ChanBeDu/relevant_section_length · Datasets at Hugging Face

1,571

150,277

2671

Discharge summary

report

Admission Date: [**2117-2-20**] Discharge Date: [**2117-2-25**] Date of Birth: [**2049-10-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: upper GI bleed Major Surgical or Invasive Procedure: EGD arterial line central venous line History of Present Illness: Briefly, pt is a 68 yo M with ESRD [**1-22**] IgA nephropathy on HD, HTN, COPD, EtOH cirrhosis initially p/w abdominal pain for several days. On [**2-19**] pt came to ED c/o abd pain. Pt had paracentesis with drainage of 2.5 L, but no SBP on diagnostics. Pt was d/c'd from ED but again returned on [**2-20**] with similar complaint. Diagnostic tap done demonstrating 695 wbcs w/ 72 polys. Pt admitted for tx of SBP. Also found to have C diff on stool studies. Initial tx ctx/vanc/flagyl. On [**2-23**] at HD, pt's sbp dropped to 70s and HD stopped after 2 hours. Pt with continued low BPs on floor post-HD. Also had episode of approx 30 cc bloody hematemesis shortly after return from HD AM of [**2-23**]. Pt taken to GI suite for EGD. Around that time pt tapped again and found to have 5650 wbcs despite abx. Of note serum wbc rose to 39 on [**2-23**] from 14 on admission. [**2-23**] EGD showed grade III esophageal varices, old blood but no active bleed, 4 bands placed. Pt transferred to MICU for further management of UGIB post banding. Past Medical History: CKD Stage V [**1-22**] IgA Nephropathy on HD ETOH Cirrhosis ETOH Abuse COPD Hypertension Gout Social History: Lives in [**Hospital1 392**] w/his wife. [**Name (NI) 1139**] use (56 pack year hx), now smokes ~8cigs/day. +ETOH 2 beers/day. Denies any other drug use. Family History: non-contributory Physical Exam: Vitals: T: 97.5 BP: 119/68 P: 96 R: 16 SaO2: 96% on RA General: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: PERRL, EOMI, no scleral icterus, MM dry, no lesions noted in OP, lips blue. Neck: no significant JVD or carotid bruits appreciated Pulmonary: Lungs with mild int3ermittent end-expiratory wheeze throughout. Good air movement. No rales or ronchi. Cardiac: RR, nl S1 S2, soft I/VI holodiastolic murmur heard best at LUSB Abdomen: Mildly distended, nontender, + flank fullness, + shifting dullness. Extremities: trace edema bilaterally Skin: no jaundice, few spider angiomas across chest, telangiectasias on nose. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal strength throughout. No abnormal movements noted. Mild intermittent confusion. No asterixis. Pertinent Results: [**2117-2-19**] 08:25AM WBC-13.4*# RBC-4.59*# HGB-14.4# HCT-46.7# MCV-102* MCH-31.4 MCHC-30.9* RDW-18.5* [**2117-2-19**] 08:25AM NEUTS-93.0* BANDS-0 LYMPHS-3.1* MONOS-2.9 EOS-0 BASOS-1.0 [**2117-2-19**] 08:25AM PLT COUNT-102* [**2117-2-19**] 08:25AM ALT(SGPT)-12 AST(SGOT)-34 LD(LDH)-217 AMYLASE-35 TOT BILI-1.5 [**2117-2-19**] 08:25AM LIPASE-22 [**2117-2-19**] 08:25AM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-2.0 [**2117-2-19**] 08:25AM AFP-1.4 [**2117-2-19**] 08:25AM GLUCOSE-129* UREA N-16 CREAT-3.2* SODIUM-141 POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-33* ANION GAP-18 [**2117-2-19**] 08:25AM estGFR-Using this [**2117-2-19**] 01:13PM ASCITES WBC-140* RBC-1140* POLYS-85* LYMPHS-8* MONOS-4* BASOS-1* MESOTHELI-2* [**2117-2-19**] 01:13PM ASCITES LD(LDH)-69 ALBUMIN-LESS THAN [**2117-2-19**] 01:33PM PT-12.7 PTT-28.6 INR(PT)-1.1 . KUB ([**2-19**]): 1. Small amount of ascites is noted within the abdominal cavity. 2. No evidence of obstruction is noted . CT abd/pelvis ([**2-19**]): 1. Moderate to large amount of abdominal ascites. 2. Cirrhosis of the liver. In the absence of IV contrast, the liver is not well evaluated for focal lesions. 3. Cholelithiasis, without evidence of cholecystitis. 4. Limited assessment of the sigmoid colon for the presence of diverticulitis given large intrapelvic ascites. Brief Hospital Course: . # UGIB: Pt underwent EGD and variceal banding on [**2117-2-23**]. He was maintained on Protonix and octreotide drips. He was also started on sucralfate. He received 2U FFP to reverse his INR in the setting of bleeding. His hematocrit was subsequently stable. . # C. difficile colitis: He had a rising white blood cell count on broad spectrum antibiotics. Stool sample from [**2-21**] was positive for C. diff toxin. CT abdomen on [**2-24**] showed pancolitis but did not show megacolon or abscess. He was maintained on IV Flagyl. An NG tube was not placed given the recent banding, so he could not be given oral antibiotics. Due to his continually rising WBC count, he was started on vancomycin PR. Surgery was consulted for fulminant C. diff. They felt he would likely need total colectomy, but that his morbidity and mortality would be extremely high. . # Bacterial peritonitis: Spontaneous vs. secondary to translocation or microperforation from C. difficile colitis. He was maintained on vancomycin, Zosyn, Flagyl. . # Altered mental status: He became increasingly somnolent in the MICU. His altered mental status was felt to be multifactorial, secondary to benzodiazepine effect, hepatic encephalopathy, uremia, and ICU psychosis. He was given flumazenil with some clearing. . # Hypotension: He developed hypotension in the MICU and required pressors. His hypotension was felt most likely secondary to sepsis given his fulminant C. diff and his bacterial peritonitis. . # ESRD on HD: On HD as outpatient. Followed by the Renal team. With dropping BP, was being evaluated for CVVHD. . # ETOH: He had some signs and symptoms suggestive of withdrawal. He was placed on a CIWA scale, folate, thiamine, mvi. He received benzodiazepines initially, but was subsequently given flumazenil for concern for altered mental status. . ## In the MICU, he continued to decompensate with worsening C. diff, worsening encephalopathy, and development of hypotension. Several family meetings were held with the patient's wife, daughters, and son. On the night of [**2-24**], the team and the family decided to pursue comfort measures only for the patient. He was started on a morphine drip. He expired at 7:35am on [**2-25**]. . Medications on Admission: Nephrocaps 1 mg Sarna Anti-Itch 0.5-0.5 % Lotion Sevelamer 800 tid with meals Metoprolol 25 [**Hospital1 **] Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Fulminant Clostridium difficile colitis Bacterial peritonitis Esophageal variceal bleed Hepatic encephalopathy Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2117-2-25**]

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icd9cm

[ [ [] ] ]

[ "39.95", "54.91", "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

6439, 6448

4006, 5053

329, 368

6602, 6611

2644, 3983

6667, 6705

1747, 1765

6407, 6416

6469, 6581

6273, 6384

6635, 6644

1780, 2625

275, 291

396, 1440

5069, 6247

1462, 1557

1574, 1731

6,976

186,850

15973

Discharge summary

report

Admission Date: [**2146-10-12**] Discharge Date: [**2146-10-20**] Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 1973**] Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: Mesenteric angiography Flexible sigmoidoscopy History of Present Illness: [**Age over 90 **] y/o man admitted from rehab with BRBPR. Hct 31, baseline 32-33. Of note, was recently discharged [**2146-9-15**] after admission for non-healing ulcer of right posterior heel w/exposed achiles tendon. He underwent a right below knee popliteal to dorsalis pedis artery bypass with reverse saphenous vein [**2146-9-9**] followed by achilles tendon excision [**2146-9-13**]. Of note, he was discharged with Cipro, Linezolid and Metronidazole to complete a 21 day course - exact reason is not documented but presumed to be osteomyelitis in the right lateral malleolus. . In ED - the patient was hemodynamically stable, was seen by GI who recommended colonoscopy. Was found to have a supratherapeutic INR @ 4.8 and was reversed with 2 Units FFP and IV vitamin K. [**Year (4 digits) **] was contact[**Name (NI) **] who felt patient ok for reversal. CT head negative Past Medical History: 1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG 2.10/2 Achilles tendon w/ abscess excision w/ VAC placement 3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg, mitral regurg, moderate pericardial effusion. 4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in LMCA/LAD Cypher drug-eluting stent. 5.Carotid artery stenosis: Chronically occluded right internal carotid artery. Left, with 40-59% carotid stenosis. 6. Hypercholesterolemia 7. Hypothyroidism 8. Chronic low back pain 9. AFib s/p ablation [**48**]. s/p cholecystectomy [**49**]. s/p bilateral carotid endartectomies 12. s/p left knee arthroscopy 13. s/p lumbar decompression '[**34**] 14. s/p left leg thrombectomy Social History: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH. Currently at [**Hospital 169**] Center. Previously lived in the basement of his daughter's house. Walks with a cane. Family History: Non-contributory Physical Exam: Admission Physical Exam: VS 98.0 85 123/55 18 100%RA GEN: Well appearing - not oriented to date, but to person/place. HEENT: EOMI, PERRL NECK: no JVP appreciated CV: RRR s1, soft s2, II/VI early peaking systolic murmur hear best @ base RESP: CTA b/l ABD: soft, NT/ND, no masses RECTAL: large clotty bright red blood on bedsheets when patient turned. EXT: well healed scar on right dorsum of foot, doplerable pulses on right, palpable on left. Pertinent Results: Bleeding Scan: Positive bleeding scan, from rectum within the first 5 minutes. . Femoral ultrasound: Normal [**Hospital 1106**] ultrasound in the right groin. No hematoma. . Angio SMA,[**Female First Name (un) 899**],celic negative for bleeding. . Sigmoidoscopy: Bleeding rectal Dieulafoy lesion noted and clipped. . [**2146-10-12**] 05:30PM BLOOD WBC-7.1 RBC-3.39* Hgb-10.2* Hct-30.2* MCV-89 MCH-30.0 MCHC-33.7 RDW-17.8* Plt Ct-240 [**2146-10-12**] 05:30PM BLOOD Neuts-73.2* Lymphs-18.0 Monos-4.7 Eos-3.8 Baso-0.2 [**2146-10-12**] 05:30PM BLOOD PT-42.0* PTT-37.2* INR(PT)-4.8* [**2146-10-18**] 05:07AM BLOOD PT-12.4 PTT-32.8 INR(PT)-1.1 [**2146-10-19**] 03:57PM BLOOD WBC-6.0 RBC-3.38* Hgb-10.5* Hct-30.5* MCV-90 MCH-31.2 MCHC-34.6 RDW-16.8* Plt Ct-150 [**2146-10-12**] 05:30PM BLOOD Glucose-109* UreaN-24* Creat-1.3* Na-139 K-3.8 Cl-103 HCO3-26 AnGap-14 [**2146-10-19**] 05:50AM BLOOD Glucose-97 UreaN-9 Creat-1.0 Na-137 K-3.5 Cl-105 HCO3-26 AnGap-10 [**2146-10-12**] 10:42PM BLOOD ALT-12 AST-14 CK(CPK)-76 AlkPhos-68 Amylase-30 TotBili-0.6 [**2146-10-12**] 10:42PM BLOOD Lipase-41 [**2146-10-12**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2146-10-12**] 10:42PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2146-10-12**] 10:42PM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.1 Mg-1.9 [**2146-10-19**] 05:50AM BLOOD Albumin-2.4* Calcium-7.9* [**2146-10-13**] 04:28AM BLOOD TSH-14* [**2146-10-14**] 01:33AM BLOOD T4-3.9* Free T4-0.69* [**2146-10-15**] 04:00AM BLOOD CRP-28.6* [**2146-10-13**] 07:37PM BLOOD Type-ART pH-7.33* Comment-GREEN TOP [**2146-10-13**] 12:50PM BLOOD freeCa-1.02* [**2146-10-18**] 03:38PM BLOOD freeCa-1.14 [**2146-10-19**] 03:57PM BLOOD WBC-6.0 RBC-3.38* Hgb-10.5* Hct-30.5* MCV-90 MCH-31.2 MCHC-34.6 RDW-16.8* Plt Ct-150 [**2146-10-20**] 05:18AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-134 K-3.5 Cl-105 HCO3-25 AnGap-8 Brief Hospital Course: Patient is a [**Age over 90 **] year old man admitted from rehab with BRBPR, supratherapeutic INR, confusion, now doing well after flexible sigmoidoscopy, and colonoscopy, both with clipping of rectal bleeding souce. . # Acute Blood Loss Anemia due to Rectal Bleeding: Patient presented with BRBPR. Initially, a tagged red blood cell scan showed bleeding from the rectum. However, subsequent angiography was unable to localize and embolize the source of bleed. A fexible sigmoidoscopy showed an actively bleeding Dielafoys lesion which was successfully clipped. The patient subsequently remained hemodynamically stable, with minimal further RBC transfusions. Coumadin, aspirin, and Plavix were initially held. Aspirin and Plavix were resumed prior to discharge. . # Coagulopathy: He was taking coumadin for a history of atrial fibrillation. He presented with active GI bleeding in the context of a supratherapeutic INR. He was reversed with vitamin K and FFP. Coumadin, aspirin, and Plavix were initially held, though aspirin and Plavix were resumed prior to discharge. Given his recent large volume bleed, the risks of reinitiating coumadin were felt to outweigh the benefits of stroke prevention. . # Atrial Fibrillation: Patient carries a history of atrial fibrillation, status post ablation. He was noted to be in sinus rhythm throughout his hospitalization. No details are available as to what his history of "ablation" entailed. His coumadin was stopped during this hospitalization, as described above. . # Delerium: Pt had sundowning at night and with aggitating procedures that responded well to prn haldol. His mental status improved with treatment of his medical illnesses and with his daughter at bedside. . # Heel Ulcer: Patient was on cipro/Linezolid/Flagyl as outpatient for 3 week course for suspected osteomyelitis, as reported by [**Age over 90 1106**] surgery. ID was consulted. Given the combination of non-elevated ESR/Sed rates and no sign of osteo on f/u x-rays, the diagnosis of osteo was felt questionable. A 3 week course of Zosyn was initiated for treatment of pseudomonas cultured from a wound swab. . # CAD: Patient had a DES placed in his LMCA in 1/[**2145**]. Although antiplatelets were briefly held in the setting of active GI bleed, they were restarted prior to his discharge. His antihypertesnives and antianginals were also initially held in the MICU. However, Imdur was restarted at 30 mg for elevated blood pressures. . # Peripheral [**Year (4 digits) **] Disease: Seen by [**Year (4 digits) 1106**] in ED, and enlisted help of podiatry. [**Year (4 digits) **] surgery followed patient and podiatry took care of the vac dressings changes. . # Hypothyroid: TSH in [**2146-4-12**] was 14 and currently on levothyroxine. TSH was 14 here with low T4 and free T4, so increased levothyroxine dose to 150 mcg. . # Urinary retention: Patient had a foley placed [**9-9**] by urology for tight phimosis, incontinence, and urinary retention. Followed by urology as outpatinet. Voiding trial was to be attempted as outpatient, unclear if this happened. Did not have foley on arrival to ED, foley placed with pus expressed from penis. U/A positive for yeast on [**10-18**]. Voiding trial attempted and failed. Flomax was initiated, and a foley replaced. A voiding trial should be reattempted at rehab. . # ACCESS: 2 PIV, and a right IJ central line were placed. The IJ was discontinued on [**2146-10-18**]. . # PPx: The patient was placed on Heparin SQ for DVT prophylaxis and continued on his PPI for GI prophylaxis. Medications on Admission: 1. Aspirin 81 mg PO Daily 2. Isosorbide Mononitrate 60 mg PO Daily 3. Furosemide 60 mg PO Daily 4. Levothyroxine 125 mcg PO Daily 5. Atorvastatin 80 mg PO Daily 6. Docusate Sodium 100 mg PO BID 7. Heparin (Porcine) 5,000 units TID 8. Pantoprazole 40 mg PO Q24H 9. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed 10. Warfarin 5 mg / 2.5 mg PO alternating days 11. Clopidogrel 75 mg PO Daily 12. Ciprofloxacin 500 mg PO Q12H 13. Ibuprofen 400 mg PO Q6H as needed for shoulder pain 14. Metronidazole 500 mg PO TID 15. Metoprolol Succinate 50 mg PO Daily 16. Linezolid 600 mg PO BID Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule 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. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 3 weeks: Please take until [**11-2**]. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Discharge Diagnosis: Primary Diagnosis: Bleeding from a rectal Dieulafoy lesion Secondary diagnoses: Right achilles tendon pressure ulcer PVD s/p PO-DP bypass graft aortic stenosis hypercholesterolemia hypothyroidism hypertension Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for gastrointestinal bleeding. You had a sigmoidoscopy that showed a Dieulefoy lesion that was treated with a surgical clip. You recieved several units of blood and platelets while you were in the hospital. Upon arrival at the hospital, your INR (a measure of blood clotting) was found to be high. You were taken off of the drug Coumadin and do not need to take it again. The remainder of your home medications have been continued. You will also need to take three weeks of antibiotics for your ankle wound, until [**11-3**]. You should also follow up with gastroenterology to schedule a follow up colonoscopy. If you experience any additional bleeding, changes in thinking or behavior, experience shortness of breath, chest pain, or lightheadedness, or other concerning symptoms please consult your primary care physician or return to the emergency room. Please follow up with the following doctors once [**Name5 (PTitle) **] are discharged from the rehabilitation hospital. Followup Instructions: You will need to make followup appointments with the following providers once you are discharged from rehab. Gastroenterology: [**Telephone/Fax (1) 13246**] [**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] (primary care): [**Telephone/Fax (1) 26860**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology): [**Telephone/Fax (1) 2394**] Dermatology: ([**Telephone/Fax (1) 45763**] . You have the following appointments scheduled: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-11-10**] 1:00 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-11-10**] 2:00

