time. It was noted the enzymes had not been continuously cycled and his troponins remained stable, however elevated likely secondary to his renal failure. A repeat echo that afternoon showed significant left ventricular dysfunction consistent with possible myocardial infarction. Cardiology was consulted and felt that he was not a candidate for a balloon pump, or catheterization, or sort of intervention at this time, and recommended medical management. We switched his pressors over to milrinone and attempted the [**Hospital1 **] without success. He continued to do poorly with pressures in the 70s. We had a lengthy discussion with the family and went over his echocardiogram with the family and cardiology to explain this new finding in that his overall condition had continued to deteriorate over this period. The family at this point wished to continue with full medical support. He started to have worsening metabolic acidosis and we attempted to try some CVAs, however his pressures would not tolerate this, so he received bicarbonate for his acidosis. We continued to increase milrinone while he was maxed out on Neo-Synephrine, vasopressor and Levophed. His pressures remained in the 70s but stable. On the evening of [**1-29**], his pressures started to decrease below 70s, and then systolic pressures in the 60s. He was maxed out on all of his pressors. At this point the family was concerned and felt that if situation got worse they did not want to resuscitate him or proceed with any cardioversion or chest compressions. He was made DNR on [**2107-1-29**], at 11:30 p.m. At this point his pressures maxed out on 4 pressors and continued to dwindle into the 50s. Family again called at [**1-30**] at 1 a.m. with concern that he was not getting better and wished to make him CMO and felt that he would not wish to have any further intervention and that it would be within his wishes to make him CMO. At 1 a.m. to [**2107-1-30**], he was made CMO and his pressors were all weaned off. He expired at 1:36 a.m. on [**2107-1-30**]. It was discussed with family for postmortem and the family declined and they also declined for any autopsy. They felt that they were happy with his overall care and felt that the intensive care unit was quite supportive during his entire course. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26687**] were informed of both his DNR and CMO status when they occurred. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], M.D. [**MD Number(1) 4417**] Dictated By:[**Name8 (MD) 57264**] MEDQUIST36 D: [**2107-1-30**] 05:50:23 T: [**2107-1-30**] 13:47:04 Job#: [**Job Number 61976**]

[ "276.1", "789.5", "403.91", "V66.7", "486", "585.6", "V10.46", "038.9", "V45.81", "440.23", "997.1", "458.21", "427.31", "995.91", "410.71", "440.31", "428.0", "250.40" ]

icd9cm

[ [ [] ] ]

[ "88.48", "34.91", "99.04", "96.04", "39.95", "39.29", "96.71", "39.49", "96.6" ]

icd9pcs

[ [ [] ] ]

479, 7044

315, 461

46,119

121,662

29385

Discharge summary

report

Admission Date: [**2136-8-19**] Discharge Date: [**2136-9-1**] Date of Birth: [**2052-8-3**] Sex: F Service: CARDIOTHORACIC Allergies: Nifedipine / lisinopril / Felodipine / fosinopril / Ace Inhibitors / ibuprofen Attending:[**First Name3 (LF) 1406**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**2136-8-27**] aortic valve replacement (21mm [**Last Name (un) 3843**] [**Doctor Last Name **] pericardial),coronary artery bypass graft (Svg-RCA) [**2136-8-23**] Simple extractions numbers 10 and 20 [**2136-8-21**] left and right heart catheterization, coronary angiogram History of Present Illness: 84 yo F with PMH severe AS by echo ([**2136-6-8**]) with peak gradient 66mg, mean of 38mmHg, aortic valve area 0.5cm2 without aortic insufficiency, COPD (mild), GERD, HLD, arthritis, and occult anemia transferred from [**Hospital3 **] for evaluation for valve replacement. She was in her usual good state of health until 2 days prior to admission at [**Hospital1 **] on [**8-17**], when she noticed DOE and mild SOB. She denied any chest pain, palpitations or cough. At baseline, works 4 days/week and is physically active. On admission, she had SOB and AMS requiring intubation in ER. CXR showed pulmonary edema. She received 40mg IV Lasix and had significant diuresis. While in ICU, she was agitated on vent. She was extubated this AM and found to have mild confusion but alert and oriented to place, person, month, year and day (not date). Of note, she was also started on abx and steroids due to D/D of COPD acute exacerbation; is planned for quick prednisone taper and short abx course. cardiac surgery was consulted for aortic valve replacement. Past Medical History: - Severe aortic stenosis - Hypertension - Hypercholesterolemia - Arthritis - COPD (mild) - GERD - Anemia - b/l knee replacement Social History: lives in [**Location 5110**] alone. Works for a fuel company doing billing, 4 days a week. -Tobacco history: Smokes 2ppd for at least 60 yrs -ETOH: social, ~1 month -Illicit drugs: none Family History: Mother died of old age, father died of lung cancer Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.1 100/63 109 18 97% on 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm. CARDIAC: Tachy, normal S1, S2. Systolic murmur. LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB, no crackles, wheezes or rhonchi. Poor inspiratory effort. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: 1+ [**Last Name (un) **],a. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ECHO [**2136-8-22**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. 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 are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. IMPRESSION: Suboptimal image quality. Critical aortic stenosis. Moderate to severe global left ventricular systolic dysfunction. Moderate diastolic dysfunction with elevated estimated PCWP. Very small anterior pericardial effusion. . CAROTID US [**2136-8-22**]: Right ICA <40% stenosis. Left ICA <40% stenosis. . CXR [**8-18**] OSH: Mild pulmonary edema, improved from day prior. Small right pleural effusion. . ECHO [**2136-6-8**] OSH: Severe AS with peak gradient of 66 mmHg, mean of 28 mmHg. Valve area os 0.5 cm2. Thickened mitral leaflets, calcified annulus, mild MR. [**First Name (Titles) **] [**Last Name (Titles) 1754**]. Normal RV. Borderline normal LV. LVEF 50-55%. Mild pulm hypertension, estimated PA pressure 45mmHg. [**2136-9-1**] 07:05AM BLOOD WBC-9.0 RBC-3.67* Hgb-9.1* Hct-28.1* MCV-76* MCH-24.7* MCHC-32.4 RDW-16.7* Plt Ct-199 [**2136-8-19**] 05:12PM BLOOD WBC-16.6* RBC-4.48 Hgb-11.3* Hct-34.6* MCV-77* MCH-25.2* MCHC-32.7 RDW-16.0* Plt Ct-294 [**2136-8-29**] 02:31AM BLOOD PT-14.5* PTT-32.4 INR(PT)-1.2* [**2136-8-19**] 05:12PM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.0 [**2136-9-1**] 07:05AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-139 K-4.6 Cl-99 HCO3-36* AnGap-9 [**2136-8-19**] 05:12PM BLOOD Glucose-141* UreaN-28* Creat-0.8 Na-138 K-4.5 Cl-99 HCO3-27 AnGap-17 [**2136-8-21**] 08:19AM BLOOD ALT-45* AST-26 AlkPhos-113* TotBili-0.4 Brief Hospital Course: Mrs. [**Known lastname 36589**] was admitted to the [**Hospital1 18**] on [**2136-8-19**] via transfer from [**Hospital3 **] for aortic valve replacement.On arrival she was stable, but still with some dyspnea. Over the course of the day her respiratory status worsening, with hypoxia, increasing respiratory rate, increasing pulse and hypertension. A chest xray revealed worsening pulmonary edema. She responded well to lasix 40mg IV and morphine, with resolution of symptoms after diuresis. She remained stable and comfortable on home regimen of lasix 20mg PO daily. She was initially brought to the OR on [**8-24**], but had a coughing fit with concern for pneunomia. She was brought back to the floor and a chest xray revealed improving pulmonary edema without infiltrates. She was monitored over the weekend without event and returned to the OR on [**2136-8-27**] where she underwen Coronary bypass grafting x1 with reverse saphenous vein graft to the right coronary artery/ Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease pericardial tissue valve. CROSS-CLAMP TIME:87 minutes.PUMP TIME:106 minutes. Please see operative note for details. Postoperatively she was transferred to the intensive care unit for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. Her CVICU course was uneventful and she transferred to the SDU on postoperative day two. Chest tubes and pacing wires were removed without complication. Beta blockade was resumed and advanced as tolerated. An ACE-I was not able to be resumed at this time due to her blood pressure. This will need to be readdressed as an outpatient due to her LVEF=30%. She remained in a normal sinus rhythm. Over several days, she continued to make clinical improvement with diuresis. She was eventually cleared for discharge to [**Hospital3 13990**] Health Care rehab on postoperative day # 5.All follow up appointments were advised. Medications on Admission: HOME MEDICATIONS: Lasix 20mg daily Omeprazole 20mg daily Simvastatin 20mg QHS MVI Colace Tylenol Levalbuterol inhaler 0.31mg neb . MEDICATIONS ON TRANSFER: Prednisone 60mg (quick taper) Nicotine 21mg PO daily Ceftriaxone 1gm IV daily Pantoprazole 40mg IV daily Duonebs q6hours Furosemide 10mg [**Hospital1 **] IV Albuterol 2.5mg nebs q2hr prn SOB ASA 325 mg PO daily NTG prn Heparin 5000 IU q8hr SQ 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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) 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 Q6H (every 6 hours) as needed for pain. 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: 40mg daily x 1 week, then resume 20mg daily. 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day) for 1 weeks: [**Hospital1 **] x 1 week, then resume daily dose. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Severe Aortic Stenosis ([**Location (un) 109**] 0.5cm2) coronary artery disease s/p aortic valve replacement, coronary artery bypass Hypertension Hypercholesterolemia Arthritis Chronic Obstructive Pulmonary Disease (mild) Gastroesophageal Reflux Disease Osteoarthritis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema: 1+ 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: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2136-9-27**] at 1:15 pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2136-9-20**] at 2:00PM Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15942**] ([**Telephone/Fax (1) 60570**]in [**4-17**] 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:[**2136-9-1**]

[ "401.9", "305.1", "428.31", "491.21", "V43.65", "428.0", "414.01", "521.00", "424.1", "514", "272.0", "530.81" ]

icd9cm

[ [ [] ] ]

[ "88.53", "39.61", "88.56", "35.21", "37.23", "36.11", "23.09" ]

icd9pcs

[ [ [] ] ]

9126, 9156

5146, 7108

351, 630

9469, 9695

2832, 5123

10669, 11306

2082, 2134

7557, 9103

9177, 9448

7134, 7134

9719, 10646

2149, 2159

7152, 7265

2181, 2813

304, 313

658, 1712

7290, 7534

1734, 1863

1879, 2066

45,659

110,432

12824

Discharge summary

report

Admission Date: [**2194-12-8**] Discharge Date: [**2194-12-14**] Date of Birth: [**2125-12-15**] Sex: F Service: CARDIOTHORACIC Allergies: Ibuprofen Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2194-12-9**] Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Epic Porcine), reduction aortoplasty [**2194-12-8**] Cardiac Cath History of Present Illness: 68 year old female with coronary artery disease status post myocardial infraction with angioplasty in [**2175**] and known aortic stenosis who has been followed by serial echocardiograms. Over the past year, she has noted progressive dyspnea on exertion, fatigue and mild peripheral edema. He most recent echocardiogram revealed severe aortic stenosis with a mean gradient of 36mmHg. Given the progression of her symptoms and the severity of her aortic stenosis, she had been referred for surgical management. Admitted today s/p cardiac catherization as preop for AVR with Dr [**Last Name (STitle) **] in the morning. Past Medical History: Aortic stenosis Coronary artery disease s/p angioplasty Myocardial infarction [**2176-9-30**] Hypertension Dyslipidemia Diabetes mellitus type 2 Pancreatitis [**2179**] developiong diabetes after GERD Anemia Bilateral shoulder fractures (Left [**2191**], Right [**2192**]) Past Surgical History: Cholecystectomy with drainage of pancreatic cyst Incisional hernia repair [**2188**] Ganglionic cyst of wrist surgical excised Social History: Race: Caucasian Last Dental Exam: 6 months ago - clearance obtained. Lives with: Alone, son and [**Name2 (NI) **] in law live upstairs in 2 family house (Husband recently passed away from pancreatic cancer). Occupation: Retired Tobacco: Quit [**9-/2176**]. 48 year pack history ETOH: Denies Family History: Sister with CABG at age 70. Uncle died of MI at age 21. Mother with angina. Father with fatal MI at age 74. Physical Exam: Pulse: Resp:20 O2 sat: 97% RA B/P Right:91/58 Left: Height: 4'[**93**]" Weight: 181 General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Distant breath sounds Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit: Transmitted murmur vs bruit B/L Pertinent Results: [**2194-12-8**] Cardiac cath: 1. No angiographically-apparent flow-limiting CAD. 2. Normal pulmonary capillary wedge pressure. 3. Mild pulmonary arterial hypertension. 4. Low normal systemic systolic arterial pressure with occasional hypotension. 5. Sheaths to be removed. 6. Additional plans per Dr. [**Last Name (STitle) **]. Admit to CSurg. 7. Reinforce primary preventative measures against CAD. 8. Follow-up with Dr. [**Last Name (STitle) 39486**]. [**2194-12-8**] Carotid U/s: 1. No evidence of internal carotid artery stenosis on either side. 2. Reversal of flow in the right vertebral artery, which is usually associated with subclavian steal. Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname 18654**] was admitted following her cardiac cath and underwent pre-operative work-up. On [**2194-12-9**] she was brought to the operating room where she underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta blockers and diuretics were started and she was diuresed towards her pre-op weight. Later on this day she was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. During her post-op course she worked with physical therapy. On post-op day five she appeared ready for discharge home with VNA services and the appropriate medications and follow-up appointments. She will take lasix for 2 weeks and then resume her spirinolactone if instructed by Dr. [**Last Name (STitle) 39487**]. Medications on Admission: Aspirin 81mg daily Cardizem CD 240mg daily Cozaar 50mg twice daily Spirinolactone 25mg daily Zocor 40mg daily Zetia 10mg daily Glucophage 1000mg twice daily Humalog sliding scale 10-15 units TID Lantus 50units daily Amitriptyline 10mg daily Calcium 600mg daily Vitamin D 2000units daily Multivitamins Mobic 15mg daily Omeprazole 20mg daily Ativan 0.5 mg po QHS Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Mobic 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. insulin glargine 100 unit/mL Cartridge Sig: Please refer to provided instruction sheet for daily dose and sliding scale Subcutaneous As Instructed. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Past medical history: Coronary artery disease s/p angioplasty Myocardial infarction [**2176-9-30**] Hypertension Dyslipidemia Diabetes mellitus type 2 Pancreatitis [**2179**] developiong diabetes after Gastresophageal reflux disease Anemia Bilateral shoulder fractures (Left [**2191**], Right [**2192**]) Past Surgical History: Cholecystectomy with drainage of pancreatic cyst Incisional hernia repair [**2188**] Ganglionic cyst of wrist surgical excised Angioplasty [**2175**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: 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 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. 6) No lifting more than 10 pounds for 10 weeks 7) Take lasix and potassium daily in the morning for 14 days then stop. You may then resume your spirinolactone if instructed by Dr. [**Last Name (STitle) 39488**]. 8) You may resume your insulin sliding scale and night time lantus 20 units. Please refer to dosage sheet provided. 9) 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 10_ You may resume your at home vitamins. **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) **] [**1-8**] at 1:15pm Cardiologist: Dr. [**First Name (STitle) 39489**] [**Name (STitle) 39488**] on [**1-9**] at 10:45am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-3**] 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:[**2194-12-14**]