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icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "45.43", "38.93", "88.47" ]

icd9pcs

[ [ [] ] ]

10060, 10112

4505, 8051

231, 278

10365, 10374

2649, 4482

11436, 12271

2144, 2162

8682, 10037

10133, 10133

8077, 8659

10398, 11413

2202, 2630

10213, 10344

179, 193

306, 1186

10152, 10192

1208, 1906

1922, 2128

50,735

106,850

54548

Discharge summary

report

Admission Date: [**2190-3-3**] Discharge Date: [**2190-3-9**] Date of Birth: [**2108-5-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / E-Mycin / Flagyl / Pepcid Attending:[**First Name3 (LF) 602**] Chief Complaint: GIB Major Surgical or Invasive Procedure: NONE History of Present Illness: 81F with critical AS awaiting AVR recently s/p pre-op catheterization c/b R MCA CVA who was later discharged to rehab [**2190-2-26**] on aspirin, now re-admitted after two episodes of maroon-colored stools. Pt passed two marroon stools at rehab, loose but non-malodorous or tarry. When pressed she described intermittent episodes similar stools over the past several weeks, last 2 weeks ago. At rehab ahe did not have any abdominal pain, but did have some cramping and nausea without emesis. No dizziness, lightheadedness, CP or shortness of breath. Brought into the ED where her initial vitals were 97.2 80 100/50 16 97% RA. Her hematocrit was noted to be 23.4 which is down from discharge [**2-26**] of 30.8. Of note when she presented for Cath [**2-23**] her HCT was 22.9 for which she was transfused one unit PRBCs. Two large bore IVs were placed, she was typed and crossed for two units and admitted to the MICU. Vitals on transfer were HR 79 BP 98/46 RR 23 O2 100%RA. . On arrival to the MICU, patient's VS were 74 97/52 20 100%/RA. She feels well and the previous nausea has resolved. Of note she has recently ([**1-3**]) had an EGD at [**Hospital **] hospital for dysphagia. Per pts report she was treated by botox injections for esophageal spasm. A colonoscopy was attempted but was unsuccessful because of a hernia that resulted from her prior cystectomy. She also reports a history of "Mediteranean Anemia." Her father is from Sicily. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Critical aortic stenosis [**Location (un) 109**] 0.5cm2, [**2190-2-23**] R MCA CVA, no residula deficits "Mediterranean Anemia" Hypertension Hysterectomy [**2135**] Dyslipidemia GERD Bladder CA s/p cystectomy [**2165**] Dysphagia Neuropathy Anemia CCY [**2137**] Hernia [**2175**] Back surgery [**2183**] Cataract removal Social History: Lives at home, son lives at home with her. Retired from sewing business. Tobacco: never. ETOH: denies. Drug use: denies. Family History: Mom passed away age 59 from heart problems. [**Name (NI) **] passed away age 74 from PNA. Sister passed away age 79 had a history of valve surgery but died from leukemia. Brother passed away age 50 from cancer. Brother alive age 84 had a valve replacement one year ago. Physical Exam: ADMISSION EXAM Vitals: 74 97/52 20 100% on RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, [**1-26**] harsh systolic murmur loundest at RUSB with radiation to carotids, no rubs, gallops Lungs: Prominnet kyphosis, clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Left sided nephrostomy tube collecting clear urine and appering clean and not infected. Large left sided distension which is not painful. Otherwise soft, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Rectal: large external hemmorhoids present, no obvious bleeding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . DISCHARGE EXAM VS Tc 97.9 110/64 84 16 94/RA GEN: elderly woman walking with PT in NAD, awake, AOX3 HEENT: NCAT, MMM, dentures, JVP flat, no LAD LUNGS: kyphoscoliotic posture, lungs CTAB, no wheezes, rales, rhonchi CV: RRR, [**1-26**] harsh systolic murmur swallows S2, loudest RUSB w/radiation to carotids ABD: obese soft nontender, ventral hernia, L-sided neobladder stoma pink and nontender, collecting clear yellow urine in attached urine bag EXT: WWP, +pulses, trace bilateral edema NEURO: AOX3, CNII-XII intact, 5/5 strength upper/lower extremities, 2+ reflexes bilaterally, gait stable w/assistance Pertinent Results: ADMISSION LABS [**2190-3-3**] 03:25PM WBC-7.6 RBC-3.18* HGB-6.7*# HCT-23.4* MCV-73* MCH-20.9* MCHC-28.5* RDW-17.1* [**2190-3-3**] 03:25PM NEUTS-88.6* LYMPHS-7.8* MONOS-2.9 EOS-0.3 BASOS-0.4 [**2190-3-3**] 03:25PM PLT COUNT-357 [**2190-3-3**] 03:25PM PT-13.4* PTT-27.8 INR(PT)-1.2* [**2190-3-3**] 03:25PM GLUCOSE-161* UREA N-45* CREAT-1.1 SODIUM-141 POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 [**2190-3-3**] 03:25PM ALT(SGPT)-7 AST(SGOT)-17 LD(LDH)-225 ALK PHOS-45 TOT BILI-0.3 [**2190-3-3**] 03:25PM LIPASE-20 [**2190-3-3**] 03:25PM cTropnT-<0.01 [**2190-3-3**] 03:25PM ALBUMIN-3.0* [**2190-3-3**] 03:38PM LACTATE-1.2 . URINALYSIS [**2190-3-3**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG [**2190-3-3**] 05:50PM URINE RBC-17* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 [**2190-3-3**] 05:50PM URINE WBCCLUMP-FEW MUCOUS-RARE . HCT TREND [**2190-3-3**] 03:25PM BLOOD Hct-23.4* [**2190-3-3**] 04:45PM BLOOD Hct-24.7* (+1U PRBC) [**2190-3-4**] 12:10AM BLOOD Hct-27.4* [**2190-3-4**] 02:25AM BLOOD Hct-25.5* (+1U PRBC) [**2190-3-4**] 11:02AM BLOOD Hct-28.9* [**2190-3-4**] 03:20PM BLOOD Hct-29.0* [**2190-3-4**] 08:05PM BLOOD Hct-29.9* [**2190-3-5**] 06:38AM BLOOD Hct-28.4* [**2190-3-5**] 03:45PM BLOOD Hct-32.2* [**2190-3-6**] 06:50AM BLOOD Hct-32.7* [**2190-3-7**] 07:40AM BLOOD Hct-29.7* [**2190-3-8**] 06:11AM BLOOD Hct-27.5* [**2190-3-9**] 06:43AM BLOOD Hct-30.7* . DISCHARGE LABS [**2190-3-9**] 06:43AM BLOOD WBC-10.3 RBC-3.87* Hgb-8.9* Hct-30.7* MCV-79* MCH-23.1* MCHC-29.1* RDW-18.5* Plt Ct-330 [**2190-3-9**] 06:43AM BLOOD Glucose-95 UreaN-23* Creat-0.9 Na-142 K-4.6 Cl-111* HCO3-23 AnGap-13 [**2190-3-9**] 06:43AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.4 . MICROBIOLOGY URINE CULTURE (Final [**2190-3-4**]): NEGATIVE MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. H PYLORI SEROLOGY [**2190-3-6**] EQUIVOCAL . IMAGING - NONE . EKG [**2190-3-5**] Sinus rhythm, HR 75. Left axis deviation. Borderline left atrial abnormality. Non-diagnostic Q waves in the high lateral leads. Early R wave transition. Non-specific ST segment changes in the inferolateral leads. Compared to the previous tracing of [**2190-2-25**] strict criteria for left ventricular hypertrophy are no longer met and the ventricular rate is slower. Brief Hospital Course: 81F with critical aortic stenosis with recent cardiac catheterization complicated by right MCA stroke, on aspirin admitted with gastrointestinal bleeding and hematocrit in the low 20s. Hospital course was notable for stabilization of hematocrit without significant intervention. Endoscopic evaluation for source of bleeding has been deferred until patient is 1 month out from her stroke given high risk within this period and the stability of hematocrit for 4 days on aspirin prior to discharge. Patient will have close GI follow up after discharge for consideration of capsule endoscopy. . #Gastrointestinal bleeding, likely due to right sided colonic lesion or small bowel lesion/Acute blood loss anemia: Pt presented with two episodes of maroon-colored loose stools preceded by crampy epigastric abdominal pain along with a drop in hematocrit from 30 to 23 over the past few weeks suggesting gastrointestinal bleeding of acute to sub-acute time course. Patient was hemodynamically stable throughout hospitalization but did require 2 units of packed red blood cells and monitoring in the ICU initially. Patient was evaluated by GI and after discussion with both GI and Cardiology it was felt that the patient would be at high risk for endoscopic procedures such as EGD and colonoscopy given the sedation needed both because of her critical aortic stenosis, but also because of her recent stroke within the past one month. She was monitored and had a stable hematocrit for 4 days prior to discharge without any need for transfusion and without any stools suggestive of recurrent GI bleeding. Given the high risk of procedures within 1 month of recent stroke, the plan on discharge is to have the patient follow up in the next 4 days with GI in outpatient clinic for consideration of capsule endoscopy to evaluate both the small bowel and hopefully the right side of the colon as this would not carry the risks of EGD or colonoscopy. If this is not revealing or if bleeding recurs, further consideration will be given to more expedited EGD and colonoscopy. At rehab, the patient should have hematocrit checked 2x/week to determine if bleeding has recurred. Given the high likelihood of AVM related to critical AS, it is possible that the bleeding may recur intermittently until her valve is fixed. Hct was 27-30 on discharge. She was discharged on iron, but given her need for PPI, she may require IV iron transfusions to replace her iron losses over time. . #Urinary tract infection: Pt has a chronic urinary bag into which her neobladder w/anterior abdominal stoma drains, leaving her at increased risk for UTIs. Admission UA grossly positive. Ciprofloxacin started empirically for a 10-day total course (3d additional at discharge) and continued despite contaminated urine cultures because benefits of treating possible UTI in this pt w/low physiologic reserve thought to outweigh risks. . #Acute renal failure: On admission, creatinine elevated to 1.1 from baseline of 0.8 which was felt to be from prerenal azotemia. Creatinine improved to baseline following blood transfusion and improved PO intake. . #Critical aortic stenosis: Valve area 0.5 on last catheterization earlier this morning with gradient >40mmHg. She had evidence of pulmonary edema and was never hypotensive or had symptoms of exertional presyncope or arrythmia on telemetry. Her Lasix was initially held on admission and then restarted on discharge. She is undergoing workup for AV repair/replacement, with outpatient cardiac surgery evaluation scheduled at prior discharge. Cardiology and cardiac surgery consult services were aware of admission. . # RECENT R MCA STROKE: Suffered during last admission, prompted [**Hospital 3058**] rehab stay. Family and pt very satisfied with her rehabilitation, report no residual deficits. Neuro exam nonfocal - no speech, cognitive, or gait disturbances but did require support to walk. Eager to continue rehab PT. Continued home aspirin. . # THRUSH Noted on exam, not bothersome. Prescribed 10 days nystatin swish & swallow for total 14d course. . TRANSITIONAL ISSUES *GI followup appt in 1 week to assess any evidence of ongoing GI bleeding, discuss any necessary endoscopy. Needs follow-up Hct on Thursday [**3-11**] and Sunday [**3-13**] (rehab MD to review). *Ongoing outpatient cardiac surgery evaluation as previously planned. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 8. multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a day. 10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) ml PO once a day as needed for constipation. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a day. 10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) ml PO once a day: hold for loose stools. 11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*7 Tablet(s)* Refills:*0* 12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 10 days. Disp:*100 ML(s)* Refills:*0* 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*QS Capsule(s)* Refills:*0* 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*QS Tablet(s)* Refills:*0* 15. Outpatient Lab Work Draw blood Thursday [**3-11**] and Sunday [**3-11**]. Check Hct. Rehab MD to review results. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY DIAGNOSES Upper gastrointestinal bleed Critical aortic stenosis Recent cerebrovascular attack . SECONDARY DIAGNOSES Hypertension GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [**Known lastname 111600**], You were admitted to the hospital for 2 episodes of marroon-colored stool, which suggests gastrointestinal bleeding. You were seen by gastroenterologist who recommended increasing your omeprazole and a follow-up gastroenterology appointment. At that visit they will discuss possible options for further work-up of your bleeding. Your blood counts have been stable for the past 4 days. We also treated you for a urinary tract infection and thrush. We made the following changes to your medications: CHANGED OMEPRAZOLE TO PANTOPRAZOLE 40 MG TWICE DAILY STARTED Ciprofloxacin, TAKE ONE 250 mg TAB EVERY 12 HOURS FOR 3 ADDITIONAL DAYS STARTED NYSTATIN SWISH AND SPIT, USE EVERY 4 HOURS FOR 10 DAYS STARTED ADDITIONAL LAXATIVES (COLACE AND SENNA) TO KEEP YOUR BOWELS LOOSE (STRAINING WITH DEFECATION IS DANGEROUS WITH YOUR AORTIC STENOSIS) We did not make any other changes to your medications. Followup Instructions: You need to have follow-up blood counts checked on Thursday results. FOLLOW-UP APPOINTMENTS: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2190-3-16**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: NEUROLOGY When: TUESDAY [**2190-3-23**] at 4:00 PM With: DRS. [**Name5 (PTitle) **] & HAUSSEN [**Telephone/Fax (1) 1694**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SURGERY When: WEDNESDAY [**2190-4-7**] at 2:00 PM With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage When you leave rehab, please call your primary care doctor for a follow-up appointment within 1 week.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13613, 13683