[ "416.8", "424.1", "250.00", "511.9", "272.4", "V45.82", "412", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "35.21", "39.61", "37.23" ]

icd9pcs

[ [ [] ] ]

6479, 6554

3388, 4432

298, 469

7120, 7344

2711, 3365

8626, 9138

1886, 1995

4843, 6456

6575, 6620

4458, 4820

7368, 8603

6948, 7099

2010, 2692

239, 260

497, 1116

6642, 6925

1578, 1870

81,740

140,571

40474

Discharge summary

report

Admission Date: [**2187-5-12**] Discharge Date: [**2187-5-22**] Date of Birth: [**2102-5-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 85-year-old female with a h/o CAD, CHF 20-25% with apical hypokinesis, who presented with a 5 day history of shortness of breath. She went to [**Hospital1 **] [**Location (un) 620**] and was noted to be in acute heart failure. She was also found to have a troponin of 0.05 with an abnormal EKG and was ASA 325mg, NG, Lasix, and started on a heparin drip. She never endorsed chest pain. En route she pulled out both IVs and tried to bite EMS. . In the ED, initial VS: 97.6 64 110/36 22. Her symptoms were almost resolved. EKG was noted to have STE v1-v4 with TWI in I and aVL, but were similar comapared to priors on [**4-9**] and 11/[**2185**]. CXR and EKG showed no change compared to that from OSH. However patient now recognized to be delirious and agitated and received haldol 2.5IV X2. She was placed in soft restraints. Cardiology was consulted to review the case, recommended continuation of heparin. She was initally admitted to [**Hospital1 1516**] for heart failure and possible ACS. However, patient then decompensated with possible flash pulmonary edema, was started on nitro gtt, 40mg lasix with over 400ml out then continued to put out. She was delerious requiring restraints. She was placed on bipap for about one hour, now on NRB and weaning. . Of note, she was quite agitated and she received haldol 2.5mg IV x3 and ativan 0.5 x1 over the night. She had a baseline dementia, still altered and confused. Baseline mental status was unclear and her records are in [**Name (NI) 620**]. She also recieved Morphine 1mg x1 this am, is currently on heparin, nitro gtt. . On the floor, patient was on a non-rebreather and denied any acute complaints. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: - CHF EF 20-25% followed by Dr. [**Last Name (STitle) **] - CAD status post MI - LV aneurysm with thrombus on echo in [**11-8**] - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: Unknown - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Chronic kidney disease- stage III (creatinine 1.4 at [**Hospital1 18**] [**Location (un) 620**] in [**11-8**]) - Restless leg syndrome - Dementia - Hypothyroidism Social History: She lives at home with 24-hour care. She is dependent for ADLs. She does not drink alcohol or smoke. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: VS: T=99.8 BP=170/47mmHg HR=91 RR=22 O2 sat=99% GENERAL: Non-rebreather in place, restraints on; patient agitated, trying to remove restraints; oriented to person, hospital ([**Hospital1 112**]), and [**Month (only) 116**]. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to the earlobe at 45 degrees. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4 appreciated. LUNGS: Crackles b/l, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis. Small scabs on her b/l pre-tibial areas. PULSES: [**Name (NI) **] PTs and DPs b/l. . On Discharge: Pertinent Results: [**2187-5-12**] 12:10AM WBC-7.2 RBC-4.57 HGB-12.6 HCT-37.6 MCV-82 MCH-27.7 MCHC-33.6 RDW-14.8 [**2187-5-12**] 12:10AM NEUTS-69.5 LYMPHS-21.9 MONOS-5.5 EOS-2.4 BASOS-0.7 [**2187-5-12**] 12:10AM PLT COUNT-188 [**2187-5-12**] 12:10AM PT-13.6* PTT-43.3* INR(PT)-1.2* . [**2187-5-12**] 12:10AM GLUCOSE-229* UREA N-40* CREAT-1.4* SODIUM-141 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-28 ANION GAP-18 [**2187-5-15**] 04:44AM BLOOD Glucose-232* UreaN-58* Creat-1.6* Na-140 K-4.2 Cl-100 HCO3-27 AnGap-17 . [**2187-5-12**] 11:56AM TSH-58* [**2187-5-13**] 05:23AM BLOOD T4-3.2* [**2187-5-14**] 05:52AM BLOOD Free T4-0.40* . [**2187-5-12**] 12:10AM BLOOD CK(CPK)-877* [**2187-5-12**] 11:56AM BLOOD CK(CPK)-1486* [**2187-5-12**] 06:29PM BLOOD CK(CPK)-2396* [**2187-5-13**] 05:23AM BLOOD CK(CPK)-2877* [**2187-5-14**] 05:52AM BLOOD CK(CPK)-1789* [**2187-5-12**] 12:10AM BLOOD cTropnT-0.08* [**2187-5-12**] 06:00AM BLOOD cTropnT-0.16* [**2187-5-12**] 11:56AM BLOOD CK-MB-17* MB Indx-1.1 cTropnT-0.25* [**2187-5-12**] 06:29PM BLOOD CK-MB-21* MB Indx-0.9 cTropnT-0.21* [**2187-5-14**] 05:52AM BLOOD CK-MB-16* MB Indx-0.9 cTropnT-0.18* . ECG ([**2187-5-12**] 12:10:38 AM) Artifact is present. Sinus rhythm. Left axis deviation. Left ventricular hypertrophy with associated ST-T wave changes. There are Q waves in the anterior leads with ST segment elevation in the anterior and anterolateral leads with terminal T wave inversion consistent with acute or evolving infarction. Clinical correlation is suggested. TRACING #1 . ECG ([**2187-5-12**] 5:36:38 AM) Artifact is present. Sinus tachycardia. Left axis deviation. There are Q waves in the anterior leads with ST segment elevation in the anterior and nterolateral leads consistent with acute or evolving infarction. Left ventricular hypertrophy with associated ST-T wave changes. Compared to the previous tracing of the same date the rate is faster. TRACING #2 . ECG ([**2187-5-13**] 10:12:04 AM) Sinus rhythm. Left axis deviation. Left ventricular hypertrophy with associated ST-T wave changes. There are Q waves in the anterior leads with ST segment elevation in the anterior and anterolateral leads with terminal T wave inversion consistent with acute or evolving infarction. Compared to he previous tracing of [**2187-5-12**] the rate is slower. TRACING #3 . CHEST (PORTABLE AP) ([**2187-5-12**] 12:00 AM) IMPRESSION: Mild cardiomegaly. Diffusely increased interstitial markings, likely represent CHF in this setting. . CHEST (PORTABLE AP) ([**2187-5-15**] 1:26 PM) FINDINGS: In comparison with the study of [**4-12**], there is little overall change. Low lung volumes may contribute to the prominence of the transverse diameter of the heart. Diffuse prominence of pulmonary markings bilaterally may be slightly improved, relating to the diuresis. Although this may represent elevated pulmonary venous pressure, the possibility of severe underlying chronic pulmonary disease must be considered. Brief Hospital Course: 85 year old woman with h/o CHF (EF 20-25% in [**11-8**]), CAD s/p MI, DM, hypothyroidism, and dementia transferred from [**Hospital1 18**] [**Location (un) 620**] with acute shortness of breath consistent with acute CHF exacerbation, in house found to be profoundly hypothyroid. # CHF Exacerbation: Admitted with hypoxemia, requiring non-rebreather and CXR suggestive of florid pulmonary edema. Known EF 20-25% and LV thrombus on echo in [**11-8**]. Unclear reason for decompensation - medication non-compliance vs. ischemia vs. dietary non-compliance. TSH 58 and hypothyroidism (FT4 0.4) can lead to worsened diastolic dysfunction so this could be contributing. Was actively diuresed at first successfully, over past 24h reacted less to lasix and developed othro-hypo, Diuresis held [**5-15**] with even goal, [**5-16**] +300cc for 24h, lungs sound more congested this morning but clinically stable and not hypoxic. Her metoprolol 12.5mg [**Hospital1 **] was continued. As her blood pressures and creatinine were stable, home lisinopril 5mg was started [**5-15**]. She was also put on a cardiac healthy, low Na diet and her I/Os were targeted to be even. She was gradually weaned down from 2L delivered via nasal cannulae to O2 sats of the low-90s on room air. Patient remained euvolemic with no need for diuresis in house on days preceding discharge. Decision made to hold diuresis at time of discharge. . OUTPATIENT ISSUES: - Continue metoprolol XL - Consider performing echocardiography to reassess functional status and ejection fraction - Follow-up with new cardiologist at [**Location (un) 620**] (Dr. [**Last Name (STitle) **] has retired) regarding LV thrombus and ?anticoagulation. If goal of care is comfort, would only schedule follow-up with primary care (done) - Reassess need for PO diuretic as outpatient . # Cough- Persistent, non-productive. Has a history of bronchitis. Initially attributed to fluid overload. The concern was for pulmonary edema vs aspiration pneumonia vs bronchitis. She was afebrile, w/o leukocytosis and w/o infiltrates on repeat CXR. Impression was residual bronchitis in the setting of resolving pulmonary edema, with no pneumonic process. She was assessed by Rehab and placed on aspiration precautions with soft solids and thin liquids (Functional Oral Intake Scale (FOIS) rating of 7 out of 7). Nebulisers were ordered PRN. Stable and largely resolved prior to discharge . OUTPATIENT ISSUES: - Follow-up speech and swallow recommendations - Follow-up with primary care physician for bronchitis - Start Albuterol inhaler as needed at home - Aspiration precautions at home . # CAD: Known CAD s/p MI; No stress tests or cath reports available in our system. Here with troponin leak, but no complaints of chest pain and EKG at baseline with pre-cordial anteroseptal ST elevations c/w known LV aneurysm. Enzyme leak most likely demand related in setting of CHF exacerbation. Troponins peaked at 0.25, MB: 21, and CK rose to 2396 thus far. Elevated CK likely secondary to immobilization. Heparin gtt d/c-ed on [**5-12**]. No active issues related to CAD during hospitalization. . OUTPATIENT ISSUES: - Continue home ASA - Continue metoprolol XL - Continue lisinopril 2.5 mg if BPs remain stable - Continue simvastatin . # RHYTHM: No known history of arrhythmias, been consistently in normal sinus rhythm since admission. . # Agitation/Dementia: Patient with significant agitation (including removing IVs, biting EMS) with some improvement with haldol and later zyprexa. Baseline is unknown. Hypothyroidism may be contributing given elevated TSH. Per caretakers at baseline alert and oriented x3 although dementia is listed in her PMH. Mental status possibly improved with 50mg qd then 100mg qd levothyroxine replacement. UA was negative, decreasing the possiblity of a UTI. She was not hyponatremic. The nurses actively engaged her with cards, games and crossword puzzles as [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol. Tether use was minimized as far as possible. . OUTPATIENT ISSUES: - Consider, if necessary, neurology evaluation for dementia and management of behavioural and psychological symptoms of dementia (if present) - Caregiver should continue keeping her engaged in mentally-stimulating activities to prevent deterioration of cognitive function . # Acute on Chronic Kidney Disease: Stage III per [**Hospital1 18**] [**Location (un) 620**] discharge summary, with creatinine of 1.4 in [**11-8**] (unclear if this is baseline). Creatinine stably elevated at 1.6 with trending. Nephrotoxins and renally dose medications were avoided. Diuresis with lisinopril was done to improve forward flow. At time of discharge creatinine stable at 1.1. . OUTPATIENT ISSUES: - Continue to trend renal function as outpatient . # [**Name (NI) 4545**] Pt w/ high TSH of 58. Total T4: 3.2 Per discharge summary from [**11-8**] was supposed to be taking levothyroxine 200 mg PO daily, but per hand written medlist from [**Location (un) 620**], does not appear to be taking at home. Per PCP coverage, as of [**2186-11-29**] (at which time TSH was suppressed) dosing was 175mcg MWF, 200mcg TThSaSu Restarted levothyroxine initially at 50mg to prevent excessive myocardial oxygen demand. The free T4 level was low at 0.4 on [**5-14**], and her dosing was increased to 100mg. . OUTPATIENT ISSUES: - Follow-up for hypothyroidism as this may complicate her cognitive function - Will need repeat TFTs as outpatient . # DM-No active issues during CCU stay. She was continued on home lantus and put on a novolog sliding scale. . # Restless leg syndrome-No active issues during CCU stay. She was continued on home mirapex. . # Social, goals of care-Contact with son [**Name (NI) **] was established and her status was changed from full to DNR/DNI. Son agrees for rehabilitation. . OUTPATIENT ISSUES: - Hospice consult and care - PT at home Medications on Admission: Home Medications: Zocor 20 mg at bedtime Aspirin 325 mg a day Lisinopril 5 mg daily Lasix 30 mg a day Folic acid 1 mg daily Mirapex 0.5 mg twice per day Metoprolol ER 50 mg at night Lantus 30 units at nighttime NovoLog sliding scale before meals Levothyroxine 200 mcg daily Discharge Medications: 1. Comfort Care Kit Sig: One (1) kit once. Disp:*1 kit* Refills:*0* 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2-20 mg PO every 1-4 hours as needed for pain or respiratory distress. Disp:*1 bottle* Refills:*0* 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily): Hold SBP< 90, HR< 55. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 9. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. insulin aspart 100 unit/mL Solution Sig: 1-12 units Subcutaneous four times a day: before meals and hs, as per sliding scale. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* Discharge Disposition: Home With Service Facility: House of Good [**Doctor Last Name 9995**] Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure Delerium Acute on Chronic Kidney Disease Hypothyroidism Coronary Artery Disease Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You had an acute exacerbation of your congestive heart failure and needed to recive intravenous diuretics to remove the extra fluid. You did not have a heart attack. Your kidneys function worsened but now is improving after we removed the fluid. Your thyroid hormone level was also very low and we restarted the thyroid medicine. You will need to have your thyroid level checked in [**12-31**] months. You were more confused here in the hospital but this should resolve once you are home. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. It is very important that you avoid salt in your diet. . We made the following changes to your medicine: 1. Stop taking Furosemide (Lasix) for now 2. Decrease the metoprolol to 25 mg daily 3. Decrease the Lisinopril to 2.5 mg daily 4. Start taking Levothyroxine 100mcg daily 5. STart taking colace and senna to prevent constipation 6. STart taking albuterol as needed to shortness of breath Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 **] HEALTHCARE - UPPER FALLS Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14512**] Phone: [**Telephone/Fax (1) 3393**] Appointment: Tuesday [**2187-5-29**] 10:30am We are working on a follow up appointment in Cardiology at [**Hospital1 18**] [**Location (un) 620**] within 1 month. Dr. [**Last Name (STitle) **] has retired. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [**Telephone/Fax (1) 4105**]. Completed by:[**2187-5-23**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14223, 14295

6586, 12470

319, 325

14470, 14517

3623, 6563

15748, 16382

2677, 2792

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353, 2031

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31,807

134,253

34076+57891

Discharge summary

report+addendum

Admission Date: [**2164-5-4**] Discharge Date: [**2164-6-11**] Date of Birth: [**2083-5-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Prednisone / Tetanus / Paxil / Prochlorperazine Maleate Attending:[**First Name3 (LF) 3619**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo F with a new diagnosis small cell lung cancer on chemotherapy less than 24 hours, transferred to the ICU with progressive hypoxia. . ICU evaluation was requested for hypoxia. The patient arrived last night saturating well on 6L NC. This morning she was noted on routine vitals to be saturating at 83% on 6L. She responded to 91-95% on a non-rebreather. The patient denies any new symptoms. She denies chest pain or shortness of breath. She does note a non-productive cough for several hours. The patient had a CXR which did not reveal a clear etiology of her hypoxia. ABG was 7.37/51/64. She received 10mg IV furosemide given that she likely had a positive fluid balance not well recorded since admission. Due to persistent hypoxia she is transferred to the ICU. . The patient was originally transferred from [**Hospital6 17390**] ICU with a new diagnosis small cell lung cancer. She presented initially with complaints of abdominal pain, dysphagia and generally not feeling well. She underwent an outpatient work-up including normal nuclear stress test and CT abd/pelvis with mesenteric lymphadenopathy. On [**2164-3-8**] she was admitted to a hospital in [**Location (un) 78617**], FL for laparoscopic biopsy of a mesenteric node, cecal mass and omentum. Biopsy was reactive and benign. She returned to her PCP with complaints of persistent weight loss and weakness. She was admitted to [**Hospital1 16549**] and on [**2164-4-30**] underwent an excisional biopsy of a right axillary lymph node which confirmed high grade small cell lung cancer. She was found on staging to have liver mets and peribronchial lymphadenopathy. CTA at [**Hospital6 **] revealed right lower lobe bronchus compression with right lower lobe collapse, diffuse lymphadenopathy, small bilateral pleural effusions and by verbal report to have invasion of the SVC with associated SVC thrombus. . The patient was transferred from [**Hospital6 2910**] last night for emergent chemotherapy. She received cis-platinum and etoposide with steroids. . ROS: Patient denies any complaints and cannot clearly recall the symptoms that brought her in to the hospital. She denies fevers, chills, shortness of breath, chest pain, nausea, vomiting, abdominal pain, dysuria, diarrhea, rashes, arthralgias or any other concerning symptoms. Past Medical History: - Metastatic small cell lung cancer - Hypertension. - Hyperlipidemia. - Hypothyroidism. - Question depression/workup in [**Location (un) 19061**] in [**2154**] hospital for psychotic reaction to Paxil. - History of CVA with left facial numbness. Patient denies this but it was brought to her attention when hospitalized in [**Location (un) 19061**] in [**2153**]. - History of right breast calcification, stable according to patient by mammogram over the past 3 years, last done 8 months ago. Social History: Divorced, remarried twice, most recently in [**2159**] to Mr. [**Known lastname 78618**] who died a year ago from lung cancer. Heavy smoker, two packs per day for 60 years. Lives in [**State 108**] Family History: Cancer in two uncles on the maternal side and vaginal cancer in maternal grandmother. [**Name (NI) **] died of lung cancer at age 40, and was a nonsmoker. Physical Exam: 97.7 114 132/65 24 93% NRB Gen: Comfortable. NAD. HEENT: No nasal flaring or accessory muscle use. Some paradoxical breathing with exaggerated stomach expansion with inspiration. CV: Tachycardic. Normal S1 and S2. No M/R/G. Pulm: Small amount of right lung base crackles. Abd: Soft, nontender, nondistended. Ext: Trace bilateral lower extremity edema. Neuro: A&Ox3. Pertinent Results: [**2164-5-4**] 09:00PM BLOOD WBC-8.0 RBC-4.10* Hgb-12.6 Hct-37.1 MCV-91 MCH-30.8 MCHC-34.0 RDW-13.0 Plt Ct-292 [**2164-5-7**] 04:01AM BLOOD Neuts-92* Bands-0 Lymphs-7* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2164-5-4**] 09:00PM BLOOD PT-12.6 PTT-26.7 INR(PT)-1.1 [**2164-5-4**] 09:00PM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-137 K-3.5 Cl-96 HCO3-32 AnGap-13 [**2164-5-4**] 09:00PM BLOOD ALT-13 AST-24 LD(LDH)-446* AlkPhos-68 TotBili-0.4 [**2164-5-8**] 07:09AM BLOOD ALT-10 AST-23 LD(LDH)-607* AlkPhos-60 TotBili-0.3 [**2164-5-4**] 09:00PM BLOOD Albumin-2.8* Calcium-9.4 Phos-2.9 Mg-1.9 [**2164-5-5**] 09:09AM BLOOD Type-ART pO2-64* pCO2-51* pH-7.37 calTCO2-31* Base XS-2 Intubat-NOT INTUBA [**2164-5-5**] 09:09AM BLOOD Lactate-1.1 . C Diff Toxin assay ([**2164-5-8**]): Negative . CXR ([**2164-5-5**]): Bilateral pleural effusions with RLL collapse. Mediastinal widening. No significant change from 1 day prior. . CTA OSH ([**2164-5-3**]): No PE. External compression of pulmonary artery branches on the right due to extensive mediastinal adenopathy. External compression and direct invasion of the SVC. . CT [**2164-5-18**] IMPRESSION: 1. Widespread lymphadenopathy in the mediastinum, right hilum, right supraclavicular region and upper abdomen, in keeping with the history of small cell lung cancer. Left adrenal and likely widespread hepatic metastases. 2. Superior vena cava is mildly compressed by the right paratracheal lymph nodes but appears patent. 3. Moderate right and small left dependent pleural effusions. 4. Two indeterminate right breast lesions, the largest measuring 2.2 cm in diameter. In the absence of intervention in this region, a primary breast cancer should be considered for the dominant lesion, although differential diagnosis includes inflammatory and infectious etiologies as well as a metastatic focus. [**2164-5-31**] 06:50AM BLOOD WBC-10.3 RBC-3.66* Hgb-10.9* Hct-32.2* MCV-88 MCH-29.7 MCHC-33.7 RDW-14.3 Plt Ct-463* [**2164-5-31**] 06:50AM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-133 K-4.3 Cl-97 HCO3-25 AnGap-15 Brief Hospital Course: # Lung Cancer: Ms. [**Known lastname 9241**] [**Known lastname **] was transferred from the NEBH ICU for urgent chemotherapy. She began cisplatinum and etoposide on the evening of admission. The following morning, she was increasingly hypoxic to 83% on NC 6L. She was transfered to the ICU. Her respiratory compromise was felt most likely due to airway and vasculature compression/obstruction from tumor burden as seen on recent CTA at the OSH. PE was felt possible though not likely given recent CTA that was negative. The patient also probably had a component of volume overload as seen on CXR and consistent with a recent history of volume rescucitation. Of note she likely has a contribution of compression from pleural effusions though this was felt not likely to be the primary force causing hypoxia. The patient was started on chemotherapy with the goal of reducing tumor burden. She received 3 days of cisplatinum and etoposide. Radiation oncology was consulted for consideration of palliative XRT. Unfortunately the patient was not able to lie flat in bed and therefore could not receive radiation. If her respiratory status improves and she is able to lie flat, then she could be an XRT candidate in the future. In addition, the patient was diuresed as much as possible though she required fluid boluses with chemotherapy administration and therefore was only negative 1.6L during her stay in the ICU. She also continued to receive nebulizer treatments. Her oxygenation did improve somewhat and the patient left the ICU on 15L 40% high flow mask. The patient and her family clearly wished for the patient to be DNR/DNI with palliative therapy as possible. On the floor, she was further diuresed. Her oxygen was weaned down and her respiratory status improved. She was reimaged on [**2164-5-18**] and in comparison to previous CT scan showed 40-50% reduction in tumor burden post-chemotherapy. A decision was made to initiate a second cycle of chemotherapy with 3 days of etoposide and cisplatinin which she tolerated without difficulty. A repeat CT scan on day #14 after this chemotherapy showed regression of previously extensive hilar adenopathy. Her oxygenation status continued to improve and at time of discharge she was satting 95-97% on room air. She is scheduled to unergo the third cycle of chemotherapy on Monday, [**6-18**]. . # Hyponatremia: She also was found to have hyponatremia to 125 without mental status changes. Urine lytes revealed SIADH, likely [**12-24**] paraneoplastic effect of small cell lung ca. TSH and cortisol were normal. She was placed on fluid restriction. Hyponatremia eventually resolved and was normal at time of discharge. . # Neutropenia: patient became neutropenic likely secondary to chemotherapy dosing on admission. She was given Filgrastim for two days after the first cycle of chemotherapy with improvement in her white cell counts. Her white count was monitored closely after second cycle of chemotherapy and became neutropenic with lowest measured ANC of 144 at time of discharge. She remained afebrile however. She will need to have a recheck of her white count on Friday, [**6-15**] prior to starting her third cycle of chemotherapy on Monday, [**6-18**] to ensure that her counts have recovered. # UTI: A screening urinalysis with culture showed enterococcus in the urine on [**5-26**] and vancomycin was given empirically. Final culture results showed sensitvity to macrobid, ampicillin and vancomycin and patient was started on IV ampicillin. Patient was switched to oral therapy with macrobid and will continue on this for a total of four doses to complete a 10-day course of antibiotic treatment for urinary tract infection. # Diarrhea: Developed diarrhea several days after cycle 2 of chemotherapy with multiple watery bowel movements daily (up to 10 bm's per day). Infection with Clostridium difficile was suspected, and antibiotics were started. Diarrhea resolved one-day after initiation of antibiotics, however C. difficile toxin assay was negative x3 and antibiotics were discontinued. It is thought that diarrhea was likely chemotherapy induced. Medications on Admission: Lovenox 40mg daily Aspirin 81mg daily Synthroid 112mcg daily Vicodin 10/500 2 tabs PO Q6 hours Klonopin 0.5mg [**Hospital1 **] Mirapex 0.125mg PO bid Alphagan 0.15% ophthalmic solution OU TID . Meds on transfer: Hydrocodone-Acetaminophen [**11-23**] TAB PO Q4H:PRN pain Ipratropium Bromide Neb 1 NEB IH Q6H Levothyroxine Sodium 112 mcg PO DAILY Allopurinol 150 mg PO DAILY Lorazepam 0.5 mg PO/IV Q8H:PRN nausea Mirapex *NF* 0.125 mg Oral Twice daily Aprepitant 80 mg PO DAILY Mirtazapine 7.5 mg PO HS Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H Ondansetron 8 mg IV Q 8H Dexamethasone 20 mg IV DAILY Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO Twice daily PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES twice daily Senna 2 TAB PO Twice daily:PRN constipation Heparin 5000 UNIT SC three times daily Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 12. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 17. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: The [**Location (un) 33316**] Home Discharge Diagnosis: Primary: Small Cell Lung Cancer Secondary: Hypertension Depression Hypothyroidism Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admiited for urgent chemotherapy of a newly diagnosed small call lung cancer. You were treated with two cycles of chemotherapy with etoposide and cisplatin. You should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**], your primary oncologist, for follow-up. Please return to the emergency room if you experience difficulty breathing, shortness of breath, chest pain, or any other symptoms that are concerning to you. Followup Instructions: You need to have a cbc drawn at the rehab center on Friday, [**6-15**] and faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] at [**Telephone/Fax (1) 78619**]. You will also need to be readmitted to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 7712**], [**6-18**] for cycle 3 of chemotherapy, pending the results of the lab tests on Friday, [**6-15**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**] Completed by:[**2164-6-11**] Name: [**Known lastname 6212**] [**Known lastname **],[**Known firstname 173**] M Unit No: [**Numeric Identifier 12655**] Admission Date: [**2164-5-4**] Discharge Date: [**2164-6-11**] Date of Birth: [**2083-5-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Prednisone / Tetanus / Paxil / Prochlorperazine Maleate Attending:[**First Name3 (LF) 12656**] Addendum: To clarify, on [**5-5**] patient was found to have RML and RLL complete collapse with a possible post-obstructive pneumonia. She was started on ceftriaxone and flagyl for presumed post-obstructive pneumonia. Clinical impression was that she did in fact have post-obstructive pneumonia. Later in her hospital course, she was having difficulty with thin liquids and a speech and swallow evaluation raised concerns for possible aspiration. A Chest X-ray on [**5-22**] was performed but was without infiltrates. The clinical impression at that time was that she did not have an aspiration pneumonia and as such, she was not treated. Discharge Disposition: Extended Care Facility: The [**Location (un) 8631**] Home [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 12657**] Completed by:[**2164-6-30**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.25" ]

icd9pcs

[ [ [] ] ]