6919, 11268

311, 317

13868, 13868

4521, 6896

15008, 15078

2663, 2934

12123, 13590

13704, 13847

11294, 12100

14050, 14562

2949, 4502

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14591, 14985

1813, 2163

268, 273

345, 1794

13883, 14026

2185, 2508

2524, 2647

76,654

177,370

1622

Discharge summary

report

Admission Date: [**2163-1-23**] Discharge Date: [**2163-1-26**] Date of Birth: [**2111-11-5**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Tape / Ativan / Aloe / Dilantin Attending:[**First Name3 (LF) 5123**] Chief Complaint: Rash/Fever Major Surgical or Invasive Procedure: None History of Present Illness: 51 year old female h/o metastatic melanoma s/p ICH and placement of VP shunt presented [**1-24**] with fever and rash. On [**1-2**] patient had left hemiplegia and HA, was diagnosed with ICH from metastatic melanoma. Underwent emergent craniotomy for evacuation of bleed and tumor rescetion, she was also started on dilantin for seizure prophylaxis. She then developed hydrocephalus and had VP shunt placed on [**1-6**] and repeat VP shunt operation on [**1-14**] secondary to her failure at clamping trials. Prior to discharge she was noted to be febrile to 103 on [**11-13**] temp spiked to 101.5 with a productive cough, influenza was negative so she was discharged on levofloxacin, completed course [**1-21**]. Three sets of blood cultures and urine culture negative. She also developed a diffuse morbiliform eruption rash after dilantin was started. However, Dilantin was continued since the benefits of sizure prophylaxis outweighed risks of continuing medicaitons. After discharge her fever resolved but the rash did not. She used Sarna lotion and benadryl at home, but noted spread of the rash from truck outwards to extremities, sparing face palms and soles. . On day of admission ([**1-23**]) she developed a high fever with chills and was brought to [**Hospital3 3583**], and was then transfered here for further care. Upon arrival to the ED the patient recieved 125 mg Solumedrol, 50 mg IV Benadryl, 1 gram tylenol, Motrin 800 mg and 4 liters of normal saline. Her fever initially was >104.8 rectally (107 temporal) but trended down to 99.1. Got CXR, cultures, urine and shunt tapped. ID was consulted who recommended holding on Abx given lack of source, did not feel that VP fluid cell count was indicative of shunt infection, more likely blood. Dermatology was also consulted. Past Medical History: - Malignant melanoma w/ metastases to brain s/p ICH evacuation and IP shunt placement for hydrocephalus - Graves' disease s/p Tapazole treatment 13yrs ago - cervical dysplasia s/p LEEP - s/p resection of melanoma from left lower back - s/p resection of intradermal melanocytic nevus from left lateral chest wall Social History: Previous smoker 28 pack years, recently quit. Social alcohol. Denies illicit drug use. No pets, currently living with her mother and working as a buyer for [**Name (NI) 9400**] NY. Never married. Family History: Father with carotid stenosis and history of CVA x2, age 78. Mother age 68 and healthy. Brother, age 50, healthy. No known early CAD or cancer history. Physical Exam: On Admission Vitals: T: 99.6 BP: 110/58 HR: 117 RR: 18 02 sat: 97% GENERAL: awake, conversant HEENT: Large craniotomy wound w/o erythema or purulence on R skull. Smaller shunt wound w/ shunt present on L skull, no erythema, tenderness or purulence, no fluctuence. MMM, OP clear, slight exophthalmos CARDIAC: RRR, No MRG LUNG: CTAB ABDOMEN: Soft, NT, ND, BS+, 6cm well healing surgical wound in RUQ, no erythema or purulence, nontender. EXT: No edema, 2+ DP/PT pulses. NEURO: A&Ox3, Slight facial droop on left o/w CNII-XII intact, 5/5 strength, no gross sensory deficits SKIN: Diffuse, highly confluent, deeply erythematous maculopapular blanching rash, no bullae, no bleeding. Mucous membranes and palms/soles unaffected. On Discharge: GENERAL: NAD HEENT: Large craniotomy wound w/o erythema or purulence on R skull. Smaller shunt wound w/ shunt present on L skull, no erythema, tenderness or purulence, no fluctuence. MMM, OP clear without evidence of oral lesions CARDIAC: RRR, No MRG LUNG: CTAB ABDOMEN: Soft, NT, ND, BS+, 6cm well healing surgical wound in RUQ, no erythema or purulence, nontender. EXT: No edema, 2+ DP/PT pulses. NEURO: A&Ox3, Slight facial droop on left o/w CNII-XII intact, 5/5 strength, no gross sensory deficits SKIN: Diffuse, highly confluent, erythematous maculopapular blanching rash, no bullae, no bleeding over truck and extremities. Mucous membranes and palms/soles unaffected. Pertinent Results: Labs on admission: WBC-7.3# Hgb-10.9* Hct-31.4* MCV-88 MCH-30.7 MCHC-34.8 RDW-13.7 Plt Ct-518*# diff: Neuts-74.8* Lymphs-11.0* Monos-2.8 Eos-11.0* Baso-0.5 PT-11.6 PTT-26.7 INR(PT)-1.0 Ret Aut-2.8 calTIBC-173* Ferritn-769* TRF-133* Glucose-124* UreaN-12 Creat-0.8 Na-131* K-6.7* Cl-95* HCO3-26 AnGap-17 ALT-78* AST-111* AlkPhos-107 TotBili-0.3 Lipase-39 HBsAg-NEGATIVE HBsAb-PND HBcAb-PND IgM HBc-NEGATIVE IgM HAV-NEGATIVE HCV Ab-NEGATIVE Labs on discharge: WBC-8.7 Hgb-9.6* Hct-29.1* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.9 Plt Ct-525* diff: Neuts-48* Bands-1 Lymphs-21 Monos-7 Eos-23* Baso-0 Atyps-0 Metas-0 Myelos-0 Glucose-117* UreaN-4* Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-27 AnGap-11 ALT-78* AST-62* AlkPhos-116 TotBili-0.1 Albumin-3.0* Calcium-7.9* Phos-3.4 Mg-1.8 [**2163-1-23**] 11:57PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-1075* Polys-10 Lymphs-18 Monos-0 Eos-57 Macroph-15 [**2163-1-23**] 11:57PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-95 Imaging: CXR: No acute cardiopulmonary process. CT head: 1. Interval evolution of encephalomalacia and decrease of blood products at prior sites of hemorrhage. 2. Slight increase in right frontal subdural low density collection. 3. Stable ventriculostomy catheter location with no interval development of hydrocephalus. 4. No new site of hemorrhage. 5. 4-mm leftward midline shift. CT abd/pelv: 1. Interval VP shunt placement, with no adjacent fluid collection. No evidence of acute intra-abdominal process. 2. Left adrenal adenoma, unchanged. 3. Small amount of pelvic free fluid, fluid in the endometrial cavity, and a small amount of air in the bladder may relate to recent LEEP procedure. 4. Increase in size of left buttock subcutaneous nodule, highly concerning for metastatic disease in this patient with known melanoma. 5. Right paramedian Bartholin gland cyst with tiny dependent stone; less likely urethral diverticulum. EKG: Sinus tach Brief Hospital Course: Initially transferred to MICU for closer monitoring for development vessicles/bullae or mucosal involvment. Stable overnight. Developed fever to 104 following morning with HR in the 130s, which improved with fluids, acetaminophen and motrin. Dilantin held and Keppra started for seizure [**Last Name (LF) 9401**], [**First Name3 (LF) **] Dr. [**Last Name (STitle) 724**]. #Rash: Most likely hypersensitivity reaction (DRESS) from dilantin vs famotidine. Both were held. Concerned for SJS initially, however rash did not appear to involve mucosa or palms/soles, and no bullae. Also considered toxic shock syndrome initially w/ fever and rash, but no tampon use. No evidence of meningitis given neck supple, no headache, CSF fluid does not appear infected, no fluid around abdominal portion of VP shunt. Seen by dermatology who recommended clobetasol, hydrocortisone cream, steroids as well as benadryl, Sarna and atarax. Rash remained stable, not spreading and perhaps slighty improving. Her fever decreased and she was able to tolerate PO. LFTs trending down, Cr stable, but she had a persistant eosinophilia. Per derm, rash likely to last for several weeks prior to resolution. Will follow up with dermatology as an outpatient. . #Fever: Most likely drug reaction. Infection considered, however no localizing signs of infection and no sick contacts. Cultures negative. No Abx given. Flu negative. Given acetaminophen and motrin as well as IVF. Temperature trended down and had normalized at time of discharge. . # Tachycardia: Persistant in 90-100s, fluid responsive, improving when afebrile. Likely [**3-15**] insensible losses from fever and rash. Encouaged PO fluids on discharge, fever control and close followup. . #Malignant melanoma: s/p ICH w/ multiple mets to brain. No current e/o neurologic defict other than left facial droop likely residual from previous ICH. Will follow up as outpatient. . Medications on Admission: Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours prn Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY finished 2 days ago. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) Benadryl Discharge Medications: 1. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks. Disp:*1 tube* Refills:*0* 2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) for 2 weeks: Do not use for greater than 2 weeks. Disp:*1 tube* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 4. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO every 6-8 hours as needed for itching. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pruritis. Disp:*30 Tablet(s)* Refills:*0* 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 7 days. Disp:*140 ML(s)* Refills:*0* 8. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day for 10 days: Take 5 tabs daily for two days, take 4 tab daily for two days, take 3 tabs daily for two days, take 2 tabs daily for two days and then take 1 tab daily for two days. 10 days total. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Drug Related Esosinophilia and Systemic Symptoms Secondary Diagnosis: Metastatic Melanoma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were seen in the hospital for a fever and rash that is likely due to the dilantin you were prescribed for seizure propalaxis. You were evaluated by the dermatology team and given steroids and medication to decrease itching. It is important to drink lots of fluids to avoid dehydration with your fever. The rash might worsene before it gets better and it is possible your skin will slough off as it heals. You should STOP your dilantin. Instead take Keppra as prescribed for seizure prophalaxis. You were given prescriptions for steroids and anti-itch cream that you should take as directed. Followup Instructions: [**Company 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2163-1-31**] 1:50 Dermatology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-2-2**] 2:30