15121, 15333

6071, 10194

346, 353

12921, 12960

3989, 6048

13475, 15098

3432, 3588

11068, 12710

12815, 12900

10220, 10414

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3603, 3970

299, 308

381, 2684

2706, 3201

3217, 3416

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26,494

112,397

5140

Discharge summary

report

Admission Date: [**2158-6-22**] Discharge Date: [**2158-9-16**] Date of Birth: [**2103-6-1**] Sex: F Service: MEDICINE Allergies: Dilaudid / Codeine / Ativan Attending:[**First Name3 (LF) 5301**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 55 F with complicated medical history who has been transferred from Rehab/[**Hospital3 417**] for dyspnea, acute on chronic renal failure, volume overload, and fungemia. In [**Month (only) 116**] of this year, presented to [**Hospital1 18**] ED with abdominal pain. Has significant PMHx for T1DM, HTN, PVD and was found in the ED to have extensive calcification of her mesenteric arteries. She was taken to the OR and found to have infarction of her colon with intact small bowel. She under went a colectomy with iliostomy at that time. Post op had respiratory failure requiring prolonged intubation and eventual tracheostomy. The etiology of her respiratory failure was unclear at her discharge. She was discharged to [**Location (un) 4368**] [**Hospital 21079**] rehab on [**2158-6-1**] after ~30 day hospitalization on TPN via CVL with tube feeds started. The plan was to advance tube feeds and wean TPN. On [**2158-6-17**], she was still on TPN at rehab and spiked a temperature up to 103 and blood cultures were positive for yeast ([**Female First Name (un) **] albicans by telephone report but not documented in transfer records). She was transferred to [**Hospital3 417**] in [**Hospital1 1474**] for further management. There she was initially given voriconazole and her central line replaced. Culture from the line again reportedly grew [**Female First Name (un) **]. She was then switched to fluconazole and finally to caspofungin today. She was also treated with ticarcillin/clavulanate for unclear reasons. During her hospitalization, she also had a "troponin leak" without EKG changes thought to be demand ischemia by their cardiology consultants. An echo done on [**2158-6-18**] showed global hypokinesis with EF 25-30%, dilated LA, LVH, moderated MR, moderate TR, although image quality was poor. Her hospitalization was also complicated by hyponatremia of unclear [**Name2 (NI) 10810**]. Her hospitalization was also complicated by acute on chronic renal failure (s/p transplant in [**2143**]). She did have episode of ATN in setting of her mesenteric ischemia with peak Cr of 4.3 with return to her baseline of 1.4-1.8 at time of discharge. Upon admission to [**Hospital3 417**] her Cr was 3.7 and remained elevated. It is unclear what work up was done for this. On the day of admission, she also developed respiratory distress with increasing volume retention. Attempts at diuresis with Lasix 400 mg IV were unsuccesful. She was transferred to [**Hospital1 18**] for management of her fungemia, renal failure and repiratory distress. Immediately prior to discharge or in the ambulance she was started on a nitro dip for again unclear reasons. Past Medical History: PMH: -Mesenteric ischmia requiring coloectomy [**2158-4-24**] -Respiratory failure requiring trach [**4-/2158**] -CRI s/p transplant in [**2143**] (followed by Dr[**Doctor Last Name **] at [**Last Name (un) **], transplant followed by Dr. [**Last Name (STitle) 15473**] -b/l Breast Cancer s/p lumpectomy/XRT and Chemo 199 (followed by Dr. [**Last Name (STitle) 3274**] -PVD s/p L BKA (followed by Dr.[**Last Name (STitle) 21080**]) - [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] with [**Doctor Last Name **]-DP bypass, -MI X2 s/p CABG times 2 -hypercholesterolemia -DM1 with retinopathy/neuropathy/nephropathy -left eye prosthesis -bilateral breast cancer -chronic anemia -gout Social History: lives with husband (a math professor [**First Name (Titles) **] [**Last Name (Titles) **]). Family History: NC Physical Exam: Vitals: T:96.0 P:98-107 R:22-24 BP:163-176/76-95 SaO2:98% on 4L CVP 21 General: Awake, alert, . HEENT: NC/AT, Pupil reactive on right, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no carotid bruits appreciated. unable to assess JVP Pulmonary: crackles bilaterally Cardiac: distant RRR, nl. S1S2, no M/R/G noted Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 2+ edema in upper and lower ext, 2+ radial, DP and PT pulses on right. Skin: diffuse brusing on abdomen. No other rash noted. Neurologic: -mental status: Alert, oriented x 3. -cranial nerves: II-XII Pertinent Results: POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-16* ANION GAP-23* [**2158-6-22**] 08:23PM WBC-18.9*# RBC-3.13* HGB-9.9* HCT-29.5* MCV-94 MCH-31.7 MCHC-33.6 RDW-18.9* NEUTS-95* BANDS-1 LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2158-6-22**] 08:53PM PT-12.8 PTT-25.9 INR(PT)-1.1 [**2158-6-22**] 08:51PM TYPE-ART TEMP-36.7 O2 FLOW-3 PO2-40* PCO2-29* PH-7.36 TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2158-6-22**] 08:51PM LACTATE-2.4* [**2158-6-22**] 08:23PM GLUCOSE-293* UREA N-131* CREAT-3.1*# SODIUM-125* [**2158-6-22**] 08:23PM CK(CPK)-17* [**2158-6-22**] 08:23PM CK-MB-4 cTropnT-0.26* [**2158-6-22**] 08:23PM CALCIUM-8.3* PHOSPHATE-4.7*# MAGNESIUM-2.5 Brief Hospital Course: 55 YOF with volume overload, dyspnea, renal failure, elevated WBC, fungemia, chest pain, and hyponatremia; details below. . ## Fungemia: Patient was diagnosed with fungemia by blood culture at [**Hospital1 **] and [**Hospital3 417**], likely due to TPN. Other sources include possible seeding of chronic thrombus in UE. TTE on [**2158-6-23**] demonstrated no evidence of vegetations. Ophthalmology eval demonstrated no opthalmic candidemia. Patient was initially started on PO fluconazole from 6.30.06-7.13.06. Patient did however continue to spike fevers while on antibiotic therapy, concerning for a new or resistant infection in the context of patient's immunosuppresion. Another possible source was pulmonary since patient's CT chest from [**2158-7-6**] demonstrated interval development of bilateral pulmonary nodules. Unclear etiology for bilateral pulmonary nodules. Nodules may have represented septic emboli from endocarditis, although no vegetations were demonstrated by echo on [**2158-6-23**] or [**2158-7-11**]. Patient was converted to IV caspofungin on [**2158-7-6**] until [**2158-7-12**]. During this time, patient remained afebrile and was converted back to PO fluconazole prior to discharge. Blood cultures from [**7-23**] had come back positive for yeast and per ID was switched to caspofungin. The evening before transfer to the floor, the patient's HD cath was removed as a possible site for infection. She was given a loading dose of 70mg IV and then given a daily dose of 50mg IV. She remained afebrile. Further workup was done to search for the source of the fungemia. A renal ultrasound was done which was normal. Ophthalmology was consulted to evaluate eye grounds and they did not feel the eye was a source of infection. A TTE was done which showed a small (0.7 x0.7 cm) mass attached to the highly calcified mitral annulus which may be a vegetation or a mobile piece of calcification coming off the larger mitral annular calcification. A follow up TEE was recommended, however the patient began to have increased emesis and it was unable to be performed. ID further recommended the PICC line to be replaced which was to be done with HD catheter placement. Cultures from [**Date range (1) 21081**] remained negative and a urine culture from this time was negative as well. . ## Klebsiella PNA: retrocardiac, pt received 10d of cefepime. course completed. . ## Renal Failure: Patient was admitted to MICU initally and received hemodialysis which greatly improved mental status. Renal u/s [**2158-6-23**] showed stable borderline hydronephrosis in the transplant kidney with elevated resistive indices and CT ab/pelvis [**2158-6-23**] showed air within the transplant kidney collecting systems, new from comparison, likely iatrogenic from foley placement. Then upon admission to the floor, patient had intractable fluid overload with associated edema and shortness of breath. Patient underwent hemodialysis three times which greatly improved fluid overload and shortness of breath. The patient's creatinine fell to a low of 1.9 while on the floor. However, the creatinine soon began to rise again to a high of 3.3 on the floor. The patient's acute on chronic renal failure was believed to be ATN vs. prerenal. The renal service was closely following the patient and recommended placement of an HD catheter in preparation for hemodialysis based on her worsening renal function and fluid status. She was given boluses and started on NS at 50cc/hr per renal. She was started on Bicitra 30 mL TID for acidosis. Allopurinol was decreased to q48h from q24 based on the renal function. The tacrolimus dose was halved and then held. . ## s/p renal transplant: Pt is normally on prednisone, tacrolimus, and azathioprine for immunosuppression. Patient was continued on steroids but tacrolimus and azathioprine were temporarily discontinued during this admission secondary to fungemia. Patient was eventually restarted on tacrolimus once she demonstrated improved control of her infection. Tacrolimus and prednisone was continued while the patient was on the floor. The FK506 was elevated and the tacrolimus dose was halved. When the level did not decrease, tacrolimus was held. Tacrolimus levels were followed with a goal trough [**2-26**]. Azathioprine was held. . ## Respiratory failure and shortness of breath: Patient initially had respiratory failure in the MICU, likely secondary to a combination of acid-base abnormalities, stiffness from fluid overload, and infectious process. Patient was started on cefepime and vancomycin initially for concern of gram negatives and MRSA, which was noted on OSH blood culture. Cefepime was discontinued since there was no obvious target and vancomycin was maintained for MRSA. Vancomycin was then discontinued given negative blood cultures and concern for vancomycin-induced thrombocytopenia. After transfer from the MICU, patient developed increasing shortness of breath with concern for fluid overload and infectious process. Patient's shortness of breath improved significantly with three rounds of hemodialysis. However, a CT scan of chest demonstrated interval development of pleural effusions and bilateral pulmonary nodules, concerning for an infectious process. Thoracentesis demonstrated a transudate effusion. Patient received antibiotic treatment with PO fluconazole and IV caspofungin. The patient was transferred on a trach collar, 40%, satting 100%, with upper airway secretions. She was suctioned frequently and O2 sats remained within normal limits. She was given nebulizers as indicated. Her fluid status was closely monitored as she was getting an increasing fluid load for hypercalcemia treatment. The patient was triggered on 8/? for altered mental status and question of respiratory distress. A CXR was done which showed worsening pulmonary edema however the patient had good oxygen saturation The patient's mental status did not impro . ## Hypercalcemia: Ms. [**Known lastname **] had a persistently elevated Ca with unknown cause. A bone scan was negative for metastatic osseous disease. TSH and PTH were within normal limits. She was treated with calcitonin and pamidronate, given lasix and fluids with some response. Per renal, further calcitonin was held as the patient did not respond adequately to it and they did not recommend pamidronate as it can contribute to renal failure. PTHrp was sent and was normal. Hypercalcemia thought to be secondary to imobilization. . ## Hyponatremia: Pt was initially hyponatremic to 125 on admission, likely in setting of volume overload from CHF/renal failure. Patient's sodium resolved with hemodialysis and was stable during admission. The patient's sodium remained stable while on the floor. . ## Type 1 Diabetes melitus: Patient has type 1 diabetes with major complications as listed above. She initially was started on an insulin drip and her insulin regimen was adjusted with help from [**Last Name (un) **]. . ## Anemia: Patient had anemia of chronic disease, most likely secondary to chronic renal insufficiency. HCT was trending down and guiac was positive, and patient received 1unit pRBC. She was stable post transfusion on [**6-26**]. No other transfusions were given, and th pt may require outpt colonoscopy. .. ## Thrombocytopenia: Patient developed thrombocytopenia during admission. Thrombocytopenia was thought to have developed secondary to vancomycin and platelets increased after discontinuing vancomycin. . ## UTI: During admission, patient's urine culture began growing vancomycin-resistant enterococcus. Patient was treated with linezolid. She again grew out many bacteria on a urine culture and was treated with ciprofloxacin and fluconazole (last day of cipro [**2158-9-23**], last day of fluconazole [**2158-9-18**]) . ## CAD: Patient is s/p MI x 2. Patient had no symptoms during admission. Patient was maintained on home meds of ASA, BB, and isosorbide dinitrate. . ## HTN: Patient's blood pressures have been occasionally elevated and hydralazine was increased to 15mg PO qid to assess for improved BP control. Patient was otherwise maintained on home doses of Clonidine, Metoprolol, and Isosorbide without other problems. . ## Depression/anxiety Patient was maintained on paxil. Ativan and ambien were discontinued secondary to increased somnolence with these meds. . . . MICU Transfer [**2158-8-21**] - [**2158-9-3**] Pt was admitted for hypotension. There was no clear source, with possiblities being septic (LLL opacity and 4+ MRSA in sputum, though no fever or WBC), adrenal insufficiency (started empirically on stress dose steroids), or cardiogenic. As she was not felt to clearly be septic and didn't seem to briskly respond to stress dose steroids, she had an echo performed, showing an EF of 25%, down from an echo one month prior showing 35-45%. Cardiology was consulted who felt that this was not acute ischemia, and that the decrement in function was likely overstated; it was felt that her prior study had been of sub-optimal quality and that probably had not been a significant interval change in LV-EF, and that this low EF was probably a mix of a baseline ischemic cardiomyopathy with a superimposed toxic/infectious cardiomyopathy. There was also concern, despite the physiologic controversy of this theory, that she was grossly volume overloaded and thus had tipped over to the disadvantageous arm of Starling's curve. In the setting of this gross volume overload with associated large bilateral pleural effusions (that had been tapped one month prior and found to be transudative, thought to be due to heart failure), she developed worsening respiratory distress and was placed back on the ventilator on minimal settings (p/s [**9-28**], fio2 40%) with immediate relief of her dyspnea. Over the next few days, she continued with treatment of her VAP and was diuresed during CVVH. She tolerated this well and was able to be weaned off pressure support and onto a trach mask without difficulty. By the time she was called out of the unit she had been tolerating trach collar alone for several days. . She was treated for ten days with vancomycin and ceftazidime for a hospital acquired pneumonia. Her stress dose steroids were tapered after three days of full dose, over the course of the following week. She was started on CVVHD to relieve her gross volume overload. With the combined effect of these interventions, her bp slowly climbed over the week, and she eventually became hypertensive with bp's in the 140-160's. She was then switched from CVVHD back to intermitten HD. . During the course, she had one episode of afib with RVR. At the time, her hr was in the 140's to 160's and a bp was not able to be obtained, though she did not lose conciousness. She was bolused 500cc of NS and a phenylephrine drip was started. She received 20mg of diltiazem IV with heart rate decreasing to the 90's to low 100's and bp up to the 120's. She receieved a 24` IV amiodarone load with reversion to sinus rhythm and was then switched over to oral amiodarone. . FLOOR COURSE: . ## Hallucinations/delusions: Pt having active hallucinations. Being treated for urine bacterial and fungal infections. No other abnormalities other than encephalopthy per EEG to explain new hallucinations. Unlikely to be from new-onset psyichiatric disease. MRI was unrevealing, Ca under control, head CT negative x2. Continue ciprofloxacin until [**9-23**]. Continue fluconazole until [**9-18**]. . ## Atrial fibrillation: Pt went into atrial fibrillation in the unit. Now in sinus rhythm after being treated with amiodarone. Rate-controlled. INR goal is 2.0-3.0. Pt's warfarin dosing has not been finalized, so should be adjusted daily. She was continued on metoprolol 50 [**Hospital1 **] for rate control and amiodarone 200 for rhythm control. . ## Coronary artery disease: No evidence of active ischemia. Continued metoprolol 50 PO bid, aspirin 81 PO qd . ## HTN: Pt is relatively normotensive. Continued metoprolol, hydralazine, isosorbide. . ## Ischemic cardiomyopathy: Total body volume overloaded given sacral edema and bilateral pleural effusions. Not symptomatic. . ## End stage renal disease s/p transplant: Needed HD and CVVH in unit. Now being evaluated daily for HD requirement. . ## Diabetes mellitus, Type 1: Mildly hyperglycemic throughout the day. Followed by [**Last Name (un) **] service to adjust insulin daily. . ## Respiratory failure: Pt c/o mild shortness of breath, but ascribes this to the valve on the trach collar. Has required intermittent nebs for wheeziness. . ## Hypercalcemia: Unlikely to be related to breast cancer as she has had a negative bone scan during this hospitalization. [**Month (only) 116**] be hypercalcemia from immobility. Received pamidronate 30 mg IV x2 with some normalization of calcium. . ## Breast cancer: Pt was started back on letrozole, but then discontinued again when she started having hallucinations. Medications on Admission: -hydrocortisone 100 mg iv q8h -SSI -azathioprine 50 mg qd -tylenol prn -allopurinol 100mg qd -clopidogrel 75 mg qd -metoclopramide 20 mg qid -nystatin swish and spit qid -epo 10K qwk -Femara 2.5 mg qd -tacrolimus 1mg [**Hospital1 **] -clonidine 0.2 mg tid -Colshicine 0.6 mg qd -colace -emeprazole 40 qd -Caspofungin 70 mg iv times 1 given [**6-22**] -lasix 40 mg iv bid -ASA 81 mg qd -paroxetine 20mg qd -metoprolol 50 mg tid -lorazepam 0.5 prn -Calcium [**Last Name (un) **] 500 mg tid -calcium acetate 667 tid -isosorbide dinitrate 50mg tid -albuterol prn -ipratropium prn -Ticarcillin/clavulanate 3.1g q8h -Nitro drip Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: PRIMARY - s/p renal transplant in [**2143**] - Candidemia - Urinary tract infection - Fluid Overload - Acute on Chronic Renal Failure - Thrombocytopenia - Anemia - Type 1 Diabetes Mellitus - Hypertension SECONDARY - Depression Discharge Condition: Fair - Patient is taking oral intake and breathing well on room air. Patient still requires PT to help her mobilize. Discharge Instructions: Please take all medications as prescribed. If you have symptoms of fevers, chills, night sweats, chest pain, worsening shortness of breath, or worsening swelling in lower extremities, please seek immediate medical attention. Followup Instructions: -- Please see your kidney transplant [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD on Date/Time:[**2158-7-25**] 10:45. His phone number is [**Telephone/Fax (1) 673**]. -- Please see your infectious disease physician, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD on Date/Time:[**2158-8-17**] 11:00. Her phone number is [**Telephone/Fax (1) 457**]. -- Please see your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. at Date/Time:[**2158-8-29**] 11:20. His phone number is [**Telephone/Fax (1) 5003**]