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

9780, 9786

6252, 8173

326, 332

9940, 9940

4326, 4331

10710, 10980

2727, 2879

8624, 9757

9807, 9807

8199, 8601

10085, 10687

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2514, 2711

31,811

150,408

33868+57874

Discharge summary

report+addendum

Admission Date: [**2184-5-11**] Discharge Date: [**2184-5-20**] Date of Birth: [**2113-5-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: S/P fall with intracranial hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: This is a 70 y/o male with a PMH significant for MDS, CAD s/p MI in [**2180**] and [**2182**], possible CHF, who presented on [**2184-5-11**] following a fall from a ladder on [**2184-5-10**], resulting in hitting his head. He began having left-sided weakness at home, prompting him to go to an OSH for evaluation. He was found to have a subarachnoid hemorrhage and intraparenchymal hemorrhage involving the frontal and right parietal lobe and was transferred to [**Hospital1 18**] ED for further evaluation. He was admitted to the neurosurgical ICU and monitored closely overnight without any intervention. His platelets on admission were 38 (baseline) and Hct was 21.5, so he was transfused 2 units of PRBCs and platelets. He had a repeat head CT on [**5-11**] that was stable, and was transferred to the floor and ultimately the medicine service on [**2184-5-12**]. . On [**2184-5-12**], he had respiratory distress overnight off of O2 (increased RR) and required 4 L O2 to achieve normoxia. His IVF were d/c'd (started on admission) and he received 20 mg IV lasix along with his regular 80 mg oral dose, with good effect. Today, the patient desaturated again on 4 L to 88-90%, requiring 50% O2 by facemask, and was noted to be tachypneic to the 20s-30s. He received 20 mg IV lasix x 2 and his regular 80 mg po dose, with an output of 2.8 L thus far. Per nursing, has been having increased secretions with periodic desaturations, which resolve with suctioning. Repeat CXR was significant for worsening pulmonary edema. In addition, he spiked a temperature to 101.8 this afternoon. . Of note, the patient has been O2-dependent at home on 2 L NC since his MI in [**2182**]. Has had worsening LE edema after his MI in [**2182**], requiring an increase in lasix dose (40->80 mg daily) and was recently on metolazone with good effect. . Currently, the patient reports slight difficulty breathing, but denies any chest pain, dizziness/LH. +sweats. Denies any cough, abdominal pain, nausea/vomiting, diarrhea, or dysuria. Past Medical History: 1. Seizure disorder 2. Myelodysplastic syndrome, requires weekly transfusions - baseline Hct 21-23, plts 20-30, WBC [**2-24**] 3. CAD, s/p MI [**2180**] with balloon angioplasty, s/p MI [**11-28**] with no intervention 4. DM II 5. Stasis dermatitis 6. h/o polio . Social History: Lives at home with his wife, who is a RN. Former smoker 30 years ago. No EtOH, illicits. Very functional at home. . Family History: NC Physical Exam: VS: Tc 100.4, Tm 101.8, BP 136/57, HR 110, RR 25, SaO2 98%/50% FM General: Diaphoretic male in bed, breathing heavily, able to complete sentences. AO x 3 HEENT: NC/AT, PERRL, EOMI. +shovel mask in place Neck: supple, + JVP approx 10 cm Chest: bilateral crackles [**12-24**] way up, no wheezes CV: RRR s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS Ext: +chronic venous stasis changes, mild pitting edema Neuro: AO x 3, non focal Pertinent Results: [**2184-5-20**] 06:35AM BLOOD WBC-2.8* RBC-2.69* Hgb-7.8* Hct-22.6* MCV-84 MCH-29.0 MCHC-34.5 RDW-15.8* Plt Ct-46* [**2184-5-18**] 06:40AM BLOOD WBC-2.3* RBC-2.74* Hgb-8.2* Hct-23.5* MCV-86 MCH-30.1 MCHC-35.1* RDW-15.7* Plt Ct-38* [**2184-5-16**] 08:30AM BLOOD WBC-2.3* RBC-2.77* Hgb-8.0* Hct-23.5* MCV-85 MCH-29.0 MCHC-34.1 RDW-16.1* Plt Ct-41* [**2184-5-14**] 06:45AM BLOOD WBC-2.7* RBC-2.54* Hgb-7.4* Hct-21.9* MCV-86 MCH-29.2 MCHC-33.9 RDW-15.7* Plt Ct-35* [**2184-5-11**] 08:26AM BLOOD WBC-3.2* RBC-2.56* Hgb-7.5* Hct-21.5* MCV-84 MCH-29.4 MCHC-35.0 RDW-15.6* Plt Ct-38* [**2184-5-14**] 06:45AM BLOOD Neuts-77.7* Lymphs-18.9 Monos-2.5 Eos-0.6 Baso-0.3 [**2184-5-20**] 06:35AM BLOOD Plt Smr-VERY LOW Plt Ct-46* LPlt-2+ [**2184-5-20**] 06:35AM BLOOD PT-13.2 PTT-28.6 INR(PT)-1.1 [**2184-5-20**] 06:35AM BLOOD Glucose-142* UreaN-21* Creat-0.7 Na-136 K-4.3 Cl-97 HCO3-34* AnGap-9 [**2184-5-11**] 08:26AM BLOOD Glucose-157* UreaN-18 Creat-0.8 Na-139 K-3.6 Cl-99 HCO3-35* AnGap-9 [**2184-5-13**] 03:30PM BLOOD ALT-15 AST-25 LD(LDH)-531* CK(CPK)-36* AlkPhos-111 TotBili-0.7 [**2184-5-13**] 03:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2184-5-16**] 08:30AM BLOOD Calcium-8.6 Phos-2.7# Mg-2.3 [**2184-5-11**] 08:26AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 [**2184-5-20**] 06:35AM BLOOD Phenyto-6.5* [**2184-5-19**] 06:40AM BLOOD Phenyto-2.9* [**2184-5-12**] 02:13AM BLOOD Phenyto-10.1 [**2184-5-11**] 08:26AM BLOOD Phenyto-16.5 [**2184-5-13**] 09:40PM BLOOD Type-ART FiO2-95 O2 Flow-4 pO2-88 pCO2-56* pH-7.45 calTCO2-40* Base XS-12 AADO2-535 REQ O2-89 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2184-5-13**] 11:07AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2184-5-13**] 11:07AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD [**2184-5-13**] 11:07AM URINE RBC-4* WBC-35* Bacteri-FEW Yeast-NONE Epi-0 [**2184-5-13**] 11:07AM URINE CastGr-4* [**2184-5-13**] 11:07AM URINE WBC Clm-RARE Mucous-RARE [**2184-5-13**] 11:45 pm URINE Source: Catheter. **FINAL REPORT [**2184-5-16**]** URINE CULTURE (Final [**2184-5-16**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S RADIOLOGY Final Report MR HEAD W & W/O CONTRAST [**2184-5-11**] 8:05 PM MR HEAD W & W/O CONTRAST Reason: please evaluate for underlying mass as source of hemorrhage. Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 70 year old man with subarachnoid and intraparenchymal bleeds REASON FOR THIS EXAMINATION: please evaluate for underlying mass as source of hemorrhage. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 70-year-old male with subarachnoid and intraparenchymal hemorrhages after fall. COMPARISON: CT head of [**2184-5-11**]. TECHNIQUE: Axial T1, FLAIR, T2, gradient echo, and diffusion-weighted images as well as sagittal T1-weighted images were acquired prior to administration of IV contrast. Subsequent multiplanar T1-weighted imaging was performed after administration of IV gadolinium. MR HEAD: A 3.7 x 1.8 cm right frontal parafalcine intraparenchymal hemorrhage with mild surrounding edema is grossly unchanged in appearance compared to the CT performed earlier on the same day at 10:33. Regions of subarachnoid hemorrhage are also noted in the bilateral frontal and parietal lobes, also unchanged. A small amount of intraventricular hemorrhage is noted in both occipital horns. In addition, a tiny focus of gradient echo signal drop-out in the right occipital lobe (9:10) likely represents a focus of microhemorrhage; no other foci of microhemorrhage are seen. There is no shift of normally midline structures, hydrocephalus, or loss of the basal cisterns. There is no region of diffusion abnormality to suggest underlying infarction. No region of abnormal enhancement is seen to suggest underlying mass. The normal vascular flow voids are demonstrated. No MRI signs of venous sinus thrombosis are seen. Decreased T1-weighted signal in the clivus may relate to myelodysplastic changes or an infiltrative process. The paranasal sinuses and mastoid air cells remain well aerated. The patient is status post bilateral lens replacement. IMPRESSION: 1. Right frontal parafalcine intraparenchymal hemorrhage, multiple foci of subarachnoid hemorrhage, and tiny bilateral intraventricular hemorrhage unchanged. Tiny focus of susceptibility artifact in the right occipital lobe may represent focus of microhemorrhage. 2. No definite evidence of underlying mass, infarct or vascular abnormality. 3. Decreased T1 signal in the clivus may represent myelodysplastic changes in this patient with history of myelodysplastic syndrome. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: [**Doctor First Name **] [**2184-5-13**] 1:25 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2184-5-11**] 9:12 AM CHEST (PORTABLE AP) Reason: ?PNA [**Hospital 93**] MEDICAL CONDITION: 70 year old man with SAH, mild hypoxia REASON FOR THIS EXAMINATION: ?PNA HISTORY: 70-year-old male with subarachnoid hemorrhage, mild hypoxemia. Please evaluate for pneumonia. COMPARISON: None available. SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The patient is rotated. However, there is no definite cardiomegaly. The left hemidiaphgragm is elevated with associated left basilar atelectasis. In this setting, a pneumonic consolidation or aspiration is difficult to exclude. There is no pleural effusion or evidence of pulmonary interstitial edema. The bony thorax is normal. IMPRESSION: Left basilar atelectasis associated with left hemidiaphragm elevation. Difficult to exclude pneumonic consolidation or aspiration in this setting. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: TUE [**2184-5-11**] 10:03 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2184-5-12**] 11:29 AM CT HEAD W/O CONTRAST Reason: please eval progression of bleed [**Hospital 93**] MEDICAL CONDITION: 70M with SAH s/p fall REASON FOR THIS EXAMINATION: please eval progression of bleed CONTRAINDICATIONS for IV CONTRAST: None. EXAM: CT of the head. CLINICAL INFORMATION: Status post fall, subarachnoid hemorrhage. TECHNIQUE: Axial images of the head were obtained without contrast. Comparison was made with the previous study of [**2184-5-11**]. FINDINGS: Again a right posterior frontal intra-axial hematoma is identified with mild surrounding edema. The edema is slightly more prominent than the previous study. There is no mass effect or midline shift seen. Again subarachnoid hemorrhage and intraventricular blood is identified which has not significantly changed. No significant new areas of hemorrhage seen. IMPRESSION: Slightly more prominent hypodensity due to edema surrounding the intra-axial hemorrhage in the right posterior frontal lobe along the midline. This could be secondary to evolution. No change in the subarachnoid hemorrhage or ventricular size seen. DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: [**Doctor First Name **] [**2184-5-13**] 1:26 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2184-5-13**] 9:45 PM CT HEAD W/O CONTRAST Reason: please eval for worsening bleed [**Hospital 93**] MEDICAL CONDITION: 70 year old man with mental status changes and worsening weakness on left side REASON FOR THIS EXAMINATION: please eval for worsening bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Mental status changes, evaluate for worsening bleed. COMPARISON: [**2184-5-12**]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: No significant change is seen compared to study performed one day prior. Again seen is a right posterior frontal intra-axial hematoma with surrounding edema. No shift of midline structures is identified. Subarachnoid hemorrhage with intraventricular blood is also not significantly changed compared to prior study. No definite new areas of hemorrhage are identified. Configuration of the ventricles is unchanged from prior. IMPRESSION: No significant change seen compared to prior study. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: FRI [**2184-5-14**] 9:57 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2184-5-11**] 8:47 AM CT HEAD W/O CONTRAST Reason: eval ICH [**Hospital 93**] MEDICAL CONDITION: 70 year old man with SAH s/p fall, eval progression of bleed REASON FOR THIS EXAMINATION: eval ICH CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 70-year-old male with subarachnoid hemorrhage status post fall, please evaluate progression of bleed. COMPARISON: None available. TECHNIQUE: Contiguous axial imaging was obtained from the cranial vertex to the foramen magnum without IV contrast. Please note that significant motion during the scan limits interpretation. CT HEAD WITHOUT IV CONTRAST: The quality of the scan is severely compromised by significant patient motion. However, the cranial vertex is relatively spared with respect to motion artifact, and numerous foci involving the frontal and parietal lobes bilaterally demonstrate subarachnoid hemorrhage in the sulci interdigitating with the gyri. Although there is surrounding edema, there is no apparent mass effect or midline shift of normally midline structures.Parenchymal hematoma right cingulate gyrus may also be present. Although no fracture is definitely identified, severe motion degradation limits the ability to detect a fracture. IMPRESSION: Subarachnoid hemorrhage involving the frontal and parietal lobes bilaterally. Because of significant motion artifact, it is not possible to assess for fracture. If there is high concern for fracture, a repeat scan would be helpful. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: TUE [**2184-5-11**] 5:53 PM RADIOLOGY Final Report -76 BY SAME PHYSICIAN [**2184-5-13**] 7:31 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN Reason: please rule out pneumonia/effusion [**Hospital 93**] MEDICAL CONDITION: 70 year old man with dyspnea REASON FOR THIS EXAMINATION: please rule out pneumonia/effusion REASON FOR EXAMINATION: Dyspnea. Portable AP chest radiograph compared to [**2184-5-13**]. There is interval worsening in bilateral perihilar opacities especially in the right lower lung consistent with worsening pulmonary edema. Slight asymmetry in the left lower lobe opacity is demonstrated which might be due to underlying infectious process. Small bilateral pleural effusions are present. There is no change in the moderate-to-severe cardiomegaly. There is no pneumothorax. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: SAT [**2184-5-15**] 1:52 PM RADIOLOGY Final Report -77 BY DIFFERENT PHYSICIAN [**2184-5-13**] 2:10 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN Reason: please rule out pneumonia/effusion [**Hospital 93**] MEDICAL CONDITION: 70 year old man with increasing respiratory distress REASON FOR THIS EXAMINATION: please rule out pneumonia/effusion REASON FOR EXAMINATION: Increasing respiratory distress. Portable AP chest radiograph compared to [**2184-4-23**] obtained at 1:15. Interval progression in bilateral perihilar haziness is demonstrated on the left concerning for progression of pulmonary edema. The bilateral pleural effusions cannot be ruled bowel. The left hemidiaphragm is elevated most likely due to left lower lobe atelectasis. IMPRESSION: Worsening bilateral parenchymal opacities are consistent with worsening pulmonary edema. Findings were communicated to Dr. [**Last Name (STitle) 78273**] over the phone by Dr. [**Last Name (STitle) **] at the time of dictation. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: [**Doctor First Name **] [**2184-5-13**] 5:18 PM RADIOLOGY Final Report PORTABLE ABDOMEN [**2184-5-13**] 12:10 PM PORTABLE ABDOMEN Reason: please r/o obstruction [**Hospital 93**] MEDICAL CONDITION: 70 year old man with right sided abdominal pain REASON FOR THIS EXAMINATION: please r/o obstruction ABDOMINAL RADIOGRAPH: INDICATION: 70-year-old man with right-sided abdominal pain. COMPARISON: Not available. FINDINGS: Single supine abdominal radiograph is presented for review. There is no supine radiographic evidence of free intraperitoneal air. Small bowel is not dilated. Air is seen in the large bowel. Phleboliths are present in the pelvis. There is no pneumatosis or portal venous gas. IMPRESSION: Limited study. No evidence of small bowel obstruction. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: FRI [**2184-5-14**] 1:51 PM RADIOLOGY Final Report BILAT LOWER EXT VEINS [**2184-5-14**] 1:27 PM BILAT LOWER EXT VEINS Reason: eval for DVT in bilateral lower extremities [**Hospital 93**] MEDICAL CONDITION: 70 year old man with COPD, CHF, now with worsening hypoxia despite diuresis REASON FOR THIS EXAMINATION: eval for DVT in bilateral lower extremities INDICATION: 70-year-old man with hypoxia; evaluate for lower extremity DVT. COMPARISONS: None. FINDINGS: The bilateral common femoral, superficial femoral and popliteal veins are patent and compressible, without filling defect. The calf veins are also patent. Waveforms demonstrate appropriate respiratory phasicity and response to distal augmentation. In the left popliteal fossa, there is a 4.3 x 2.3 x 3.1 cm echogenic lesion just deep to the subcutaneous fat, which may represent a lipoma. IMPRESSION: 1. No evidence of DVT in either lower extremity. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7805**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SAT [**2184-5-15**] 7:47 AM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2184-5-14**] 8:10 AM CHEST (PORTABLE AP) Reason: eval for interval change [**Hospital 93**] MEDICAL CONDITION: 70 year old man with SAH, IPH, and pulmonary edema REASON FOR THIS EXAMINATION: eval for interval change PROCEDURE: Chest portable AP [**2184-5-14**]. COMPARISON: [**2184-5-13**]. HISTORY: 70-year-old male with SAH hemorrhage, intracranial pressure, hypertension and pulmonary edema. Evaluate for interval change. FINDINGS: The pulmonary edema has DEcreased. The heart size is within normal limits. There is no pleural effusion. Persistent abnormal elevation of the left hemidiaphragm seen. IMPRESSION: 1) Lesser pulmonary edema. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 11004**] [**Name (STitle) 11005**] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2184-5-14**] 2:59 PM RADIOLOGY Final Report LUNG SCAN [**2184-5-15**] LUNG SCAN Reason: ? CHF ? COPD HYPOXIA EVAL FOR PE RADIOPHARMECEUTICAL DATA: 43.2 mCi Tc-[**Age over 90 **]m DTPA Aerosol ([**2184-5-15**]); HISTORY:70-year-old male with SAH hemorrhage, intracranial pressure, hypertension and dyspnea. Please evlaute for pulmonary embolism. INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate abnormal decreased ventilation of the left lung base which corresponds to the CXR finding of the elevated left hemidiaphragm. Perfusion images were not performed based on patient request. Patient quit the study against medical advice. Chest x-ray shows decreasing pulmonary edema, no pleural effusion and persistent abnormal elevation of the left hemidiaphragm. The above findings are consistent with an inconclusive study as no perfusion phase has been performed. IMPRESSION: Inconclusive study as no perfusion phase has been performed. The patient did not want to continue with perfusion phase. [**Name6 (MD) 1831**] [**Name8 (MD) 1832**], M.D. [**Last Name (NamePattern5) **], M.D. Approved: WED [**2184-5-19**] 4:08 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2184-5-18**] 11:36 AM CT HEAD W/O CONTRAST Reason: Please evaluate for interval change [**Hospital 93**] MEDICAL CONDITION: 70 year old man with MDS, SDH REASON FOR THIS EXAMINATION: Please evaluate for interval change CONTRAINDICATIONS for IV CONTRAST: not needed HISTORY: 70-year-old male with history of myelodysplastic syndrome presenting with intraparenchymal and subarachnoid hemorrhages after fall. COMPARISON: CT head from [**2184-5-11**] through [**2184-5-13**] as well as MR head of [**2184-5-11**]. TECHNIQUE: Contiguous axial imaging was performed through the brain without administration of IV contrast. CT HEAD: A parafalcine right frontal intraparenchymal hemorrhage measuring 35 x 20 mm is little changed; surrounding edema may be slightly more prominent. While there is associated mild sulcal effacement, there is no shift of normally midline structures, and the basal cisterns are preserved. Multiple bilateral foci of subarachnoid hemorrhages along the superior convexity are grossly not changed. No definite new focus of hemorrhage is seen. There is no evidence of acute large vascular territory infarction or hydrocephalus. The previously seen intraventricular hemorrhage is no longer apparent. Evaluation of fine bony detail is somewhat limited by patient motion, however, the visualized paranasal sinuses and mastoid air cells are grossly clear. Vascular calcifications are again noted in the cavernous carotid and vertebral arteries. The patient is status post bilateral lens replacement. IMPRESSION: Slightly more prominent edema surrounding posterior parafalcine right frontal lobe intraparenchymal hemorrhage, again with sulcal effacement but without shift of normally midline structures. Findings again likely represent continued evolution of hemorrhage. Scattered foci of subarachnoid hemorrhage little changed. Intraventricular hemorrhage no longer seen. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 10627**] PERI Approved: WED [**2184-5-19**] 11:03 AM Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 50-55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly dilated right ventricle with preserved biventricular systolic function. Moderate tricuspid regurgitation. Severe pulmonary hypertension. ICAEL Accredited Brief Hospital Course: A/P - 70 y/o male with CAD s/p NSTEMI x 2, seizure d/o, MDS, likely [**Hospital 27810**] transferred to medicine service after neuro-surgical admission after a fall, transferred to medicine after developing respiratory distress and fever. . # Fever/UTI - Blood cultures and urine cultures were taken. Chest x-ray was most consistent with fluid overload rather than pneumonia as was subsequent clinical course. He was started on ciprofloxacin then narrowed to ampicillin for pan-sensitive enterococcus in the urine; he should be continued for a total of 7 day course of antibiosis, which will be completed on [**5-24**]. # Respiratory distress - due to CHF. Lasix was given with improvement. An echo did not provide an obvious explanation for why he has a 2L O2 requirement at home after his MI, and it may be that pulmonary follow-up would be appropriate to consider his pulmonary hypertension. He was stable on his baseline O2 requirement when discharged to the rehabilitation facility. # Acute-on-chronic diastolic heart failure An echo was performed - results above. # Subarachanoid and intraparenchymal hemorrhages: he was initially monitored in the neurosurgical ICU and blood pressure controlled with IV nicardipine. Serial CT and clinical exam suggest resolution; most recent CT scan showed mild cerebral edema without shift of any midline structures and resolving blood with resorption of intraventricular blood. Pt did not want another MRA because of the length of the study and discomfort. # DM: - glyburide initially held in case pt would require any procedures that would require him to be NPO; restarting at 5mg on discharge # seizure disorder: cont outpatient dilantin dose. Levels should be monitored. Levels was 6.5 at discharge (with albumin 3.3) #. MDS, myelofibrosis: Transfusion dependent. - plan to keep HCT >21, and plt >40K; ideally over 50K if possible atleast initially after bleed. His diastolic CHF does necessitate an extra dose of lasix 40mg po with each blood transfusion. # Transient hematuria was noted likely from foley trauma. Resolved prior to discharge. Void trial is advised at rehab. If recurs, suggest urology consult. Code: DNR/DNI. The patient was discharged to rehab for PT. Palliative care team here also saw the patient at his and his wife's request and informed them of hospice options. Medications on Admission: 1. Zocor 40 mg daily 2. Atenolol 37.5 mg daily 3. Prinivil 5 mg daily 4. Lasix 80 mg daily 5. Glyburide 10 mg daily 6. Dilantin 330 mg/300 mg daily 7) allopurinol 300mg PO / day Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO qAM: with 30 mg capsule, for total of 330 in AM; (plus separate order of 300 in PM); overall schedule is 330 in AM, 300 in PM. . 7. Phenytoin Sodium Extended 30 mg Capsule Sig: One (1) Capsule PO qAM: with 300 mg capsule, for total of 330 in AM; (plus separate order of 300 in PM); overall schedule is 330 in AM, 300 in PM. . 8. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 13. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 10 days: day 1=[**5-16**]; total = 14 day course. 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 16. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 17. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): mealtimes: 150-199: 2 units; 200-249: 4 units; 250-299: 6 units: 300-349: 8 units; 350-400: 10 units; over 400 [**Name8 (MD) 138**] MD. Bedtime: 150-199: 1 units; 200-249: 2 units; 250-299: 3 units: 300-349: 4 units; 350-400: 5 units; over 400 [**Name8 (MD) 138**] MD. 18. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Fall/intracranial, subarachanoid hemorrhage Enterococcal urinary tract infection, catheter-associated Acute-on-chronic diastolic heart failure Hematuria, resolved Depression Myelofibrosis History of seizure disorder, DM type 2, CAD, acute on chronic CHF Discharge Condition: Good Discharge Instructions: You were admitted after a fall and bleeding in your brain. The bleeding appears to be resolving. You're now being transferred to a rehabilitation facility to continue to try to build up your strength and your health. . You had a urinary tract infection whiile in the hospital. Your urinary catheter was changed and you were given antibiotics which will also be given in the rehabilitation facility. REHAB FACILITY: patient should be given trial of voiding to assess whether Foley can be discontinued. . . It's important that you follow up with your physicians. Followup Instructions: It is important that if Mr [**Known lastname 1391**] is still in rehabilitation that transportation be arranged for this appt: [**6-1**], 2 pm, Dr [**Last Name (STitle) 548**] (neurosurgery); [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 1535**]. [**Telephone/Fax (1) 2992**]. . You should make an appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (primary care) for shortly after your discharge from the rehabilitation facility; call his office at [**Telephone/Fax (1) 10508**]. Name: [**Known lastname **],[**Known firstname 389**] Unit No: [**Numeric Identifier 12616**] Admission Date: [**2184-5-11**] Discharge Date: [**2184-5-20**] Date of Birth: [**2113-5-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1455**] Addendum: A preliminary discharge summary, written by the covering intern but not yet reviewed by the attending physician, [**Name10 (NameIs) **] originally sent to [**Hospital1 **] with the patient. The attending review showed that it contained two errors: it did not list allopurinol as one of his home medications, and it improperly stated his code status. His proper code status through this admission and on discharge (and confirmed with a transport DNR/DNI sheet signed by patient and intern) was DNR/DNI. . The errors and updated correct information were discussed verbally with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] RN on [**2184-5-24**], who stated that she verbally updated the covering physician at that time; and an updated discharge summary was received by the [**Hospital1 12617**] facility in the afternoon of Monday [**2184-5-24**] by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] RN, and put in the chart then. This was confirmed with Ms [**Name13 (STitle) **] in the morning of [**2184-5-25**] by the covering intern. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 4415**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**] Completed by:[**2184-5-25**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "88.72" ]

icd9pcs

[ [ [] ] ]

31110, 31323

23421, 25764

353, 359

28476, 28483

3313, 6029

29092, 31087

2845, 2849

25993, 28082

20500, 20530

28196, 28455

25790, 25970

28507, 29069

2864, 3294

276, 315

20559, 20997

387, 2407

21006, 23398

2429, 2695

2711, 2829

26,860

140,672

49562

Discharge summary

report

Admission Date: [**2171-8-26**] Discharge Date: [**2171-9-3**] Date of Birth: [**2100-7-6**] Sex: F Service: MEDICINE Allergies: Gentamicin / Amoxicillin Attending:[**First Name3 (LF) 898**] Chief Complaint: Two day history of increasing dyspnea, productive cough, and wheezing, with markedly decreased functional capacity. Major Surgical or Invasive Procedure: NG tube placement Flex sigmoidoscopy and placement of rectal tube History of Present Illness: Pt is a 71F with a history of COPD, DM, CAD, and multiple other medical problems presenting with a two-day history of increasing dyspnea, marked decrease in functional capacity, and increased wheezing and cough productive of whitish-clear sputum. The patient states that this episode was very similar to COPD flares the patient has experienced in the past, and the patient did not want to go to the hospital but felt she had to. The patient denies fevers, but does note occasional chills that appear to be recurrent. Significantly, the patient reports that in the days prior to the onset of the patient's symptoms, she noted that she felt that she was "coming down with something." The patient admits to chest tightness while coughing, but denies other CP, palpitations, and nausea/vomiting. Of note, the patient admits to a previous, but less severe, COPD exacerbation for which she was seen on [**2171-7-30**] by her PCP. [**Name10 (NameIs) **] was given an 8 day prednisone taper and her symptoms rapidly resolved. . In the ED, the patient pt's vitals were T: 100.1 BP: 185/77 HR: 112 RR 20 O2 sat 94% on 3L NC. Pt received solumedrol 120mg IV, ipratropium/albuterol neb, albuterol neb x2, levaquin 750mg IV x 1, and vancomycin 1gm IV x 1 for erythema on L leg suspicious for cellulitis. Pt is a MRSA carrier per OMR. Past Medical History: COPD x 10+ years, ? asthma. Spirometry [**1-1**] showed FEV1 65%, FEV1/FVC 93%. CAD: No recent echo. Stress test [**4-1**] showed persantine-induced anginal symptoms, but no ischemic ST segment changes, and atrial ectopy. Three-pillow orthopnea. DM x 15 years: poorly controlled HTN x 15+ years Dyslipidemia x 15+ years Chronic renal insufficiency: Cr of 1.4 documented in [**2157**], likely [**1-26**] diabetic nephropathy Depression: since car accident in [**2141**]; pt reports multiple social stressors Muscle spasms, intermittent but over many years GERD OA Osteopenia Anemia Chronic LBP: ? related to [**2141**] car accident; recently exacerbated by fall that injured shoulder Shoulder injury [**2167**]: complicated by rhabdomyolysis/ARF necessitating 5 sessions of HD. s/p L hemiarthroplasty. Shoulder pain continues to bother pt. Trauma [**2141**]: car accident killed mother, daughter is amnestic s/p ex-lap, splenectomy s/p cholecystectomy SBO [**2161**]: s/p ex-lap to remove vegetable bezoar Social History: Pt lives independently with her husband. Had four children, 1 son deceased from car accident. Reports some social support from her family. Has a 100+ pack year history of smoking, and continues to smoke 1 ppd. Does not really have desire to quit smoking, and is aware of complications of smoking, particularly as related to her medical history. Minimal EtOH use. No IVDA or recreational drug abuse. No exercise. No home O2. Pt states that she takes care of her own medical care, including medicines, and reports that she takes her medications faithfully and requires no additional help to manage her medications. Family History: 3 living children, one daughter IVDU with hepatitis. One elder brother 71yo, recent cardiac BPG, otherwise healthy. Mother died in [**Name (NI) 8751**] at 79yo, hx emphysema, former smoker, heart disease. Father died in 50s from throat cancer, ?smoker. Physical Exam: T: 98.7 BP: 152/76 HR: 88 RR: 24 O2 93% 2L Gen: Pleasant, NAD, tremulous [**1-26**] albuterol, on NC HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple. No masses. No LAD, No JVD. CV: Difficult to hear heart sounds due to body habitus and breath sounds. RRR. nl S1, S2. No murmurs, rubs or gallops appreciated. LUNGS: BS poor at bases BL. Marked coughing and wheezing throughout. Mild bibasilar crackles. I:E ratio significantly elevated. Mild supraclavicular retractions. ABD: +BS. Soft, NT, ND. No fluid wave. Normal tympany to percussion. Unable to assess hepatomegaly d/t obesity. No spleen. EXT: WWP, NO CCE. 2+ radial pulses BL. Nl capillary refill throughout. No LE edema. SKIN: No rashes, lesions, jaundice, ecchymoses. LLE has scars and sequelae of car accident 28 years ago but appears to have a new redness, non-tender, not markedly swollen. NEURO: A&Ox3. Appropriate. CNII: PERRLA. CNIII,IV,VI: EOMI, no nystagmus or ptosis. CNV: sensation to light touch intact in all three distributions b/l. Good masseter/temporalis strength. CNVII: equal, symmetric facial movements. CNIX/X: No difficulties with swallowing, symmetric and normal palate elevation. CNXI: SCM and trapezius muscle strength 5/5. CNXII: tongue protrudes to midline with no fasciculations. Preserved sensation throughout. 5/5 strength in the R upper extremity and lower extremities. L upper extremity is [**2-27**] d/t continuing shoulder pain from fall 2 years ago. 1+ reflexes, equal BL throughout. Normal coordination including [**Doctor First Name **] and FNF. Gait assessment deferred. PSYCH: Listens and responds to questions appropriately, pleasant. Describes mood as "could be better," but states that she is near her baseline mood. States some anxiety regarding hospitalization. Pertinent Results: [**2171-8-26**] 05:40AM GLUCOSE-362* UREA N-15 CREAT-1.3* SODIUM-137 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16 [**2171-8-26**] 05:40AM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.6 [**2171-8-26**] 05:40AM WBC-6.7 RBC-4.27 HGB-11.0* HCT-34.9* MCV-82 MCH-25.7* MCHC-31.5 RDW-14.5 [**2171-8-26**] 05:40AM NEUTS-92.3* LYMPHS-6.8* MONOS-0.6* EOS-0.1 BASOS-0.2 [**2171-8-26**] 05:40AM PLT COUNT-258 [**2171-8-25**] 10:09PM GLUCOSE-146* LACTATE-1.3 [**2171-8-25**] 09:51PM PT-13.0 PTT-23.5 INR(PT)-1.1 [**2171-8-25**] 09:51PM cTropnT-<0.01 [**2171-8-25**] 09:51PM CK(CPK)-92 [**2171-8-25**] 09:51PM WBC-7.3 RBC-4.24 HGB-11.2* HCT-34.1* MCV-80* MCH-26.5* MCHC-32.9 RDW-13.9 . CXR Admission: PA and lateral views of the chest are obtained. There are no new parenchymal abnormalities in the lungs. Areas of probable scarring are noted in the left lower lung. No evidence of CHF or pneumonia. No pleural effusion or pneumothorax is seen. Relative upper [**Name2 (NI) 3630**] lucency and splaying of bronchial vasculature is again noted, likely related to underlying COPD. Cardiomediastinal silhouette is stable. Left humeral head prosthesis is again noted. Osseous structures appear stable. Clips are noted in the right upper quadrant. . KUB [**2171-8-28**]: Dilated loops of colon with no air seen in the rectum suggestive of colonic ileus or possible toxic megacolon. Early distal obstruction cannot be excluded secondary to paucity of air noted in the rectum. . CT ABDOMEN WITH IV CONTRAST [**2171-8-28**]: Liver appears normal. No evidence of intra- or extra-hepatic bile duct dilation. Patient is status post cholecystectomy. Pancreas, spleen, adrenal glands and kidneys appear normal. There is a 1.6 cm parapelvic cyst in the interpolar region of the right kidney. The tip of the nasogastric tube is in the stomach. No evidence of mesenteric or retroperitoneal lymphadenopathy. Right renal artery stent unchanged in appearance. Small bowel is unremarkable. Scattered sigmoid diverticula without evidence of diverticulitis. There is gaseous distention of the colon from the cecum through the sigmoid colon where it tapers gradually to the decompressed rectum. No evidence of volvulus, pneumatosis, a transition point or obstructing mass lesion. The ascending colon is dilated up to approximately 10 cm. Note is made of an anterior midline healed surgical scar. CT PELVIS WITH IV CONTRAST: Bladder is distended and appears normal. Uterus is unremarkable. No evidence of pelvic or inguinal lymphadenopathy. BONE WINDOWS: Multilevel degenerative changes are seen in the lower thoracic and lumbar spine. No suspicious osteolytic or osteoblastic lesions are identified. IMPRESSION: Gaseous distention of the colon without evidence of volvulus or obstructing mass lesion. KUB [**2171-9-3**]: No abnormally dilated large or small bowel. Brief Hospital Course: # Dyspnea: COPD exacerbation. Given lack of chest pain, the progressive nature of her symptoms, and characteristic wheezing, course breath sounds and pursed lip breathing. Treated as COPD exacerbation. Patient treated with IV steroids and transferred to po Steroids. Discharged on Prednisone 50 mg once a day. Recommend 5-10 mg decrease over 14 days starting on [**2171-9-11**]. Recommend slow taper because patient was admitted on a prednisone taper 10mg daily. . After pt developed ?SBO (see below), pt's respiratory status worsened [**1-26**] pain/anxiety/possible compression of lungs from hugely distended bowel. At this point, she was transferred to the MICU and all PO meds were changed IV, including methylprednisolone 20mg IV q8h, azithromycin 250mg IV qd, and metronidazole 500mg IV q8h. . # Abdominal pain/nausea/vomiting: Pt reports that she had not had a bowel movement in 3 days. On the morning of [**8-28**], she was severely nauseated, with vomiting and abdominal pain that did not respond to zofran dilaudid, or laxatives. Pt was tachy to 100s and hypertensive to 170s SBP. Pt received two doses of hydralazine with minimal effect. Pt was placed on tele given tachycardia, hypertension, and known CAD. NG tube was placed with drainage and was made NPO. However, she continued to vomit around NG tube. Pt had hypoactive bowel sounds. A portable abd xray noted marked colonic distension which was confirmed on CT abd. There was no visible free air or colonic tickling but given the marked colonic distension she was transferred to the ICU for emergent evaluation. Pt has a history of SBO s/p multiple surgeries. A surgery consult was obtained prior to transfer who felt that this was most likely an ileus and given that she is a poor surgical candidate, recommended endoscopic decompression. Also, consulted GI who performed colonic decompression and rectal tube placement via sigmoidoscopy. Pt was started on levofloxicin and flagyl. Following decompression, surgery requested another KUB which showed interval improvement and surgery signed off. Pt was subsequently called out to the floor for continued conservative management. Patient tolerated clears. NG tube and rectal tube were removed. Patient able to tolerate regular diet and po meds. KUB on day of discharge demonstrated no abnormally dilated large or small bowel. . # DM: Pt's DM has been poorly controlled 200-300 as an outpt. Expect higher blood sugar levels while on steroids. On day of discharge increase breakfast NPH to 12 and bedtime NPH 7 units. Adjust insulin sliding scale as needed to control sugars. . # CAD: Has baseline orthopnea. Unknown EF. Continued ASA, statin. Not on BB [**1-26**] COPD. . # Hypertension: While on the floor, continued home regimen of long acting nifedipine 90mg Qday. During MICU stay, this med was d/c'ed and her pressures were closely monitored. . # Depression: Pt has long history of depression starting in [**2141**] with [**Year (4 digits) 8751**] that killed mother. Over the years that patient has reported significant social stressors, including physical health issues, problems with husband, children, and other family member, housing difficulties, and financial difficulties. Pt reports that current mood is near baseline, and "could be better." States anxiety regarding hospitalization. Pt was taking fluoxetine and trazodone, but these were d/c'd while pt was NPO. Re-started when able to tolerate po. Started Lorazepam 0.5 mg PO Q4H:PRN anxiety during hospital stay. Patient has baseline anxiety which could be related to psychiatric baseline and COPD. . # Musclespams: Continue outpatient gabapentin Medications on Admission: Albuterol neb QID:PRN Atorvastatin 80mg qd Fluoxetine 20mg qd Fluticasone-salmeterol 500/50mcg 1 puff [**Hospital1 **] Gabapentin 100mg TID Ipratropium 17mcg 2 puffs QID Ipratropium-albuterol 103/18mcg 2 puffs [**Hospital1 **] Lidocaine patch 5% 12 hours on, 12 hours off Nifedipine 90mg qd Nitrogycerin 0.4mg SL PRN Orphenadrine 100mg qhs:PRN Prednisone taper to 10mg qd Trazodone 100mg qhs ASA 325mg qd Ferrous sulfate 325mg [**Hospital1 **] Insulin NPH 50AM, 30PM Omeprazole 20mg qd Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Hold if ambulating. 3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation prn q4hr as needed for shortness of breath or wheezing. 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): On [**2171-9-11**] decrease 5-10 mg every 14 days. . 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. Tablet, Chewable(s) 18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: [**2171-8-29**] to [**2171-9-8**] for 10 day duration. . 20. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: COPD exacerbation Bowel obstruction due to colonic stenosis and constiptation . Secondary: Diabetes HTN CAD Discharge Condition: Good, stable vitals. 92% O2 on 2L. Discharge Instructions: You were admitted for COPD flare. You developed an obstruction and went to the ICU for a sigmoidoscopy. You had a NG tube and rectal tube placed. The obstruction resolved and the tubes were removed. . We have made some changes to your medication, please follow them closely. . Please attend your follow-up appointments. . Return to the ER if you experience abdominal pain, nausea, vomiting, bloody stools, shortness of breath or any other concerning symptoms. Followup Instructions: Please have the rehab make the following appointments: 1) Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1144**] in [**12-26**] weeks. Discuss with him whether you need to follow up in [**Hospital **] clinic. 2) Lung Doctor: PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2171-9-26**] 9:00, [**Doctor Last Name 4506**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2171-9-26**] 9:30. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] PULMONARY UNIT-CC7 (SB) Completed by:[**2171-9-3**]

[ "250.40", "728.85", "491.21", "733.90", "560.9", "272.4", "414.01", "401.9", "583.81", "584.9", "305.1", "427.89", "530.81", "311" ]

icd9cm

[ [ [] ] ]

[ "96.09", "45.24" ]

icd9pcs

[ [ [] ] ]