[ "287.4", "174.9", "349.82", "584.5", "275.42", "E930.8", "599.0", "519.1", "427.31", "112.5", "780.1", "V55.0", "403.91", "285.21", "996.81", "585.6", "482.0", "250.41", "428.0", "518.84", "V55.2" ]

icd9cm

[ [ [] ] ]

[ "00.14", "88.72", "39.95", "96.72", "38.95", "34.91", "38.93", "96.6", "33.22", "99.04" ]

icd9pcs

[ [ [] ] ]

18899, 18980

5280, 18226

295, 302

19251, 19370

4532, 5257

19643, 20272

3833, 3837

19001, 19230

18252, 18876

19394, 19620

4504, 4513

3852, 4451

248, 257

330, 2997

4466, 4487

3019, 3708

3724, 3817

4,382

184,581

48458

Discharge summary

report

Admission Date: [**2119-3-24**] Discharge Date: [**2119-4-1**] Date of Birth: [**2073-8-1**] Sex: F Service:GYN HISTORY OF THE PRESENT ILLNESS: This is a 45-year-old gravida III, para II with a history of tubal ligation and status post cesarean section times one complains of menorrhagia and known fibroid uterus. The patient presents 8 by 5.9 by 7.6 cm fibroid in the uterus. PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Status post low-transverse cesarean section times one. PAST MEDICAL HISTORY: 2. Hepatitis C. PAST OBSTETRICAL HISTORY: One ectopic pregnancy, one spontaneous vaginal delivery, one low-transverse cesarean section for a low-lying placenta. PAST GYNECOLOGICAL HISTORY: Not significant except for the history of the present illness. ALLERGIES: The patient has no known drug allergies. CURRENT MEDICATIONS: 1. Valium p.r.n. 2. Sonata p.r.n. for sleeping. SOCIAL HISTORY: The patient was a chronic smoker, stopped three years ago. Alcohol usage was in moderation. No substance abuse. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate, normal rhythm, with a II/VI systolic ejection murmur heard at the left sternal border. Breasts: Normal. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. Pelvic: External genitalia within normal limits. Vaginal support was intact. Vagina: Normal mucosa. No discharge. Cervical: No cervical motion tenderness. No blood noted. Uterus: Bulky, 12-14 cm size, irregularly firm, mobile, nontender uterus. Adnexa was not palpable on the right side secondary to an ultrasound that had shown an ovarian small cyst. HOSPITAL COURSE: On hospital day number one, the patient underwent a total abdominal hysterectomy for symptomatic fibroids. The EBL was 1,300 cc. Intraoperatively, her hematocrit was 29%. There was normal uterus, tubes, and ovaries. There were no complications intraoperatively. 1. GYN: The patient underwent a total abdominal hysterectomy on [**2119-3-24**] which was uncomplicated. The EBL, however, was 1,300 cc as the only complication. The patient had minimal vaginal bleeding to no vaginal bleeding throughout her hospital course. There were no further issues. 2. CARDIOVASCULAR: The patient remained stable from this standpoint. Her hematocrit, however, initially was 29% intraoperatively. It had nadir'd down on postoperative day number two to 22.9%. The patient continued to have excellent urine output, no tachycardia, and remained stable. At the time of discharge, her hematocrit had risen back to 24% on [**2119-3-28**] and at the time of discharge her last hematocrit on [**2119-3-29**] was 22.9%. Otherwise, stable. 3. PULMONARY: The patient had desaturated on [**2119-3-25**] to 84-85% on room air. The patient had a negative CT angiogram which showed no pulmonary embolus visualized. However, there was mild bibasilar atelectasis and minimal amount of bullae noted secondary to her chronic asthma. Since that time, the patient's pulmonary status and oxygen saturations were above normal, 96-98% on room air. It was thought that this desaturation was secondary to severe atelectasis because the patient was not getting out of bed and ambulating nor was she using the incentive spirometer. The patient did have pneumoboots that were placed throughout her hospital course to prevent DVTs or pulmonary embolus. 4. NEUROLOGICAL STATUS: On postoperative day number one, the patient complained of numbness and tingling in her legs on her right leg. She had a 4+ to 5- strength in her lower extremities bilaterally. However, we did obtain a Neurology consult secondary to the fact that the patient was not able to bear weight on her right extremity. The Neurology Service recommended doing an MRI which was obtained on [**2119-3-27**]. The MRI was negative for compression; however, they thought that there was a femoral nerve palsy. The patient continued to get physical therapy throughout the hospital course and actually did extremely well. She did have one fall secondary to her leg giving out on postoperative day number five; however, she remained stable from this standpoint. At the time of discharge, she had [**5-29**] muscle strength and it seemed like her right femoral leg palsy was resolving. The patient will continue to get physical therapy as an outpatient every day and after home PT will then progress to outpatient physical therapy. 5. INFECTIOUS DISEASE: The patient continued to have elevated fevers, spiking up to 102 postoperatively. However, she had a negative urine analysis. Her complete blood count remained stable at the highest level at 5.9 WBCs with a normal differential. Her blood cultures were negative throughout her hospital course as well as two urine cultures which were negative. Infectious Disease was consulted on [**2119-3-29**] secondary to elevated fevers. The patient had completed a five day course of ampicillin, gentamicin, and Flagyl without any difficulty but she continued to spike temperatures throughout. ID was consulted. They felt that given the fact that the CT angiogram demonstrated no focal consolidations for pneumonia, her blood and urine cultures all remained negative, that this fever was secondary to severe atelectasis versus a drug fever. The patient was discontinued with all antibiotics on [**2119-3-29**] and continued to remain afebrile since that time. There were no other infectious disease aspects. 6. FEN/GI: The patient had a low phosphorus of 1.7 on [**2119-3-26**]. We repleted her phosphorus with Neutra-Phos and subsequently did well. There were no other abnormalities and her electrolytes remained stable. The patient started tolerating a regular diet on [**2119-3-26**] without difficulty. DISCHARGE MEDICATIONS: 1. Percocet p.r.n. pain, a total of 50 tablets will be dispensed. 2. Motrin p.r.n. pain every 6-8 hours, a total of 60 tablets will be dispensed with one refill. DISCHARGE DIAGNOSIS: 1. Status post total abdominal hysterectomy secondary to symptomatic fibroids. 2. Intermittent asthma. 3. Right femoral nerve palsy. DISCHARGE STATUS: Good. DISCHARGE PLANS: The patient will follow-up with Dr. [**First Name (STitle) **] next week. She will also receive home physical therapy which will then progress to a program of physical therapy in the future for her right femoral nerve palsy. [**First Name11 (Name Pattern1) 21939**] [**Hospital1 21940**], M.D. [**MD Number(1) 21941**] Dictated By:[**Last Name (NamePattern1) 1892**] MEDQUIST36 D: [**2119-4-1**] 08:56 T: [**2119-4-2**] 17:50 JOB#: [**Job Number **]

[ "070.54", "285.9", "218.9", "780.6", "355.2", "626.2", "998.89" ]

icd9cm

[ [ [] ] ]

[ "68.4", "68.29" ]

icd9pcs

[ [ [] ] ]

5862, 6027

6048, 6752

1725, 5839

419, 499

854, 905

1073, 1707

521, 833

922, 1058

14,391

141,988

50554

Discharge summary

report

Admission Date: [**2138-3-12**] Discharge Date: [**2138-3-14**] Date of Birth: [**2064-6-14**] Sex: M Service: CHIEF COMPLAINT: Melena. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male who was recently admitted on [**2138-3-3**], for chest pain and ruled in for a myocardial infarction with positive troponin but negative CK, and during this admission was found to have OB positive stool and underwent EGD, and was found to have arteriovenous malformations in his stomach a was transfused 3 units of packed red blood cells. He was discharged and aspirin was restarted on [**3-8**]. He presents at this time with melena and weakness. Hematocrit was 28.5, and he was transfused 2 units of packed red blood cells and admitted to the medical intensive care unit. He underwent and upper endoscopy and was found to have a bleeding arteriovenous malformation in his stomach and underwent BICAP. He is now transferred to the medicine service on Prilosec, and aspirin is being held. He is currently asymptomatic. No nausea, vomiting, melena or hematochezia. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. 3. Prostate cancer, status post radiation therapy. 4. Gastritis. 5. Coronary artery disease, status post coronary artery bypass graft 11 years ago, right bundle-branch block with sinus bradycardia. No recent cardiac studies. 6. Status post appendectomy. 7. Status post back surgery. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Cardura 1 mg p.o. q.h.s., aspirin 81 mg p.o. q.d., Norvasc 7.5 mg p.o. q.d., vitamin E 400 IU p.o. q.d., Baycol 0.4 mg p.o. q.d. (except for Tuesdays and Saturdays), Zantac 150 mg p.o. b.i.d., sublingual nitroglycerin p.r.n. MEDICATIONS ON TRANSFER: On transfer, he had received 2 units of packed red blood cells, Prilosec 40 mg p.o. b.i.d. SOCIAL HISTORY: Positive tobacco, a 50-pack-year history. No alcohol. No IV drug use. Lives with wife at home. PHYSICAL EXAMINATION: Temperature 97.7, pulse 68, respiratory rate 20, blood pressure 134/60, oxygen saturation 99% on room air. In general, he was comfortable, in no acute distress. HEENT revealed normocephalic/atraumatic. Pupils were equal, round and reactive to light. Extraocular movements were intact. Cardiovascular had regular rate and rhythm, normal S1 and S2. Chest was clear to auscultation bilaterally. Abdomen was soft and nontender. Extremities had no clubbing, cyanosis or edema. LABORATORY: White blood cell count 6.6, hematocrit 29.5, platelets 140. Electrolytes were within normal limits. BUN 25, creatinine 1.2. CKs were 244 with a negative MB, 211, 208, and troponin 0.2. HOSPITAL COURSE: The patient was transferred to the medical service from the medical intensive care unit. He remained with a stable hematocrit and no further abdominal pain, nausea, vomiting, melena or hematochezia. He will continue on Prilosec 40 mg p.o. b.i.d. and aspirin will continue to be held. From a cardiovascular standpoint the patient was able to ambulate without and anginal symptoms. He will follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on discharge. MEDICATIONS ON DISCHARGE: 1. Cardura 1 mg p.o. q.h.s. 2. Norvasc 7.5 mg p.o. q.d. 3. Vitamin E 400 IU p.o. q.d. 4. Baycol 0.4 mg p.o. q.d. (except for Tuesdays and Saturdays). DISCHARGE DIAGNOSES: Upper gastrointestinal bleed with gastric arteriovenous malformation, status post Bipolar Circumactive probe. CONDITION AT DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Known firstname 22404**] MEDQUIST36 D: [**2138-3-14**] 18:14 T: [**2138-3-18**] 07:20 JOB#: [**Job Number **]