14644, 14723

8485, 12133

398, 465

14884, 14921

5604, 8462

15430, 16034

3516, 3770

12669, 14621

14744, 14863

12159, 12646

14945, 15407

3785, 5585

243, 360

493, 1822

1844, 2860

2876, 3500

695

154,201

10671+10672

Discharge summary

report+report

Admission Date: [**2176-7-7**] Discharge Date: [**2176-7-19**] Service: GEN [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female who was transferred to [**Hospital1 188**] on [**2176-7-7**] from [**Hospital6 1109**] for long-standing alcohol related pancreatitis. She was admitted to [**Hospital1 **] one month before [**2176-7-7**] with abdominal pain, fever and a CT scan that verified a pancreatic pseudocyst, which was drained percutaneously on [**2176-6-24**] with initial improvement. She had been on total parenteral nutrition at [**Hospital1 **] and had continued abdominal pain and intermittent fevers. A repeat CT scan at [**Hospital1 **] on [**2176-7-5**] showed a recurrent collection and cyst fluid that had grown Staphylococcus non-aereus. She had been treated at [**Hospital1 **] with vancomycin, clindamycin and levofloxacin and had been put on a clear p.o. diet before transfer from [**Hospital1 **]. HOSPITAL COURSE: The patient had a CT scan on [**2176-7-8**] that confirmed a pancreatic pseudocyst collection. During this CT scan, Dr. [**First Name (STitle) **] of interventional radiology removed the patient's percutaneous pseudocyst drainage catheter. He attempted to put in a new drain, but was unsuccessful at that time. At that time, the patient was continued on vancomycin, levofloxacin and clindamycin. On [**2176-7-10**], the patient had a repeat CT scan and at that time interventional radiology was, in fact, able to place a percutaneous drain. Cultures from the percutaneous drain that was discontinued grew out 4+ gram-positive cocci on Gram's stain. Thus, the patient was again continued on vancomycin, levofloxacin and clindamycin. Over the next few days, the patient began to do better. The patient pulled her nasogastric tube out on [**2176-7-12**]. Her abdominal examination became much better over the next few days after the drain was placed. As of [**2176-7-13**], the patient was started on a clear diet. It was also noted that her white blood cell count was steadily trending down from 19,100 on [**2176-7-11**] to 16,400 on [**2176-7-12**] and to 14,200 on [**2176-7-13**]. As of [**2176-7-14**], which was hospital day #8, post percutaneous day #4, vancomycin day #7, levofloxacin day #8 and clindamycin day #8, it was decided, since the patient had been afebrile for a few days and she was now nontender on examination, that we would stop the patient's antibiotics and see if the patient had any temperature spikes. Over the next few days, she did not have any temperature spikes and thus antibiotics were not restarted. The patient was advanced to a low fat diet on [**2176-7-15**]. Her total parenteral nutrition was continued for additional nutrition support. She was placed back on her home blood pressure medications as well. CONDITION ON DISCHARGE: On the morning of [**2176-7-19**], it was decided that the patient was stable for discharge to rehabilitation. She was afebrile on total parenteral nutrition, tolerating a decent amount of p.o. intake and making good urine output. She had been afebrile for several days. DISCHARGE MEDICATIONS: Propanolol 80 mg p.o. t.i.d. Diovan 80 mg p.o. q.d. Chlorothiazide 500 mg p.o. q.d. Protonix 40 mg p.o. q.d. Total parenteral nutrition. FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **]. DISPOSITION: The patient will be discharged to rehabilitation today. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Last Name (NamePattern1) 4039**] MEDQUIST36 D: [**2176-7-19**] 06:52 T: [**2176-7-19**] 07:58 JOB#: [**Job Number 34996**] Admission Date: [**2176-7-7**] Discharge Date: [**2176-7-21**] Service: ADDENDUM: Date of discharge is [**2176-7-21**]. Patient's Foley catheter was removed on [**7-19**] and she voided well. Patient's pancreatic drain was removed on [**2176-7-20**] without any complications and patient was discharged to home on [**2176-7-21**]. She was discharged on a regular diet and with propranolol 80 mg po t.i.d., Diovan 80 mg po q.d. and Chlorthiazide 100 mg po q.d. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2176-7-24**] 15:22 T: [**2176-7-24**] 15:22 JOB#: [**Job Number 34997**]

[ "276.3", "577.2", "577.1", "305.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "52.01" ]

icd9pcs

[ [ [] ] ]

3175, 3313

994, 2853

3325, 4417

145, 976

2878, 3152

19,184

153,683

49449

Discharge summary

report

Admission Date: [**2182-12-18**] Discharge Date: [**2182-12-26**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old gentleman with a history of slurred speech and word finding difficulty who presented to the emergency room on [**2182-11-23**] and was diagnosed with a large left subacute subdural hematoma. The patient had the subdural hematoma drained and was discharged on [**2182-11-28**] to rehabilitation. Over the last couple of weeks the family has noted gradual worsening of speech and he was therefore brought to the emergency room on [**2182-12-19**]. He was admitted to the intensive care unit for observation and bedside drainage of subdural hematoma. PAST MEDICAL HISTORY: Coronary artery disease, hypercholesterolemia, and mitral regurgitation. MEDICATIONS: Atenolol 25 mg p.o. q.d.; Prinivil 20 mg p.o. q.d.; Lipitor 20 mg q.d.; Cardura 4 mg q.d. PHYSICAL EXAMINATION: The patient was awake and alert, following simple commands. He had word finding difficulties. He could not name place or time. He had no drift. He was moving all extremities with good strength. He had a pansystolic murmur. Abdomen was soft, nontender, and nondistended. LABORATORY DATA: On admission his white count was 8.1, hematocrit 26.5, platelet count 164, INR 1.1, sodium 129, K 4.2, 98/24, 24/1.3 and 102. CT scan showed slight increase in left subdural hematoma. HOSPITAL COURSE: The patient had the subdural hematoma evacuated at the bedside without complications. Electroencephalogram was done which showed no evidence of seizure activity. The patient was seen by the speech and swallow service. On [**2182-12-23**] the patient had a repeat head CT which showed good evacuation of subdural hematoma. The patient had the drain removed and was transferred to the regular floor. The patient was seen by physical therapy and occupational therapy and was felt to be safe for discharge to home. The patient was discharged to home for follow up with Dr. [**Last Name (STitle) 1327**] in [**2-13**] weeks' time for repeat head CT. DISCHARGE MEDICATIONS: The patient will take all of his home medications. 1. Lisinopril 20 mg p.o. q.d. 2. Lipitor 40 mg q.d. 3. Atenolol 25 mg q.d. 4. Doxazosin 4 mg p.o. q.h.s. 5. Protonix 40 mg q. day. 6. Dilantin 100 mg p.o. t.i.d. CONDITION: The patient's condition was stable at the time of discharge. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2183-3-20**] 12:45 T: [**2183-3-20**] 12:57 JOB#: [**Job Number **]

[ "V45.81", "412", "276.1", "424.0", "E888.9", "852.20", "272.0" ]

icd9cm

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icd9pcs

[ [ [] ] ]

2095, 2644

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922, 1402

115, 697

720, 899

40,728

138,999

52839

Discharge summary

report

Admission Date: [**2180-12-21**] Discharge Date: [**2181-1-6**] Date of Birth: [**2131-10-8**] Sex: F Service: MEDICINE Allergies: Nadolol Attending:[**First Name3 (LF) 1377**] Chief Complaint: HCV cirrhosis, upper GI bleed, cerebral edema Major Surgical or Invasive Procedure: Left IJ Central line R arterial line mechanical ventilation History of Present Illness: 49 y.o. female with Hep C/ETOH cirrhosis, who presented to [**Hospital **] [**2180-12-14**] with hematemesis. Endoscopy revealed bleeding esophageal varices which were banded x 3 but she continued to bleed and required a repeat endoscopy the following day with three more bands placed to achieve hemostasis. At least 1 liter of blood suctioned out of the stomach. She was placed on prophylactic levofloxacin on day #1. She was hypotensive, and was rescuscitated with a total of 13 units PRBCs, 20 units PLTs, and 12 units FFP. She remained hypotensive and required pressor (levophed). She was intubated on hospital day #1 for airway protection. Initially, she remained unresponsive off sedation, presumed due to hepatic encephalopathy. She received lactulose and rifaxamin. Over the next couple days, she stabilized hemodynamically and was weaned off pressor. On [**2180-12-19**] she had a tonic clonic seizure and received ativan. CT head revealed large areas of brain edema in the parietal and temporal lobes. Neurology was consulted and she received one dose of mannitol. Her serum osm was 314. She was transfered to [**Hospital1 18**] for further care. . Of note, on the AM of transfer, she bit her ET tube when sedation was lightened and required paralytic to place a bite guard. Also, just prior to transfer, sputum culture from [**2180-12-18**] grew MRSA and she was begun on vancomycin. Past Medical History: **HCV/EtOH cirrhosis, on transplant list - dx'ed in [**2176-10-14**] - decompensated in [**2177-2-11**] (+ EtOH use) - completed inpatient rehab program, sober since - sx of encephalopathy, ascites, Grade I varices (last EGD [**7-21**]) - hepatopulmonary syndrome, on home O2 at night (2L) **Depression **Hip fracture s/p ORIF [**2180-1-14**] **cholelithiasis, s/p ccy **s/p hysterectomy/BSO **s/p tonsillectomy **s/p ankle surgery **s/p miscarriage at age 16 **s/p tubal pregnancy at age 24 Social History: Married, separated from husband (but he is still involved in her care). Has adopted son in [**Name (NI) 32775**], MA. Previously worked in the banking and bond trading business for approximately 15 years, then worked part-time as a secretary and administrative assistant at a chiropractor's office. No longer working given her worsening encephalopathy. Husband is working long hours (as a truck driver) and patient is concerned about being safe at home alone. . Previous heavy EtOH (4L wine/day, occasional pint of vodka/day). Stopped in [**2177-2-11**]. Now currently in AA and has maintained sobriety for 14 months. Significant h/o polysubstance abuse, including marijuana, hallucinogens, cocaine, heroin (all last used in early 20s), as well as prescription narcotics (last in [**2-15**]), and tobacco. Max was 2 pack/day, though now ~[**10-2**] cigarettes/day. Started smoking at age 14. Family History: + lung cancer in M aunt + alcoholism M - DM type II, HTN, depression/anxiety, alcoholism F - doesn't know her father 2 brothers, 1 sister - all alcoholics one brother is being considered as her liver donor Physical Exam: VS: 98.5, 89/51, 61, 23, 93% on AC/500/12(22)/5/1.0 GEN: sedated, obese female HEENT: pupils small but reactive LUNGS: decreased BS at left base HEART: RRR, nl S1S2, no m/r/g ABD: hypoactive BS, soft, nd/nt EXT: no edema NEURO: with propofol off, withdraws to noxious stimuli. No purposeful movement Pertinent Results: ADMISSION LABS: . [**2180-12-21**] 12:34AM PT-16.2* PTT-34.6 INR(PT)-1.4* [**2180-12-21**] 12:34AM WBC-4.2 RBC-3.77* HGB-11.8* HCT-33.9* MCV-90 MCH-31.4 MCHC-34.9 RDW-17.8* PLT COUNT-37* [**2180-12-21**] 12:34AM TSH-2.7 [**2180-12-21**] 12:34AM OSMOLAL-305 [**2180-12-21**] 12:34AM ALBUMIN-2.7* CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-2.5 [**2180-12-21**] 12:34AM ALT(SGPT)-359* AST(SGOT)-57* LD(LDH)-191 ALK PHOS-54 TOT BILI-2.9* [**2180-12-21**] 12:34AM GLUCOSE-103 UREA N-18 CREAT-0.7 SODIUM-151* POTASSIUM-3.8 CHLORIDE-121* TOTAL CO2-24 ANION GAP-10 [**2180-12-21**] 12:54AM freeCa-1.13 [**2180-12-21**] 12:54AM LACTATE-1.3 [**2180-12-21**] 12:54AM TYPE-ART PO2-80* PCO2-36 PH-7.45 TOTAL CO2-26 BASE XS-1 . Initial CXR, portable [**2180-12-21**]: PORTABLE SUPINE CHEST RADIOGRAPH: The endotracheal tube is 2 cm from the carina, recommend pulling back between 2 and 3 cm. A nasogastric tube terminates overlying the mid stomach with side port well beyond the GE junction. A right subclavian catheter terminates over the mid SVC. The lung volumes are low. The cardiomediastinal silhouette is stable. There is consolidation of the left base either representing atelectasis or pneumonia. There is a likely small associated left pleural effusion . CT head [**2180-12-21**]: IMPRESSION: Bilateral temporal lobe edema with effacement of the subjacent temporal horns of the lateral ventricle temporal [**Doctor Last Name 534**] of the lateral ventricles. There appears to be extension of edema into the left parietal region with mild sulcal effacement. Images from outside hospital would be useful to assess for interval change. ATTENDING NOTE: I think that the white matter hypodensity involves both cerebral hemispheres with predominent involvement of temporal lobes. Conditions such herpres encephgalitis should be considered in the differential but extensive involvement of frontal and parietal lobes is somewhat unusual. MRI can help for firther assessment. . Abd u/s w/doppler [**2180-12-21**]: IMPRESSION: 1. Patent hepatic vasculature. 2. Ascites. A mark was made at the left lower quadrant for paracentesis to be performed by the clinical staff. 3. Small right pleural effusion. 4. Splenomegaly. . EEG [**2180-12-22**]: IMPRESSION: This telemetry captured one electrographic seizure with onset in the left temporal region, which then spread to both hemispheres and lasted for about two minutes. The background activity in wakefulness showed bursts of generalized slowing and occasional left posterior quadrant slowing. . [**12-22**] CT-A Head: IMPRESSION: 1. Normal CT angiography and CT venography with no vascular stenosis or occlusion, and no venous thrombosis. 2. Unchanged diffuse hypodensity throughout white matter tracts symmetrically involving both temporal, and, to a lesser extent, frontal lobes. The findings are suggestive of cerebral edema due to a systemic or metabolic cause, including liver failure or related metabolic abnormalities. [**12-24**] EEG Impression: This 24 hour video EEG telemetry captured no electrographic seizures or pushbutton activations. Automated and routine sampling demonstrated periods of generalized slowing consistent with an underlying encephalopathy. Occasional periods of slowing were seen in the temporal parietal leads consistent with more focal regions of underlying cortical or subcortical dysfunction. . [**12-24**] CT Head IMPRESSION: 1. Unchanged diffuse hypodensity involving the white matter tracts predominantly involving the temporal lobe, also involving the frontal lobes. The differential diagnosis includes cerebral edema due to the liver failure. Other white matter disease cannot be excluded. MRI of the head is the best modality for evaluation of the white matter disease and cerebral edema. 2. No other acute intracranial pathology is identified. . [**12-25**] EEG IMPRESSION: This telemetry captured no ongoing seizure activity. Routine samplings showed a background suggestive of an encephalopathy involving both superficial and deeper structures and additional slowing in the left mid-temporal region. . [**12-26**] EEG IMPRESSION: This telemetry captured no clinical or electrographic seizures. The background activity was slow with additional bursts of generalized slowing suggestive of an encephalopathy and with focal slowing and sharp and slow wave complexes in the left temporal and posterior areas. . [**12-26**] MRI IMPRESSION: 1. Abnormal T2- and FLAIR-signal identified bilaterally, most intense at the insular cortex. Abnormal signal also seen in the medial and inferior temporal lobes, bilaterally. Findings raise the possibility of herpetic or other viral encephalitis, though there is no restricted diffusion or hemorrhage. 2. Signal abnormality appears to involve more than simply the white matter tracts, with involvement of the insular cortex as well as the cortex in the temporal lobes. This more global picture again raises concern for previous hypoxic/anoxic brain injury, possibly with secondary acute demyelination. . [**12-31**] CXR Nasogastric tube terminates in body of the stomach and is no longer coiled. Endotracheal tube has apparently been removed. Examination is otherwise without change except for improving aeration at the lung bases with associated slight increase in lung volumes. . [**1-2**] EEG IMPRESSION: This is a normal routine EEG in the waking and drowsy states. There were no focal lateralized or epileptiform features noted . [**1-4**] CXR Bibasilar atelectasis are grossly unchanged. Cardiac size is top normal. There are low lung volumes. There is no pleural effusion. NG tube tip is in the stomach. . DISCHARGE LABS: WBC 4 HCT 31.5 PLT 63 . CHEM 10 entirely WNL (Cr 0.6) Brief Hospital Course: 49 y.o. female with Hep C and alcoholic cirrhosis, initially admitted to [**Hospital6 **] with variceal bleeding, stabilized endoscopically, but then developed altered mental status, presumed due to hepatic encephalopathy, and intubated for airway protection. Subseuqently found to have cerebral edema, transferred to [**Hospital1 18**] for further care. Hospital course by system: . # Neuro: Pt had acutely AMS at OSH and was found to have developed cerebral edema after her initial variceal bleed. Initialy, her AMS was attributed to severe hepatic encephalopathy. However, this was not typical for her, as she had previously had relatively well-compensated liver disease. Head CT revealed the cerebral edema. Nonetheless, she was continued on lactulose and rifaxamin for any contribution of hepatic encephalopathy to her AMS. TSH was checked and was normal. Also considered were infectious encephalopathies (ie HSV, bacterial). CT head upon arrival to [**Hospital1 18**] MICU revealed bilateral cerebral edema, primarily of the temporal lobes, most concerning for HSV encephalitis. Due to her extensive cerebral [**Last Name (LF) 108978**], [**First Name3 (LF) **] LP could not be performed. Neurology was consulted and recommeded EEG and empiric coverage for HSV encephalitis with acyclovir (10mg/kg Q8H). No recommendation was made for mannitol initially given her sodium of > 150, but when sodium dropped below 150 on [**2179-12-22**], several doses of mannitol were given. Serum Osm was in the low 300s. Neuro recommended stopping mannitol on [**2180-12-23**], and starting hypertonic saline instead to reach sodium goal 150-155. Sodium and serum osmolarity monitored Q6H. The MICU team also emperically covered for bacterial meningitis with CTX/Vancomycin, beginning [**2180-12-21**]. Her continuous EEG showed evidence of seizure activity at that time, and she was loaded with Keppra and maintenance dose begun. Serial repeat 24h video EEGs showed no further seziures, although she remained intubated and on propofol. Serial head imaging revealed stable cerebral edema but no evidence of CVA. On [**12-26**] a head MRI revealed not only diffuse bitemporal abnormailties as previously seen, but also extension into the grey matter, concerning for prior anoxic brain injury. Eventually neuro agreed with d/c'ing hypertonic saline and letting sodium drift down to 140 (but not below). When her mental status appeared improved, she was extubated on [**1-1**]. She had no subsequent problems protecting her airway, but remained forgetful and altered. A repeat EEG was ordered per neurology to re-evaluate for subclinical seizure, which was without any evidence of seizure. Her prognosis is uncertain as to recovery from her anoxic brain injury, and she is left with significant mental deficits (oriented to person only at time of transfer). She is to followup with behavioral neurology next month. . # Respiratory: Initially was intubated at OSH for airway protection after she became confused, felt [**1-15**] hepatic encephalopathy, later felt to be cerebral edema (see above). However, was noted at OSH to have fever and grew MRSA in sputum, so was started on Vanco on [**2180-12-20**] for a MRSA pneumonia. Also of significance, at baseline, the patient has hepatopulmonary syndrome with PaO2 in the 60s. At [**Hospital1 18**], her ventilator settings were changed to ARDSNET settings, and her FIO2 was progressively weaned. VAP precautions initiated. Culture data remained negative except for the MRSA in sputum from OSH and from intial presentation here. She completed a 2 week course of vancomycin and remained afebrile subsequently. When her mental status was felt to be clearer, she was successfully extubated on [**1-1**]. She is comfortable on nasal cannula at time of transfer. Note should be made to avoid upright positioning for extended periods of time due to hepatopulmonary syndrome and orthodeoxia. ******Her baseline O2 sats are in the upper 80s******** . # GI/Liver - Initial presentation to [**Hospital3 **] Hosptial showed bleeding [**1-15**] esophageal varices and she was stabilized with volume resuscitation. In total, received 13 units PRBCs, 12 units FFP, 20 units PLTs at [**Hospital3 **]. She had 3 bands placed by EGD on [**2180-12-14**], and repeat banding x 3 on [**2180-12-15**]. She was hemodynamically stable upon transfer and remained so in the MICU at [**Hospital1 18**]. She was continued on IV protonix daily and monitored with daily HCTs. She was also started on post-GIB SBP ppx with cipro after her broader antibiotics (vanc/ctx) were d/c'ed once bacterial meningitis was felt to be unlikely. A beta blocker was added for post-bleed ppx. Diagnostic paracentesis on admission [**2180-12-21**] was negative for SBP. She was not stooling initially; given lactulose Q1H until she began stooling. Later lactulose dose tapered. Rifaximin added. . # ID - initially was broadly covered out of concern for meningitis with vanc/CTX/acyclovir. She was also being treated for documented MRSA PNA with vancomycin. When bacterial meningitis was felt to be unlikely, the CTX was d/c'ed, but she completed a 2 week course of vanc for the MRSA PNA. She remains on acyclovir for a planned 3 week course per ID and neurology ([**Date range (1) 108979**]). She was briefly on ciprofloxacin for post-GIB sepsis ppx. . # Heme - has thrombocytopenia Likely [**1-15**] liver disease. Received several platelet transfusion at [**Hospital3 **] hosptial, but none at [**Hospital1 18**]. . # Psych - has depression, held meds given mental status . # PPx: pneumoboots, PPI . # CODE: FULL, confirmed . # Access -- CVL changed upon arrival to [**Hospital1 18**], then d/c'ed [**1-1**] after extubation with adequate PIVs in place. Has 1 PIV in place currently. . # Contact: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 23226**] is HCP: [**Telephone/Fax (1) 108980**] Medications on Admission: MEDS AT HOME: Prilosec 40mg PO BID fexofenadine 60mg po BID Maalox PRN propranolol 10mg po BID spironolactone 100mg [**Hospital1 **] rifaximin 400mg TID ursodiol 300mg [**Hospital1 **] acetaminophen PRN simethicone PRN Lexapro 20mg Daily Abilify 20mg Daily Lamictal 200mg Daily Lasix 40mg Daily Darvocet PRN . TRANSFER MEDS: Vancomycin 1000mg Q12 (day 1 = [**2180-12-20**]) Levofloxacin 500mg Daily (day 1 = [**2180-12-14**]) Protonix 40mg IV daily Insulin SS Pressidex gtt (0.7) Rifaxamin 400mg TID Reglan 5mg TID Combivent inhalers Q4H Discharge Medications: 1. Rifaximin 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO TID (3 times a day). 2. Ursodiol 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical PRN (as needed). 4. Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 1000 (1000) mg PO Q 12H (Every 12 Hours). 5. Spironolactone 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 6. Propranolol 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 7. Nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID (4 times a day) as needed. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day/Year **]: One (1) nebulizer Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) nebulizer Inhalation Q6H (every 6 hours). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Acyclovir Sodium 500 mg Recon Soln [**Last Name (STitle) **]: Six [**Age over 90 1230**]y (650) mg Intravenous Q8H (every 8 hours) for 5 days: last day [**1-10**]. 12. Lasix 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day. 13. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO QID (4 times a day): titrate to 4 BMs daily. 14. Insulin Regular insulin sliding scale Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: anoxic brain injury vericeal bleeding Possible HSV encephalitis . Secondary: end stage liver disease due to EtOH and HCV Hepatopulmonary Syndrome - baseline sats high 80s Depression Discharge Condition: improved Discharge Instructions: You were transferred to [**Hospital1 69**] after suffering a gastrointestinal bleed due to your liver disease. You lost a lot of blood at [**Hospital6 33**], but they were able to stop the bleeding. However, you suffered swelling around the brain which necessitated intubation. You were transferred to us seriously ill. You were treated for a possible infection of your brain, and will be finishing a course of medicine for this at your rehab. Your lung function returned to your baseline level. . Unfortunately, MRI scans of your head showed evidence of anoxic (lack of blood flow) brain injury, which may have occcurred from either blood loss or swelling around the brain. Our neurologists followed you closely and are uncertain of the extent of recovery that is possible. They would like you to follow up with them as follows. Followup Instructions: 1) NEUROLOGY Please follow up with our behavioral neurologists as follows: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2181-1-18**] 9:30. Behavioral Neuro is located in [**Hospital Ward Name 860**] [**Doctor Last Name **], [**Location (un) **], [**Apartment Address(1) 16806**] . 2) LIVER Please call ([**Telephone/Fax (1) 1582**] to arrange a followup liver appointment at your convenience. You should be seen in the next 4-6 weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