[ "410.72", "414.01", "537.83", "426.4", "V10.46", "V45.81", "401.9", "424.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

3371, 3492

3194, 3349

2687, 3168

1505, 1731

1987, 2669

3507, 3762

145, 154

183, 1089

1757, 1849

1111, 1483

1866, 1964

1,616

176,986

22305+57291

Discharge summary

report+addendum

Admission Date: [**2124-3-29**] Discharge Date: [**2124-4-3**] Date of Birth: [**2075-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion / Diminished exercise tolerance Major Surgical or Invasive Procedure: Second time redo (third time heart operation) for mitral valve replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and coronary artery bypass grafting x1 with reverse saphenous vein graft to the marginal graft. History of Present Illness: 48 year old gentleman with past medical history signicicant for triple vessel coronary artery bypass grafting in [**2118-9-9**] followed by a redo sternotomy with a bioprosthetic mitral valve replacement in [**2118-11-9**]. In [**2123-9-9**], he developed dyspnea on exertion with diminished exercise tolerance. An echo at that time did reveal that his mitral valve bioprosthesis had begun to degenerate by way of mitral stenosis. Over the winter, his symptoms have been progressive and worsening prompting a repeat echocardiogram this [**Month (only) 547**] which showed severe mitral stenosis and moderate mitral regurugitation. An exercise tolerance test was positive and a cardiac catheterization revealed severe three vessel native disease with severe vein graft disease. The left internal mammary artery had a patent touch down stent. Given the severity of his disease, he has been referred for a redo, redo stenotomy with mitral valve replacement and coronary artery bypass grafting. Past Medical History: Coronary artery disease s/p coronary artery bypass graft x 3 (PCI and cypher stenting of SVG-OM, LIMA-LAD [**2118-9-9**]) Mitral regurgitation s/p Mitral valve replacement [**11-11**] Biopresthetic Mitral valve stenosis/regurgitation Ischemic cardiomyopathy LVEF 40-45% by echo [**2124-3-9**] Dyslipidemia Hypertension Sleep apnea (no c-pap) Social History: Race: Caucasian Last Dental Exam: many yrs ago, edentulous Lives with: Wife and daughter Occupation: rug salesman Tobacco: 30+ pack yr history, currently smoking several cigs/day ETOH: several beers/week Family History: Brothers with CAD (1 underwent CABG, another w/ stents) Physical Exam: Pulse: 79 Resp: 16 O2 sat: 99% B/P Right: 125/90 Left: 134/105 Height: 5'9" Weight: 190 lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] well-healed sternotomy and right thoracotomy incision HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 1-2/6 systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] healed EVH incision right leg Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ (healing cath site) Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: - Pertinent Results: [**2124-3-29**]: TTE 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. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %) with mild hypokinesis in the mid and apical inferior wma. The right ventricular cavity is moderately dilated with borderline normal free wall function. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets are thickened. The gradients are higher than expected for this type of prosthesis. There is severe valvular mitral stenosis (area <1.0cm2). Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]/[**Doctor First Name **] was notified in person of the results on Mr.[**Known lastname 58103**] before surgical incision. Post_Bypass; Mild global RV hypokinesis. Mild global LV dysfunction with added focalities in the mid and apical inferior walls (similar to prebypass) There is a bileaflet metallic prosthesis in the mitral position, stable, both leaflets moving, typical washing jets present. Thoracic aorta is itnact. Mild TR. [**2124-4-3**] 05:50AM BLOOD Hct-28.1* [**2124-4-1**] 07:00AM BLOOD WBC-9.9 RBC-3.28* Hgb-9.9* Hct-28.9* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-257 [**2124-4-3**] 05:50AM BLOOD UreaN-15 Creat-0.9 K-4.0 [**2124-4-1**] 07:00AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-134 K-3.6 Cl-95* HCO3-32 AnGap-11 [**2124-4-3**] 05:50AM BLOOD PT-27.6* INR(PT)-2.7* [**2124-4-2**] 05:35AM BLOOD PT-31.7* PTT-32.9 INR(PT)-3.2* [**2124-4-1**] 08:45PM BLOOD PT-22.4* PTT-32.6 INR(PT)-2.1* [**2124-4-1**] 07:00AM BLOOD PT-21.0* PTT-28.0 INR(PT)-1.9* [**2124-3-31**] 02:46AM BLOOD PT-15.1* INR(PT)-1.3* Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2124-3-29**] where the patient underwent a second time redo (third time heart operation) for mitral valve replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and coronary artery bypass grafting x1 with reverse saphenous vein graft to the marginal graft. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was started on Coumadin on [**2124-3-31**] for his mechanical mitral valve replacement and anticoagulated for a goal INR 2.5-3.5. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged post operative day 5 in good condition with appropriate follow up instructions. He is to be followed by Dr. [**Last Name (STitle) 32255**] for Coumadin dosing and visiting nurses is to draw INR on [**2124-4-4**] and call results to [**Telephone/Fax (1) 6256**] for goal INR 2.5-3.5. He is to receive 5 mg of Coumadin [**2124-4-3**] prior to discharge. Medications on Admission: Metoprolol Succinate ER 50mg daily Lisinopril 10mg daily Buproprion SR 150mg daily **Plavix 75mg Daily** Lovaza 1gram TID Zetia 10mg daily Tricor 145mg daily Folic acid Calcium with vitamin D Multivitamins Niacin 500mg TID Aspirin 325mg daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Goal INR 2.5-3.5 - take as instructed. Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Severe prosthetic mitral valve stenosis and recurrent coronary artery disease, status post coronary artery bypass surgery and status post mitral valve replacement. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks ***NO MOTORCYCLE DRIVING 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 at [**Hospital1 **] [**Telephone/Fax (1) 6256**] for wound check and post-op follow-up Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) 12300**] in [**12-11**] weeks Cardiologist Dr. [**Last Name (STitle) 32255**] in [**12-11**] weeks ([**Telephone/Fax (1) 20259**] Labs: PT/INR for Coumadin ?????? indication mechanical mitral valve replacement Goal INR 2.5-3.5 First draw [**2124-4-4**] Results to Dr [**Last Name (STitle) 32255**] phone [**Telephone/Fax (1) 6256**] fax [**Telephone/Fax (1) 31080**] **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:[**2124-4-3**] Name: [**Known lastname 10778**],[**Known firstname **] Unit No: [**Numeric Identifier 10779**] Admission Date: [**2124-3-29**] Discharge Date: [**2124-4-3**] Date of Birth: [**2075-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Lipitor not covered by insurance company therefore medication changed to Zocor 10 mg po daily. Also added to discharge medications: Wellbutrin 150 mg SR daily Tricor 145 mg daily Zetia 10 mg daily Folic Acid 2 mg daily Lisinopril 10 mg daily Niacin 500 mg three times a day Patient instructed to restart Omega-3 acid tablets once home Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2124-4-3**]

[ "414.2", "V58.61", "305.1", "458.29", "327.23", "996.02", "414.8", "E878.1", "V53.32", "V45.82", "401.9", "414.02", "272.4", "424.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11266, 11446

5379, 7092

372, 626

8667, 8882

3125, 5356

9678, 11015

2251, 2309

11038, 11243

8480, 8646

7118, 7363

8906, 9655

2324, 3106

281, 334

654, 1647

1669, 2013

2029, 2235

23,207

171,490

24885

Discharge summary

report

Admission Date: [**2184-10-30**] Discharge Date: [**2184-11-5**] Date of Birth: [**2119-1-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: zygomatic fracture Major Surgical or Invasive Procedure: OPEN REDUCTION INTERNAL FIXATION OF ZYGOMATIC FRACTURE History of Present Illness: 65M with h/o seizure d/o tx from OSH after fall from 4 ftt off ladder on [**2184-10-29**]. Pt is amnestic to incident and it was unwitnessed. Questionable LOC. Pt cannot specifically recall events surrounding incident but denies any prodrome of dizziness or palpitation. Last seizure 2 years ago, maintained on dilantin. Pt found by EMS with GCS 14 and transferred to [**Hospital 1562**] hospital. Found on OSH CT to have small B SAH and L IPH, C-spine clear. Pt denies any visual changes now. Past Medical History: 1. Seizure disorder 2. OCD 3. HTN 4. Hyperlipidemia 5. CAD s/p stent placement x 2 6. s/p chin implant and distant rhinoplasty Social History: Denies tobacco, etoh or other drug use, Pt is unmarried, works in warehouse Physical Exam: GEN NAD LEFT EYE RACCOON SIGN, LEFT BATTLE SIGN, TENDER TO PRESSURE PERIOBITAL REGION NO CERVICAL TENDERNESS HEART REG RATE RHYTHM LUNGS CLEAR TO ASCULTATION ABDOMEN SOFT/NT/ND Brief Hospital Course: UPON ARRIVAL, THE PATIENT WAS ADMITTED TO THE TRAUMA SERVICE. A HEAD CT WAS OBTAINED SHOWING SMALL SUBARACHNOID HEMATOMA THAT DID NOT REQUIRE SURGICAL INTERVENTION BY NEUROSURGERY. A CT OF THE FACE SHOWED: L non-displaced temporal fx, L sphenoid fx, L minimally displaced zygomatic fx, L maxillary fracture, L inferior and minimally displaced posterior orbital fx. No retroorbital hematoma. ? medial wall or R maxillary sinus fx. Opacities c/w blood in L frontal, ethmoid and sphenoid sinus. X-RAY OF THE LEFT HAND: an apparent acute fracture involving the base of the distal phalynx of the left fifth finger, with the fracture line extending to the articular margin. HE WAS [**Hospital 11166**] TRANSFERRED TO THE PLASTIC SURGERY SERVICE FOR OPEN REDUCTION INTERNAL FIXATION OF THE ZYGOMATIC FRACTURE. HE TOLERATED THE PROCEDURE WELL. HIS FINGER DID NOT REQUIRE SURGERY AND WAS PLACED IN A SPLINT. HE HAS AFEBRILE WITH NORMAL VITALS. HE HAS ALSO BEEN OUT OF BED, TOLERATING SOFT DIET, PRODUCING GOOD URINE. HE WILL BE DISCHARGED IN GOOD CONDITION TO A REHAB FACILITY. Medications on Admission: 1. Dilantin 2. ASA 3. Prozac 4. Zestril 5. Lopressor Discharge Medications: 1. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H (every 6 hours) for 7 days. 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 10 days. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 15. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 16. Hydromorphone 2 mg/mL Syringe Sig: [**2-1**] Injection Q3-4H (Every 3 to 4 Hours) as needed for break through pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: FRACTURE OF ZYGOMA SMALL FRACTURE OF DISTAL LEFT SMALL FINGER Discharge Condition: GOOD Discharge Instructions: PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS CAREFULLY. IF SIGNS AND SYMPTOMS OF INFECTION, SUCH AS FEVERS/CHILLS, PURULENT DISCHARGE FROM WOUND/INCISION SITE, INCREASED REDNESS, INCREASED PAIN, PLEASE CALL OR GO TO THE EMERGENCY ROOM. REMEMBER TO CALL TO SCHEDULE YOUR FOLLOW UP APPOINTMENT (BELOW). LIGHT ACTIVITIES UNTIL SEEN IN CLINIC. [**Month (only) **] SPONGE BATH AND SHOWER TOMORROW. NO BATHS. PAD DRY, DO NOT SCRUB. PLEASE KEEP SPLINT IN PLACE UNITIL SEEN IN CLINIC. Followup Instructions: PLEASE CALL DR. [**Last Name (STitle) 2647**] FOR A FOLLOW UP APPOINTMENT ([**Telephone/Fax (1) 10419**] Completed by:[**2184-11-5**]

[ "801.21", "414.01", "272.4", "811.01", "780.39", "816.02", "802.4", "E881.0", "V45.82", "401.9" ]

icd9cm

[ [ [] ] ]

[ "76.72" ]

icd9pcs

[ [ [] ] ]