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Discharge summary

report

Admission Date: [**2166-11-7**] Discharge Date: [**2166-11-19**] Service: CARDIOTHORACIC Allergies: Penicillins / Warfarin Attending:[**First Name3 (LF) 1267**] Chief Complaint: The patient presents approximately 3 weeks after CABGx3 with purulent drainage from her median sternotomy site. The patient was afebrile and with stable vital signs. Major Surgical or Invasive Procedure: No surgical procedure performed History of Present Illness: The patient is an 86 y/o woman s/p CABG on [**2166-10-16**]. The patient presents to [**Hospital1 18**] with purulent drainage from her median sternotomy site. She is otherwise asymptomatic, afebrile tolerating a regular diet and not in any pain. Past Medical History: CAD MI renal calculi S/P right THR s/p ureteral repair HTN skin CA Social History: retired, lives alone, but son lives next door no tobacco, one drink per month Family History: sister had CVA Physical Exam: Well nourished, well developed, NAD Normocephalic head Neck: left sides swelling with tenderness to palpation Chest: 2 1.5 cm areas in line of median sternotomy with redness, warmth, and yellow drainage Cardiac: S1S2 no M/R/G Abd: soft, nontender and nondistended Ext: Right upper extremity decreased motion and strength No calf tenderness bilaterally Pertinent Results: [**2166-11-7**] 10:26PM BLOOD WBC-10.0 RBC-3.15* Hgb-9.5* Hct-28.3* MCV-90 MCH-30.2 MCHC-33.5 RDW-16.1* Plt Ct-300# [**2166-11-9**] 05:15AM BLOOD Neuts-48* Bands-2 Lymphs-32 Monos-3 Eos-13* Baso-2 Atyps-0 Metas-0 Myelos-0 [**2166-11-7**] 10:26PM BLOOD PT-15.0* PTT-35.3* INR(PT)-1.5 [**2166-11-7**] 10:26PM BLOOD Fibrino-816*# [**2166-11-7**] 10:26PM BLOOD Glucose-131* UreaN-16 Creat-0.6 Na-138 K-3.8 Cl-105 HCO3-20* AnGap-17 [**2166-11-7**] 10:26PM BLOOD ALT-33 AST-71* LD(LDH)-373* AlkPhos-107 Amylase-30 TotBili-0.7 [**2166-11-7**] 10:26PM BLOOD Lipase-34 [**2166-11-7**] 10:26PM BLOOD Albumin-2.9* Calcium-9.1 Phos-3.2 Mg-1.8 [**2166-11-11**] 04:07PM BLOOD Vanco-20.4* Brief Hospital Course: The patient is an 86 y/o woman who presents to [**Hospital1 **] DMC 3 weeks s/p CABG from rehab with a reported history since discharge of pulmonary embolism, left middle cerebral artery stroke and purulent drainage emanating from her median sternotomy for the past week. After discussion with multiple consulting services: neurology, infectious disease and vascular surgery. The patient was deemed to only have active infectious mediastinitis and positive blood cultures consistent with methicillin sensitive staphylococcus aureus. The patient had a CT scan of the chest that showed a small fluid collection inferior the sternum. The patient TTE that did not show evidence of endocarditis of vegetations on the patients valves. On hospital day 2 the patient was afebrile, WBC 8500, blood cultures pending dressing changes instituted twice daily. The patient was started on vancomycin and kept in the intensive care unit for observation. The patient was also started on a heparin drip while in the ICU for anticoagulation for PE. The patient was transferred to a telemetry hospital floor, he anticoagulation was maintained with Lovenox. She received vancomycin for her positive blood cultures. Her median sternotomy wound was changed twice daily and gradually improved. She remained afebrile with stable vital signs. She did not undergo any surgical procedures while she was at [**Hospital1 **] DMC. Imaging of her carotids via CTA did not reveal a carotid dissection. TTE did reveal vegetations on her valves nonetheless the patients positive blood cultures were treated with vanco (MSSA) and her mediastinitis was treated with [**Hospital1 **] dressing changes. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Insulin Lispro (Human) 100 unit/mL Solution Sig: [**12-15**] Subcutaneous ASDIR (AS DIRECTED). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours). 11. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous twice a day. Disp:*30 mg/ml* Refills:*2* 12. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO at bedtime. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: CAD HTN median sternitis, with infection Peripheral vascular disease Discharge Condition: Stable Discharge Instructions: You may shower with soap and water, do not bath or soak in a tub. Please resume your regular medications. If you experience fever greater than 101.5, shortness of breath, foul smelling drainage from your chest wound or any significant change in your medical condition please call your surgeon or return to the emergency room. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2230**] in 1 month, upon discharge from the hospital please call for your appointment. ([**Telephone/Fax (1) 62630**] Completed by:[**2166-11-19**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5285, 5315

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820, 900

19,493

163,901

12940

Discharge summary

report

Admission Date: [**2143-7-16**] Discharge Date: [**2143-7-19**] Date of Birth: [**2098-9-9**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl / Fentanyl Attending:[**First Name3 (LF) 905**] Chief Complaint: Abdominal pain, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 44F h/o mesenteric ischemia, cholecystectomy, CAD with recent stents presenting for one day of severe crampy abdominal pain and intermittent bloody diarrhea similar to prior presentations who then developed chest pain while in the ED. Abdominal pain is [**4-13**] intermittent and worse with bowel movements. Of note she reports chornic intermittent bloody diarrhea at baseline, and reports having small amounts of blood in her underwear daily for years, as well as blood on toilet paper and blood mixed with stool. Her last bloody BM was at nine am this morning. . Also complaining of overall weakness. No fever of chills, no SOB or chest pain prior to arrival at hospital. . In the ED initial VS were 98.7, 108, 128/89, 18 with 99% on RA. CT scan in ED showed no change in abdominal perfusion from prior. Evaluated by surgery in the ED who felt she was a nonsurgical patient. . While in the ED she also complained of chest pain. EKG showed T-wave flattening in III, aVF, V3-V6 but no ST elevations, and overall no change from prior. First set of troponins were negative. Recieved morphine 14mg morphine total, IV fluids at least 2L. Did not receive any nitroglycerin. She was chest pain free at the time of transfer to the floor. Vitals at the time of transfer were 98.6 81 114/69 18 99% on RA. . Of note on floor pt reported several weeks of constant mild lower central substernal chest pain unrelated to activity or eating and without any associated SOB, N/V or diaphoresis. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Chronic fatigue 4. Chronic headaches 5. Fibromyalgia 6. Depression/Anxiety 7. Talus fracture 8. Cervical cancer 9. GERD 10. Hydronephrosis 11. Mild COPD 14. Chronic mesenteric ischemia - known occlusion of SMA and celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by [**Year (4 digits) 1106**] surgery [**48**]. Recent admission [**7-10**] for ? TIA - foudn to have microvascular infarcts on MRI and HTN. 16. Admission for GI bleeding, antral ulcers Social History: Lives with son. History of heavy alcohol, stopped in [**2136**]. 20 pack year smoking history, still smokes 1-2 packs/day. Works as proofreader. No drug use. Family History: Mother and aunt with coronary artery disease and carotid disease. Both parents died of lung cancer, mother at age 73, father at age 68. Physical Exam: VS: 98.6, 81, 114/69, 18, 99%ra Gen: NAD HEENT: dry MM Neck: supple, no JVD CV: RRR S1 S2 no R/G/M Pulm: clear Abd: soft, mild diffuse tenderness, nondistended, normoactive bowel sounds Ext: no edema, pulses 2+ bilaterally Neuro: CNII-XII intact, moving all extremities Pertinent Results: TECHNIQUE: PA and lateral chest radiographs were taken. COMPARISON: Comparison was made to prior radiograph from [**7-18**], [**2143**]. FINDINGS: There is a left lung base pleural effusion that has increased in comparison to the prior study. There is compressive atelectases in the left lung base but pneumonia could not be excluded in the right clinical setting. Right basal opacity remains unchanged in comparison to prior study. This opacity could also represent infection and/or aspiration. Retrocardiac opacity remains unchanged compared to the prior study. Dextroscoliosis of the spine remains unchanged. Cardiomediastinal and hilar silhouettes appear unchanged. There is no pneumothorax. IMPRESSION: Increase in left lower lobe pleural effusion along with a possible overlying pneumonia. Retrocardiac and right basal opacities could represent infection and are unchanged from prior study. [**2143-7-16**] 11:45AM BLOOD WBC-13.0*# RBC-3.49* Hgb-11.3* Hct-33.9* MCV-97 MCH-32.5* MCHC-33.5 RDW-13.9 Plt Ct-388 [**2143-7-19**] 09:08AM BLOOD WBC-11.0 RBC-3.15* Hgb-10.6* Hct-30.1* MCV-96 MCH-33.8* MCHC-35.3* RDW-14.9 Plt Ct-292 [**2143-7-16**] 11:45AM BLOOD PT-12.3 PTT-24.8 INR(PT)-1.0 [**2143-7-16**] 11:45AM BLOOD Glucose-102* UreaN-12 Creat-0.9 Na-139 K-3.5 Cl-101 HCO3-26 AnGap-16 [**2143-7-19**] 09:08AM BLOOD Glucose-140* UreaN-7 Creat-0.8 Na-140 K-3.6 Cl-106 HCO3-25 AnGap-13 [**2143-7-16**] 11:45AM BLOOD ALT-22 AST-19 LD(LDH)-182 AlkPhos-143* TotBili-0.2 [**2143-7-16**] 11:45AM BLOOD cTropnT-<0.01 [**2143-7-17**] 06:55AM BLOOD CK-MB-1 cTropnT-<0.01 [**2143-7-17**] 02:10PM BLOOD CK-MB-1 cTropnT-<0.01 [**2143-7-17**] 05:41PM BLOOD CK-MB-1 cTropnT-<0.01 [**2143-7-18**] 04:13AM BLOOD CK-MB-1 cTropnT-<0.01 [**2143-7-17**] 06:55AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.5* [**2143-7-19**] 09:08AM BLOOD Calcium-8.3* Phos-1.7* Mg-2.5 [**2143-7-17**] 09:06AM BLOOD Type-ART pO2-84* pCO2-36 pH-7.35 calTCO2-21 Base XS--4 Brief Hospital Course: Ms. [**Known lastname 39729**] was admitted on [**2143-7-16**] for abdominal pain, BRBPR (chronic), chest pain. CHEST PAIN: Ruled out for MI with serial enzymes and EKGs. Continued ASA and Plavix. ABDOMINAL PAIN: Abdominal CT grossly unchanged, surgery consulted, felt nonsurgical. HYPOTENSION: On day of admission, was hypotensive with SBP in 70s-80s, intially unresponsive to fluid boluses, received 1 unit [**Hospital 39736**] transferred to the MICU for < 24h for observation, BP stablized, returned to the floor. BRBPR: Very small amount of blood. Followed Hct. Discharged to home with close followup. Medications on Admission: AMITRIPTYLINE - 25 mg Tablet -CLONAZEPAM - 1 mg Tablet prn -CLOPIDOGREL [PLAVIX] - 75 mg Tablet DICYCLOMINE - 10 mg Capsule -FLUOXETINE - 40 mg Capsule LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch -LISINOPRIL - 2.5 mg Tablet -METOCLOPRAMIDE - 10 mg Tablet TID -NITROGLYCERIN - 0.4 mg Tablet, Sublingual (rarely) -OMEPRAZOLE - -SIMVASTATIN - 20 mg Tablet -ASPIRIN - 325mg -B COMPLEX VITAMINS Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as needed for chest pain. 8. B Complex Vitamins Tablet Sig: One (1) Tablet PO once a day. 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 10. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal PRN (as needed) as needed for hemorrhoids. 11. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO three times a day. 15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypotension 2. Abdominal pain 3. Chest pain 4. Pneumonia 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 because of abdominal pain, chest pain, and EKG changes. While you were here, your blood pressure was low, so you received IV fluids and one unit of blood, and were transferred to the ICU temporarily for observation. Blood tests and more EKGs of your heart were reassuring. You should follow up with your primary card doctor, your cardiologist, and a gastroenterologist. We have made appointments for you, please see below. Quitting smoking would greatly improve your health. Please discuss strategies for quitting with your PCP. A chest x-ray shows that you may have pneumonia, an infection in the lungs. We are treating you with antibiotics: START taking cefpodoxime 200 mg twice each day for one week, then stop. It is very important to take your aspirin and Plavix every day to protect your heart. Followup Instructions: *We are working on an appointment for you to see Dr. [**Last Name (STitle) 73**] in Cardiology. The office will contact you with an appointment. If you do not hear from them, please call ([**Telephone/Fax (1) 9410**] Department: [**Hospital1 18**] [**Location (un) 2352**] When: MONDAY [**2143-7-22**] at 12:10 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [**Location (un) **] SURGERY When: TUESDAY [**2143-10-1**] at 8:00 AM With: [**Year (4 digits) **] LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name **] SURGERY When: TUESDAY [**2143-10-1**] at 9:00 AM With: [**Year (4 digits) **] LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [**2143-8-12**] at 9:30 AM Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