4087, 4199

1380, 2456

333, 390

4305, 4312

4857, 4993

2560, 4064

4220, 4284

2482, 2537

4336, 4834

1178, 1357

275, 295

418, 918

940, 1069

1085, 1163

3,052

114,338

1567+1568

Discharge summary

report+report

Admission Date: [**2155-8-14**] Discharge Date: [**2155-8-17**] Date of Birth: [**2112-9-15**] Sex: M Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old white male with past medical history significant for alcoholic cirrhosis, chronic pancreatitis resulting in pancreatic insufficiency, and insulin dependent-diabetes mellitus, chronic renal failure with baseline creatinine of 4.0, chronic thrombocytopenia, who has a recent admission to the [**Hospital1 69**], who presented on [**2155-8-13**] with acute onset fatigue, worsening dyspnea on exertion, increased lower extremity edema, and decreased urine output x3 days. The patient was recently admitted at [**Hospital1 190**] from the period of [**2155-7-12**] to [**2155-7-16**] for refractory lower extremity edema x2 weeks. This admission was also associated with a 25 pound weight gain with increased abdominal girth and exertional shortness of breath, and fatigue. He was discharged home with decreased edema on Lasix dose of 80 mg po bid, hydrochlorothiazide qod, along with levofloxacin for urinary tract infection. He now returns reporting return of the fatigue, exertional dyspnea on exertion, lower extremity edema for the past few days, and decreased urine output. On presentation, he denied any chest pain, fevers, abdominal pain, cramps, or cough. He reports baseline diarrhea which is not changed. He denied bright red blood per rectum, melena, nausea, vomiting, hematemesis. His last alcohol intake was 24 hours prior to this admission. Laboratories on admission were significant for a BUN-creatinine ratio of 58/8.6, a troponin-T of -.42 with a CK of 64, and a hematocrit on admission of 28 that dropped to 23.6 12 hours later. Electrocardiogram was unchanged. Rectal examination showed heme-negative stool. Urine electrolytes were not consistent with a prerenal etiology of acute or on chronic renal failure, but of note, he had been getting Lasix at home. On examination, he was euvolemic. PAST MEDICAL HISTORY: 1. Chronic alcoholic pancreatitis complicated by pseudocyst in 10/99, resulted in pancreatic insufficiency and insulin dependent-diabetes mellitus. 2. Insulin dependent-diabetes mellitus with nephropathy and neuropathy: Insulin dependent x3 years. He had episodes of diabetic ketoacidosis with an Intensive Care Unit admission in 08/[**2154**]. 3. Chronic renal failure with baseline creatinine of 4.0. 4. History of alcohol abuse, resulting in cirrhosis. 5. Hypertension. 6. Obstructive-sleep apnea on BiPAP at home. 7. History of bilateral nephrolithiasis, complicated by development of pyelonephritis and urosepsis. 8. Anemia secondary to renal failure. 9. History of thrombocytopenia secondary to Haldol. 10. History of multiple perirectal abscesses, status post multiple incision and drainage procedures. 11. History of ARDS in 10/99 with tracheostomy for six weeks; developed ARDS during pancreatitis episode. Complicated by Pseudomonas pneumonia, pancreatic necrosis, Clostridium difficile colitis, line sepsis, left lower extremity DVT, Haldol induced thrombocytopenia. 12. History of left lower extremity DVT. 13. History of Clostridium difficile colitis. 14. History of right vocal cord paralysis. 15. Gastritis. 16. History of diabetic foot ulcers. MEDICATIONS PRIOR TO ADMISSION: 1. Insulin-sliding scale. 2. Calcium carbonate 500 mg po tid with meals. 3. Nephrocaps one cap po q day. 4. Protonix. 5. Epogen 5,000 units subQ 2x/week administered on Tuesdays and Fridays. 6. Folic acid 1 mg po q day. 7. Pancrease three caps po tid with meals. 8. Sodium bicarbonate 1300 mg po tid. 9. NPH 10 units q am. 10. Hydrochlorothiazide 12.5 mg qod. 11. Lasix 80 mg po bid. ALLERGIES: The patient reports allergies to Haldol resulting in thrombocytopenia. SOCIAL HISTORY: Former real estate [**Doctor Last Name 360**], current unemployed. Lives alone. Smokes 1-1.5 packs per day x20 years. Currently admits to five drinks of alcohol per week. Denies any IV drug use or any recreational drug use. Divorced with no children. PHYSICAL EXAM UPON ADMISSION: Vital signs: Temperature of 96.3, blood pressure 116/70, heart rate 96, respiratory rate 12, oxygen saturation 100% on 2 liters face mask. General appearance: Supine, well-developed white male in no apparent distress, disheveled, peeling skin. HEENT: Normocephalic, atraumatic. Skin on face scaly, pupils are equal, round, and reactive to light and accommodation. Extraocular eye movements intact. Eyes and sclerae icteric. Oropharynx clear. Pulmonary examination: Bibasilar rales, occasional expiratory wheeze. Coronary examination: Regular, rate, and rhythm, no murmur. Abdominal examination: Positive bowel sounds, nontender, distended, positive fluid wave, liver and spleen not palpable. Extremities: [**1-23**]+ edema to knee bilaterally. Neurologic: Cranial nerves II through XII intact, moves all four extremities, no asterixis noted. PERTINENT LABORATORIES AND OTHER STUDIES: Complete blood cell count showed white blood cell count 12.1 with differential of 71.6% neutrophils, 16.5% lymphocytes, 5.5% monocytes, 1.2% eosinophils, 0.6% basophils. Hematocrit is 28.1, platelets 89. Serum chemistries showed sodium 138, potassium 3.5, chloride 101, bicarbonate 13, BUN 56, creatinine 8.6 (creatinine was 3.9 on [**7-23**]), glucose 304. ALT 23, AST 30, amylase 25, ALT 254, LDH 218, total bilirubin 0.9, albumin 1.8, total protein 6.4, lipase 5. Coagulation profile showed a PT of 14.5, PTT 45.1, INR 1.4. Alcohol level was 35. Chest x-ray showed small bilateral pleural effusions. Left lower lobe atelectasis. Urinalysis showed specific gravity of 1.010, large blood, negative nitrate. Positive trace protein. Moderate leukocytes, [**12-11**] red blood cells, and greater than 50 white blood cells, 0 epithelial cells, and no bacteria. Renal ultrasound showed no evidence of hydronephrosis. A large simple right kidney cyst was noted. It is not significantly changed from prior studies. SUMMARY OF HOSPITAL COURSE: 1. Acute renal failure: Patient is a 42-year-old male with a history of alcoholic cirrhosis, chronic renal failure, diabetes with nephropathy, status post recent admission for worsening renal failure, and urinary tract infection, now presents with a [**3-25**] day history of exertional dyspnea, fatigue, poor urine output consistent with fluid overload secondary to acute on chronic renal failure. The etiology of his acute on chronic renal failure is unclear. It is probably not prerenal given that he appeared euvolemic on exam, and now that although his diuretic doses had recently been increased, he was not losing any fluid wave. The plan was to initially hold off on any IV fluids and diuretics. Initially, it was felt that the patient did not have any indication for acute hemodialysis. Indications for hemodialysis were to include intractable dyspnea, uncontrolled uremic symptoms like nausea or encephalopathy, or hyperkalemia. Renal consultation service team was [**Name (NI) 653**], and they agreed with the plan to not aggressively diurese the patient initially unless his respiratory status declined. However, his respiratory status remained stable, and on hospital day #2, he reported an inability to make urine. That evening the patient was given trial of diuretics. Specifically, he was given Lasix 100 mg IV, and also he was given metolazone 10 mg po. This also failed to result in any urine production. The patient's BUN and creatinine continued to increase. He continued to complain of shortness of breath, but not to the point that it limited activity. He continued to remain alert and oriented, and without any signs of uremic encephalopathy. He was to undergo Permacath placement on [**2155-8-18**], and was to receive hemodialysis also on that day. The metabolic abnormalities associated with his uremia included calcium carbonate 500 mg po tid, Nephrocaps one cap po q day, Epogen 5,000 units subQ 2x/week on Tuesdays and Fridays, Amphojel, and calcitriol. 2. Dyspnea: The patient was only slightly dyspneic likely to compensate for the underlying metabolic acidosis secondary to his uremia. Initially, the plan was to diurese the patient or dialyze him if he became severely dyspneic and had chest x-ray evidence of fulminant failure. However, the patient's respiratory status remained stable and his level of dyspnea was felt not to warrant acute intervention. Instead he was managed symptomatically with albuterol inhalers and oxygen therapy. Initially, it felt that some component of his dyspnea might be due to his abdominal ascites collection. Therefore on hospital day #2, he underwent a paracentesis with drainage of 2 liters of acidic fluid. This resulted in some resolution of his dyspnea. Finally, the patient was to continue his BiPAP machine that he brought from home for treatment of his obstructive-sleep apnea. 3. Elevated troponin: Upon admission, the patient had an elevated troponin value. It was felt that very possibly he had an acute coronary event a few days prior to admission leading to renal hypoperfusion, which might explain his acute renal decompensation. However, it felt that based on his comorbidities, that there was no role for Heparin or emergent catheterization at his initial presentation. An aspirin was held given patient's history of thrombocytopenia and uremia. He was not given a beta blocker given that his clinical status was tenuous and there was a question of unstable hematocrit values. Cardiac echocardiogram was obtained, which demonstrated a hyperdynamic ejection fraction greater than 75% and mild left ventricular hypertrophy. 4. Diabetes: Initially patient came in on NPH 10 units q am. However, it is felt that initially his fingerstick blood glucose values were running low. Therefore, his NPH was changed to 5 units q am and he was covered additionally with regular insulin-sliding scale. 5. Cirrhosis: Upon admission, the patient had large volume ascites. He had a diagnostic tap on his previous admission in [**2155-6-22**] with no evidence of spontaneous bacterial peritonitis. He underwent a therapeutic paracentesis on the afternoon of [**2155-8-15**] with removal of 2 liters of acidic fluid. At the time of this dictation, culture results on that fluid were still pending. 6. Anemia: On the day of admission, patient had a drop in hematocrit from 28 to 23.6 in 12 hours. He was therefore transfused 1 unit packed red blood cells. His stool was checked for occult blood and was heme negative. He was given his regular outpatient dose of Epogen 5,000 units subQ on [**2155-8-15**]. He was additionally to receive Epogen during his dialysis sessions. 7. Dermatological: Patient had a two week history of erythematous, excoriated rash on his legs, back, face, and arms. Throughout the course of his hospital stay, the rash became more erythematous and excoriated. Therefore Dermatology was consulted. Per their recommendations, multiple topical ointments and moisturizing regimens were added to the patient's previous medication list. In addition, wound consult was obtained secondary to patient's history of diabetic foot ulcers. After initiation of this dermatological regimen, the patient experienced mild improvement in his skin rash and excoriation. 8. History of alcohol abuse: Patient was placed on Ativan and CIWA scale monitoring for alcohol withdrawal symptoms. The remainder of the hospital course, discharge status, condition, medications, and followup plans will be dictated as a separate addendum to this report. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**] Dictated By:[**Last Name (NamePattern1) 257**] MEDQUIST36 D: [**2155-8-17**] 17:57 T: [**2155-8-28**] 08:27 JOB#: [**Job Number 9133**] cc:[**Name8 (MD) 9134**] Admission Date: [**2155-8-14**] Discharge Date: [**2155-9-15**] Date of Birth: [**2112-9-15**] Sex: M Service: TELIS MEDICINE HISTORY OF PRESENT ILLNESS: Patient is a 42 year-old male with a history of alcoholic cirrhosis, chronic pancreatitis and pancreatic insufficiency, chronic renal failure, alcohol abuse with a recent admission for worsening renal failure, ascites, lower extremity edema. Patient is a poor historian and presents with a history of dyspnea on exertion, fatigue, exhaustion and reportedly increased lower extremity edema. He states since he left the hospital on [**7-16**] he has noticed increased swelling. He also states that he has increased shortness of breath over the past several days. He denies chest pain. He also complains of decreased urine output over the last several days, denies fevers, abdominal pain, cramping, cough. Does have some baseline diarrhea which he states has not changed. He denies bright red blood per rectum, melena, vomiting, hematemesis. He has a long history of alcohol abuse and states that his last drink was 24 hours prior to admission. EXAMINATION: Temperature 96.3, blood pressure 116/70, heart rate 96, respirations 12, oxygen saturation 100 percent on 2 liters nasal cannula. General: Patient is in no acute distress. He has some scaling on his face. Eyes: Extraocular movements intact, pupils equal, round, reactive to light. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops. Pulmonary: some bibasilar rales, occasional expiratory wheezes. Abdominal: normal active bowel sounds, nontender. Has some distention, positive fluid wave. Liver and spleen are not palpable. Extremities: 1 to 2+ edema to the knees bilaterally. Neurological cranial nerves 2 through 12 intact. Moves all extremities well and has no asterixis. LABORATORY DATA: White count 12.1, hematocrit 28.1, platelets 89, 76 percent neutrophils, 16 percent lymphocytes, 5 percent monocytes, 1 percent eosinophils. Sodium is 138, potassium 3.5, chloride 101, bicarbonate 13, BUN 56, creatinine 8.6, glucose 304. ALT is 23, AST is 30, amylase is 25, alk phos is 254, LDH is 218, total bilirubin is 0.9, albumin 1.8, total protein 6.5, lipase is 5. PT is 14.5, PTT is 45.1,INR is 1.4. Alcohol is 35. Chest x-ray shows small bilateral pleural effusions with left lower lobe atelectasis. Arterial blood gases is 7.37, 28, 114, and 17. HOSPITAL COURSE: 1) Infectious disease. Patient with MRSA sepsis and Candidemia. Patient became septic on [**8-22**] with fever, hypotension and blood culture which was positive for MRSA. Patient was started on Vancomycin for a full 20 day course. His Medical Intensive Care Unit course was also complicated by Candidemia treated with intravenous fluconazole times 11 days. He was then finished on his course with p.o. Fluconazole for a total of 28days. Patient will be discharged home with oral fluconazole to finish out his course for a total of 28 days. 2) Renal. Patient with end stage renal disease on hemodialysis. Patient presented with uremia and initiated hemodialysis. He had a Permacath placed for permanent hemodialysis access. He will continue on PhosLo and Epogen. He is followed by the renal team. 3) Pulmonary. Patient with respiratory distress on [**2155-8-22**] with saturations in the 70s on nonrebreather mask. He was transferred to the Medical Intensive Care Unit and intubated. He was extubated on the 7th and put on CPAP but underwent a bronchoscopy to look for mucous plugs. On [**8-31**] he was then reintubated and subsequently extubated on [**9-5**]. He has remained stable respiratory-wide on the floor and he has a history of obstructive sleep apnea. He has been continued on BiPAP on the floor. 4) Gastrointestinal. Alcoholic cirrhosis with diarrhea. Patient with history of encephalopathy, continued on lactulose. He has had no hepatic synthetic dysfunction this admission. His lactulose was held on [**9-13**] for some ongoing diarrhea. His mental status remained clear on he floor. He was continued on a proton pump inhibitor and the gastrointestinal team was consulted on the 23rd for work up of his diarrhea. His work up including stool culture and C. difficile remained negative except that his diarrhea improved on a lactose free diet. Patient is to have a lactose hydrogen breath test as an outpatient and can follow up with Dr. [**Last Name (STitle) 9135**] [**Name (STitle) **] for this test. 5) Endocrine. Type 2 diabetes. Patient was poorly controlled. Blood sugars on sliding scale insulin when he was transferred to the floor. We consulted the [**Hospital1 **] Diabetes service and he was started on sliding scale insulin and nighttime Lanta with some improvement of his blood sugars. Patient will be maintained on the current regimen. 6) Dermatology. Patient presented initially with maculopapular painful rash on all of his extremities on sun exposed areas. Dermatology was consulted and felt this was a photo sensitivity reaction while on hydrochlorothiazide. The patient was treated with topical steroids and his hydrochlorothiazide was held. His rash is much improved today. 7) Hematology. [**Hospital **] Medical Intensive Care Unit course is complicated with diffuse intervascular coagulation and heparin-induced thrombocytopenia. He had elevated PT and PTT and thrombocytopenia thought secondary to diffuse intervascular coagulation from sepsis in the Medical Intensive Care Unit. He gradually improved with supportive therapy and normalized his coagulations on the floor. Patient also had thrombocytopenia thought secondary to heparin in the Medical Intensive Care Unit. His heparin was discontinued and his platelets remained borderline low but improved to the low 100s. His platelets again began to drop on [**9-13**] to [**9-14**] and his cimetidine was changed to Protonix as cimetidine with known adverse hematologic effects. 8) Prophylaxis. Patient was maintained on a proton pump inhibitor and Venodynes. 9) Code status. Patient is full code. 10) Disposition. Patient is very weak and will be discharged to a rehabilitation facility as he may benefit from continued physical therapy to regain his strength. DISCHARGE STATUS: Stable. DISCHARGE DISPOSITION: Patient is full code. FOLLOW UP PLANS: When patient is discharged the patient will follow up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**] in the next two to three weeks. Patient is also to follow up with Dr. [**Last Name (STitle) 9135**] [**Name (STitle) **] of gastroenterology to be bested for lactose intolerance in the next month. CURRENT MEDICATIONS: 1) Sliding scale Humalog with seven units regular h.s. 2) Erythropoietin alpha 5,000 units subcutaneously two times per week Tuesdays and Fridays to be given at dialysis. 3) hydroxyzine 50 mg p.o. q 4 to 6 hours p.r.n. itching. 4) Bacitracin ointment one application b.i.d. 6) triamcinolone 0.1 percent cream one application b.i.d., 7) Aquaphor one application b.i.d., 8) PhosLo 1336 mg p.o. t.i.d. with meals, 9) Calcitriol 0.5 mcg p.o. q. day, 10) Tylenol 325 to 650 mg p.o. q. 4 to 6 hours p.r.n. pain. 11) albuterol 1 to 2 puffs inhalation q. 6 hours p.r.n., 12) albuterol ipratropium 1 to 2 puffs q. 6 hours, 13) calcium carbonate 500 mg p.o. t.i.d. with meals. 14) Nephrocaps 1 tablet p.o. q day. 15) Pantoprazole 40 mg p.o. q. day, 16) folate 1 mg p.o. q. day, 17) Pancrease 5 caps p.o. t.i.d. with meals, 18) fluconizole 200 mg p.o. q. day. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**] Dictated By:[**Last Name (NamePattern1) 5819**] MEDQUIST36 D: [**2155-9-14**] 20:31 T: [**2155-9-14**] 20:44 JOB#: [**Job Number 9136**]

[ "584.9", "486", "571.2", "518.82", "038.11", "286.6", "112.5", "785.59", "572.2" ]

icd9cm

[ [ [] ] ]

[ "00.14", "99.15", "39.95", "33.24", "38.93", "38.95", "93.90", "38.91", "96.72", "54.91", "96.05" ]

icd9pcs

[ [ [] ] ]

18237, 18655

14385, 18213

6065, 12086

3338, 3807

18677, 19822

12115, 14367

4110, 6037

2042, 3306

3824, 4095

592

180,029

10821

Discharge summary

report

Admission Date: [**2121-8-7**] Discharge Date: [**2121-8-14**] Date of Birth: [**2058-4-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Motor vehicle accident [The patient was an unrestrained driver who hit a bridge wall. Atthe scene, he was awake, c/o CP/SOB. By report, he had seizure activity in transit.] Major Surgical or Invasive Procedure: Exploratory Laparotomy, Gastrostomy, Jejunostomy, IVC filter placement History of Present Illness: 63yo M who was in a motor vehicle collision who was treated at an outside hospital, had a left chest tube placed and was intubated and was brought to [**Hospital1 **] for further treatment and care. The patient was an unrestrained driver who hit a bridge wall. At the scene, he was awake, c/o CP/SOB. By report, he had seizure activity in transit. Upon arrival to trauma and undergoing resuscitation the patient was found to be hypotensive and had ended up having a positive DTL. He went into PEA and had chest tube placed without blood back, had CPR, epi/atropine x 1 and was successfully resuscitated. He was deemed too unstable for the CT scanner and was brought emergently to the OR. He underwent ex-lap, which revealed pelvic hematoma. He also had a bolt placed, with opening pressure 80. Maximum GCS here was 3. Pupils were unreactive on exam, no response to painful stimuli in any extremities. Past Medical History: COPD, esophageal strictures s/p multiple dilatations, PVD, carotid stenosis, h/o arrhythmia, 70+ppy tobacco Physical Exam: P/E V/S 130s 80/40s Gen intubated CV rrr Pulm course bs b/l Abd distended, poor bs, +DPL Ext no gross deformity, 2+ pulses . NEURO MS unresponsive to noxious stimuli CN R pupil unable to open, L pupil 2mm unreactive. +gag reflex and cough Motor no response to noxious stimuli . Pertinent Results: [**2121-8-14**] 08:17AM BLOOD WBC-15.6*# RBC-3.64* Hgb-10.9* Hct-33.6* MCV-92 MCH-29.9 MCHC-32.3 RDW-17.3* Plt Ct-71* [**2121-8-14**] 02:10AM BLOOD WBC-6.2# RBC-2.97* Hgb-9.0* Hct-28.2* MCV-95 MCH-30.4 MCHC-32.1 RDW-17.2* Plt Ct-81* [**2121-8-13**] 07:36PM BLOOD WBC-1.8*# RBC-3.21* Hgb-9.6* Hct-29.7* MCV-93 MCH-29.9 MCHC-32.3 RDW-17.0* Plt Ct-105* [**2121-8-13**] 02:28AM BLOOD WBC-4.6 RBC-3.11* Hgb-9.9* Hct-28.1* MCV-90 MCH-32.0 MCHC-35.4* RDW-16.6* Plt Ct-117* [**2121-8-14**] 08:17AM BLOOD Plt Smr-VERY LOW Plt Ct-71* [**2121-8-14**] 02:10AM BLOOD Plt Smr-LOW Plt Ct-81* [**2121-8-14**] 02:10AM BLOOD PT-19.7* PTT-48.1* INR(PT)-1.9* [**2121-8-13**] 07:36PM BLOOD Plt Smr-LOW Plt Ct-105* [**2121-8-11**] 12:33PM BLOOD Fibrino-388 [**2121-8-10**] 04:33PM BLOOD Fibrino-435* [**2121-8-8**] 09:20PM BLOOD Fibrino-390 [**2121-8-14**] 08:17AM BLOOD UreaN-29* Creat-1.1 Na-143 K-5.7* Cl-110* HCO3-20* AnGap-19 [**2121-8-14**] 02:10AM BLOOD Glucose-54* UreaN-26* Creat-0.9 Na-143 K-5.5* Cl-109* HCO3-24 AnGap-16 [**2121-8-13**] 07:36PM BLOOD Glucose-78 UreaN-21* Creat-0.7 Na-145 K-4.6 Cl-110* HCO3-28 AnGap-12 [**2121-8-14**] 08:17AM BLOOD ALT-15 AST-66* LD(LDH)-406* AlkPhos-35* Amylase-40 TotBili-2.9* [**2121-8-8**] 04:22AM BLOOD ALT-18 AST-49* AlkPhos-40 Amylase-39 TotBili-0.7 [**2121-8-8**] 04:22AM BLOOD Lipase-21 [**2121-8-7**] 12:39PM BLOOD CK-MB-4 cTropnT-<0.01 [**2121-8-14**] 08:17AM BLOOD Albumin-1.7* Calcium-7.5* Phos-6.7* Mg-2.1 [**2121-8-14**] 02:10AM BLOOD Calcium-8.0* Phos-6.3*# Mg-2.1 [**2121-8-8**] 11:54AM BLOOD Osmolal-295 [**2121-8-9**] 01:50PM BLOOD Cortsol-26.7* [**2121-8-9**] 01:59AM BLOOD Phenyto-3.0* [**2121-8-7**] 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2121-8-14**] 01:14PM BLOOD Type-ART Temp-38.3 Rates-22/ PEEP-10 FiO2-60 pO2-116* pCO2-45 pH-7.28* calTCO2-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [**2121-8-14**] 10:28AM BLOOD Type-ART Temp-37.9 PEEP-10 FiO2-60 pO2-107* pCO2-44 pH-7.29* calTCO2-22 Base XS--4 Intubat-INTUBATED [**2121-8-14**] 09:28AM BLOOD Type-ART Temp-37.7 pO2-171* pCO2-45 pH-7.29* calTCO2-23 Base XS--4 Intubat-INTUBATED [**2121-8-14**] 08:27AM BLOOD Type-ART Temp-37.7 pO2-341* pCO2-47* pH-7.27* calTCO2-23 Base XS--5 [**2121-8-14**] 04:40AM BLOOD Type-ART Temp-38.3 pO2-65* pCO2-64* pH-7.17* calTCO2-25 Base XS--6 Intubat-INTUBATED [**2121-8-14**] 01:14PM BLOOD Glucose-90 Lactate-8.0* [**2121-8-14**] 10:28AM BLOOD Glucose-98 Lactate-7.0* [**2121-8-14**] 09:28AM BLOOD Glucose-126* [**2121-8-14**] 08:27AM BLOOD freeCa-1.14 [**2121-8-13**] 10:44PM BLOOD freeCa-1.08* [**2121-8-11**] 10:36PM BLOOD HEPARIN DEPENDENT ANTIBODIES- [**2121-8-12**] 10:13PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [**2121-8-7**] 10:30AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2121-8-12**] 10:13PM URINE RBC-[**5-24**]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0 [**2121-8-7**] 10:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . [**2121-8-12**] 10:13 pm BLOOD CULTURE Site: CENTRAL LINE **FINAL REPORT [**2121-8-18**]** AEROBIC BOTTLE (Final [**2121-8-18**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2121-8-18**]): NO GROWTH. . . CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN AP VIEW OF THE CHEST (TWO RADIOGRAPHS): In the interval, there has been placement of a second tube in the left hemithorax with tip in the apex. Large left pneumothorax is unchanged. Interval improvement of right upper lobe collapse with increase in aeration. Otherwise, there are no changes. . . CT ABDOMEN W/CONTRAST [**2121-8-8**] 2:23 PM CT CHEST, ABDOMEN, AND PELVIS WITH INTRAVENOUS CONTRAST IMPRESSION: 1. Multiple injuries, including rib fracture, scapular fracture, pneumothorax, pleural effusions (hemothorax could not be excluded due to limitation by extensive streaky artifact), pulmonary embolus, right upper lobe consolidation, subcutaneous emphysema, large fluid collection with air in the mid abdomen, large hematoma in the pelvis, pelvic fractures. Spleen laceration cannot be excluded. . . BILAT LOWER EXT VEINS PORT BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: Grayscale, color, and Doppler son[**Name (NI) 1417**] of the right and left superficial femoral and popliteal, as well as right common femoral veins was performed. Evaluation of the left common femoral vein was limited by overlying bandages. There is normal compression, color flow, augmentation, and waveforms. There is no evidence of deep vein thrombosis. IMPRESSION: No deep vein thrombosis in the right or left superficial femoral and popliteal veins, or the right common femoral vein. This is a limited examination. . . ABDOMEN (SUPINE ONLY) [**2121-8-13**] 8:55 PM FINDINGS: Supine abdominal radiograph was reviewed. Immediately prior to acquisition of the radiograph, contrast was injected via the G- and J-tubes. There is contrast within the stomach without evidence for extravasation. Contrast is present in the jejunum without gross extravasation. IMPRESSION: No gross extravasation. . . CHEST (PORTABLE AP) PORTABLE AP CHEST. COMPARISON: [**2121-8-13**]. There is no definitive pneumothorax on the left. Note that the left costophrenic sulcus is not included in the film. The chest tubes, the ET tube, and right subclavian catheter are in good position. Bilateral lung opacities may be consistent with resolving contusions. Essentially no change from the lung findings from prior radiograph. Brief Hospital Course: This patient was admitted to [**Hospital1 18**] on [**2121-8-7**] after sustaining a motor vehicle crash while driving as an unrestrained passenger and hitting a bridge (brick wall/pylon). He was brought to [**Hospital1 18**] as a transfer patient and there was seizure activity while in transit. He was also intubated before being brought to [**Hospital1 18**] and a left chest tube was placed for a left sided pneumothorax. At [**Hospital1 18**], his injuries were noted as the following: Mutiple scalp / facial lacerations with bleeding, Persistent pneumothorax on left, No obvious pelvic fx. There was a witness arrest in trauma bay and the ACLS protocol initiated by housestaff ?????? the patient regained vitals and bilateral chest tubes were placed. Despite all efforts, he remained hypotensive. A DPL was performed in the trauma bay which was positive, and hence the patient was taken to the OR for an exploratory lapartomy. He did not receive any furthur imaging while in the Emergency Department of [**Hospital1 18**]. In the OR, there was ontinued aggressive resuscitation with pRBC, FFP, Platelets, and cryoprecipitate. An exploratory laparotomy revealed no intraperitoneal bleeding source; however, a pelvic hematoma was seen that was non-expanding. The abdomen was left oven and the patient transfered to the recovery room, followed by the trauma ICU. An ICP monitor was placed which showed a severely elevated opening pressure. He settled out around 40-50 over the course of the next few hours. In the ICU, there was continued resuscitation with fluids and pressors. He was sedated and paralyzed, under pressure control ventilation to help his respiratory status. His injuries at this time: - No intracranial hemorrhage - Multiple facial fractures - Left sided flail chest - Left superior / inferior pubic rami fx / sacral fx The patient's family was hesitant to continue with care, as they were sure that the patient was insistent that he only wanted to live in a fully functional state. On postoperative day four, the patient was clinically stabilizing and was requiring decreased ventilator support and minimal pressor support ?????? eventually weaned off. He was then taken back to the OR for an abdominal wall closure ?????? this was done with retention sutures; a Gastrostomy tube and a Jejunostomy tube were placed. the patient then developed culture positive pneumonia with gram negative bacteria (Acenitobacter / Enterobacter) which was treated with antibiotics.On postoperative days 6 and 2, the patient displayed septic physiology: he was Hypotensive, Tachycardic, required increasing ventilation support, was sedated / paralyzed and on maximal pressor support.A chest x-ray and tube study was done to rule out recurrent pneumothorax (required multiple chest tubes to drain) and to rule out enteral leakage around feeding tubes. At this point, a family meeting was conducted, who decided they did not want to pursue further care and hence the patient was made CMO the following morning and he expired shortly after. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2121-8-24**]

[ "868.03", "873.42", "872.00", "785.4", "785.52", "285.1", "805.6", "518.5", "808.2", "305.1", "486", "860.4", "811.00", "428.0", "854.05", "807.05", "780.39", "427.5", "286.6", "415.19", "958.4", "707.09", "E823.0", "958.7", "038.9", "861.21", "496" ]

icd9cm

[ [ [] ] ]

[ "99.06", "99.60", "34.04", "18.4", "00.17", "01.18", "99.05", "33.23", "99.07", "38.91", "54.63", "38.7", "96.6", "96.72", "99.04", "89.64", "43.19", "86.59", "54.11", "46.39" ]

icd9pcs

[ [ [] ] ]

10623, 10632

7528, 10572

486, 558

10679, 10684

1937, 7505

10736, 10770

10595, 10600

10653, 10658

10708, 10713

1639, 1918

274, 448

587, 1492

1514, 1624