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15,243

190,128

43777

Discharge summary

report

Admission Date: [**2155-4-19**] Discharge Date: [**2155-5-26**] Date of Birth: [**2084-1-8**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p cardiac catheterization on [**4-24**] teeth extractions [**2155-4-28**] redo sternotomy MVR [**2155-5-5**] (25 mm [**Company 1543**] Mosaic porcine valve) pacemaker [**2155-5-13**] History of Present Illness: Pt is 71 yo F with CHF (last EF 50%, severe diastolic dysfunction, h/o multiple exacerbations), DM, HTN, CAD s/p MI, who p/w SOB. Pt called 911 this AM due to SOB, and then was taken to [**Hospital1 18**] ED. . In the [**Name (NI) **], pt had decreased responsiveness (only responding to pain), and had O2sat in mid 70's with SBP in 200's. She had rales "all the way up" bilaterally, and was emergently intubated. O2sats increased to 98% after intubation. She also was febrile to 103 and diaphoretic. Blood cx's were drawn. She was reported to have a "LLL PNA" on CXR. A right fem line was placed. She was given vanc, CTX, Flagyl, Lasix 60mg IV, Tylenol, ASA, insulin (6U IV, 4U SC), and started on a nitro gtt. She was also started on IVF at 150cc/hr, as it was thought she was intravascularly dry. Her EKG showed "increased LVH" in pre-cordial leads, and cardiology reportedly reviewed EKG and thought changes were rate-related. Cath was done [**4-24**] which showed all stents and prio PTCA stents patent with SVG occluded and LIMA to LAD patent. Past Medical History: 1. DM2 2. HTN 3. hypercholesterolemia 4. CAD s/p MI, CABG [**2145**] with occluded grafts, s/p PCI with several stents. LBBB at baseline on EKG. 5. CHF, last EF 40-45% on echo [**7-8**], frequent flashes 6. [**4-6**]+ MR 7. restless leg syndrome 8. CRI, baseline Cr 1.5 9. hysterectomy 10. spinal cyst removed 11. appendectomy 12. cataracts removed Social History: Patient lives with her daughter and grandson. [**Name (NI) **] tobacco (although past use, quit 40 yrs ago), and very occasional ETOH. The patient has had problems of [**Name2 (NI) **] abuse with her daughter, which seems to still be an active issue. Used to work in office work but currently retired. Family History: noncontributory Physical Exam: Vitals: T 99.1 BP 161/70 HR 100 RR 16 O2sat100% on AC 16/400/5/100% Gen: intubated, sedated HEENT: OGT and NGT in place. Neck: JVD @ approx 9cm Cardio: RRR, distant heart sounds, [**3-11**] sys m @ LLSB Resp: scattered rhonchi diffusely (both anteriorly and posteriorly), minimal crackles at the bases Abd: soft, nt, nd, +BS Ext: warm. 2+ DP/PT pulses BL. No edema. Scattered ecchymoses on back. Neuro: sedated. Moves all 4 ext. Discharge Vitals 98.2, 64 SR, 129/50, 20 Sat 94% RA wt 73.3kg Neuro A/o x3 nonfocal Cardiac RRR no m/r/g Pulm Clear, decreased right base Sternal inc healing no drainage/erythema sternum stable Abd soft, NT, ND BM [**5-25**] +BS Ext warm pulses palpable edema +1 nonpitting Pertinent Results: [**2155-5-25**] 06:03AM BLOOD WBC-7.5 RBC-3.30* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-15.3 Plt Ct-248 [**2155-4-19**] 10:26AM BLOOD WBC-17.3*# RBC-4.19* Hgb-12.7 Hct-39.4# MCV-94# MCH-30.2 MCHC-32.1 RDW-14.0 Plt Ct-411# [**2155-4-22**] 01:31AM BLOOD Neuts-83.8* Lymphs-11.8* Monos-3.2 Eos-1.2 Baso-0 [**2155-5-26**] 05:28AM BLOOD PT-16.1* PTT-30.3 INR(PT)-1.5* [**2155-5-25**] 06:03AM BLOOD Plt Ct-248 [**2155-5-25**] 06:03AM BLOOD PT-16.6* PTT-30.1 INR(PT)-1.5* [**2155-5-24**] 05:53AM BLOOD Plt Ct-249 [**2155-5-26**] 05:28AM BLOOD Glucose-200* UreaN-45* Creat-1.9* Na-136 K-5.3* Cl-97 HCO3-27 AnGap-17 [**2155-4-27**] 06:15AM BLOOD Glucose-97 UreaN-40* Creat-1.7* Na-135 K-4.1 Cl-97 HCO3-27 AnGap-15 [**2155-4-19**] 10:26AM BLOOD Glucose-519* UreaN-19 Creat-1.4* Na-136 K-4.8 Cl-99 HCO3-25 AnGap-17 [**2155-5-16**] 03:04AM BLOOD ALT-64* AST-47* CK(CPK)-67 AlkPhos-196* Amylase-41 TotBili-0.8 [**2155-4-19**] 10:26AM BLOOD ALT-24 AST-20 CK(CPK)-51 AlkPhos-179* Amylase-48 TotBili-0.6 [**2155-5-16**] 03:04AM BLOOD Lipase-22 [**2155-5-26**] 05:28AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.3 Pathology DIAGNOSIS: Mitral valve: Fibrosis and focal calcifications. Clinical: Gross: The specimen is received fresh labeled with "[**Known lastname 4643**], [**Known firstname **]" and the medical record number and "mitral valve" and consists of multiple tan-white to tan-yellow tissue, measuring 2 x 2 x 0.5 cm in aggregate. Representative sections are submitted in A. CHEST (PA & LAT) [**2155-5-26**] 1:59 PM CHEST (PA & LAT) Reason: evaluate for effusion [**Hospital 93**] MEDICAL CONDITION: 71 year old woman with s/p MVR REASON FOR THIS EXAMINATION: evaluate for effusion TWO VIEW CHEST of [**2155-5-26**]. COMPARISON: [**2155-5-20**]. INDICATION: Evaluate for pleural effusion following mitral valve surgery. Right internal jugular vascular sheath has been removed and a right PICC line has been placed with tip terminating in the upper superior vena cava. A permanent pacemaker is unchanged in position, and cardiac and mediastinal contours are stable. Small-to-moderate right pleural effusion has decreased in size, and small left pleural effusion is unchanged. Interstitial edema has nearly resolved. IMPRESSION: Resolving interstitial edema and improving right pleural effusion. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] PATIENT/TEST INFORMATION: Indication: Mitral valve replacement Height: (in) 64 Weight (lb): 163 BSA (m2): 1.79 m2 BP (mm Hg): 131/32 HR (bpm): 63 Status: Inpatient Date/Time: [**2155-5-21**] at 15:38 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West Echo Lab Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.9 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% (nl >=55%) Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm) Aorta - Ascending: *3.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - Pressure Half Time: 136 ms Mitral Valve - E Wave: 1.7 m/sec Mitral Valve - A Wave: 1.3 m/sec Mitral Valve - E/A Ratio: 1.31 INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal motion/position. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. No MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient is in a ventricularly paced rhythm. Conclusions: The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Septal motion is dysnchronous, but the remaining segments appear to contract well. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic valve stenosis is seen. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present with normal gradient and mobile leaflets. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2155-5-15**], biventricular systolic function is improved. The heart rate is also much lower on the current study. CLINICAL IMPLICATIONS: Based on [**2145**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a high risk (prophylaxis strongly recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data." Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2155-5-21**] 17:09. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J. Sinus rhythm. A-V conduction delay. Left bundle-branch block. Compared to the previous tracing of [**2155-5-16**] ventricular ectopy is absent and the rate has slowed. Otherwise, no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 66 [**Telephone/Fax (3) 94067**]/477 0 -20 137 Brief Hospital Course: 71F CAD s/p 3v-Cabg, CHF EF 50%, 3+MR/MS, DM2, CRI, HTN presented with respiratory failure likely CHF and PNA . # CAD: Pt with known CAD s/p 3VD s/p CABG. Found to have troponin leak in setting of CHF and renal failure. Patient remained chest pain free during hospitalization. She underwent cardiac catheterization on [**4-24**] without intervention (see cath report above). Continued aspirin, statin, and nitrates. Clopidogreal was continued until [**2155-4-29**] after CT surgeon's requested it be held prior to surgery. This was discussed with Dr. [**Last Name (STitle) **] and it was felt to be okay to hold/stop this medication for now as > 1year since most recent stent. . # PUMP: volume overloaded on admission, and diuresed. She had episodes post op of overload requiring reintubation once and mask ventilation the second time. She has had no further episodes and continues to be diuresised aggressively and blood pressure control goal SBP <125. Monitored ins and outs and daily weights. . #Complete heart block - after receiving lopressor went into complete heart block that did not resolving requiring insertion of permanent pacemaker. . # VALVES: severe mitral degenerative dz with MS and MR. [**Last Name (Titles) 8751**] 1.0-1.5cm2 on echo (1.3cm2 on cath). Mitral disease felt to be contributing to recurrent bouts of CHF requiring hospitalization. CT surgery was consulted for consideration of mitral valve replacement. She had a panorex film and and dental consult for pre-operative assessment. They recommended oral surgery consult and teeth extraction on [**4-28**]. She received ampicillin prior to oral surgery. There was concern that she also had a lesion on her right hand middle finger and Rheumatology was consulted. It was felt most likely to be either resolving gout/pseudogout(with tophi) vs resolving infection. Her uric acid was elevated at 10.2. Mitral Valve replacement was performed on [**5-5**]. . # PNA: Felt to contribute to her respiratory failure and MICU hospitalization. Resolved leukocytosis, now afebrile and breathing comfortably on room air. Completed 10 day levofloxacin course. . # Anemia: Guaiac negative. Hematocrit stable. She did receive 2 units pRBC blood transfusion for Hct > 30. . # DM: Continued RISS and home regimen of NPH 22 in AM and 8 in PM and regular insulin 8 in AM and 8 in PM. Glipizide held while an inpatient. . # Acute on CRI: recent baseline 1.1 to 1.3. Creatinine did increase to highest 1.9. Prequired natrecor and lasix for diuresis. . # Social: history of [**Month/Day (2) **] abuse in past. Report was filed. Social work following. # PPX: ambulating, PPI, bowel regimen . # Dispo: patient to be discharged to rehab with social work follow and [**Month/Day (2) **] care services. Medications on Admission: Spironolactone 25 mg qam Furosemide 80 mg [**Hospital1 **] Lisinopril 10mg qam Aspirin 325 mg qd Atorvastatin 80 mg qhs Isosorbide dinitrate 20 mg [**Hospital1 **] Clopidogrel 75 mg qd Folic Acid 1 mg qd Glipizide 10 mg [**Hospital1 **] NPH 22U qam, 8U qpm Reg insulin 8U qam, 8U qpm Quinine Sulfate 260 mg qhs Lopressor 50 mg [**Hospital1 **] Hydralazine 30 mg q6h Sertraline 50 mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: 18 units sc qam 8 units sc qhs. 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 400mg daily until [**5-30**] then decrease to 200mg daily to follow up with Dr [**Last Name (STitle) **]. 18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: goal INR 2.0-2.5 for atrial fibrillation first check [**5-28**] . 19. Insulin sliding scale Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: coronary artery disease congestive heart failure pneumonia mitral regurgitation mitral stenosis diabetes mellitus Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage may shower over incision and pat dry Followup Instructions: see Dr. [**Last Name (STitle) **] in [**3-8**] weeks [**Telephone/Fax (1) 2394**] see Dr.[**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] PT/INR for coumadin dosing first check [**5-28**] goal INR 2.0-2.5 Completed by:[**2155-5-26**]

[ "807.02", "521.09", "427.31", "424.0", "V45.82", "428.31", "250.00", "403.90", "486", "274.82", "E967.4", "518.81", "584.9", "997.1", "426.0", "333.94", "414.02", "285.9", "410.71" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.72", "99.62", "23.19", "96.04", "88.57", "88.53", "35.23", "96.6", "00.13", "37.83", "89.64", "88.56", "99.04", "37.72", "37.23", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

14672, 14733

9804, 12585

340, 529

14891, 14898

3074, 4638

15258, 15514

2317, 2334

13022, 14649

4675, 4706

14754, 14870

12611, 12999

14922, 15235

5507, 8881

2349, 3055

8904, 9284

281, 302

4735, 5481

557, 1610

9316, 9781

1632, 1982

1998, 2301

52,547

164,163

35859

Discharge summary

report

Admission Date: [**2117-9-29**] Discharge Date: [**2117-10-12**] Date of Birth: [**2042-3-13**] Sex: F Service: SURGERY Allergies: Cefepime / Dilaudid Attending:[**First Name3 (LF) 695**] Chief Complaint: Failure to thrive, Bile leaking from around PTCs Major Surgical or Invasive Procedure: [**2117-9-30**] - exchange of three biliary catheters [**2117-10-1**] - exchange of internal external biliary stent with pigtail formation in the abscess cavity and jejunum [**2117-10-9**] - pigtail catheter placement History of Present Illness: Ms. [**Known lastname **] is a 75 y/o woman with a hx of cholangiocarcinoma s/p L hepatic lobectomy, CBD excision, RNY HJ c/b liver infarction and abscess s/p drainage, who now presents with generalized failure to thrive and difficulty maintaining abdominal drains. The patient is currently 99 lbs and says that she has not been able to gain weight although she able to tolerate POs. She is concerned that her drainage bag is leaking bilious fluid onto her clothing and skin. She does have 4 hrs of VNA coverage per day, however that has been insufficient for the care of her drains. Past Medical History: HTN hypercholesterolemia hypothyroidism Type 2 DM ID History: [**2116-10-16**]: E. Coli bacteremia [**11-2**]: hepatic abscess with enterococcus and Enterobacter asburiae [**1-4**]: hepatic abscess with MDR E. coli [**4-3**]: peritoneal fluid with pan sensitive pseudomonas [**5-4**]: peritoneal fluid with pan sensitive pseudomonas [**5-4**]: bile cx with MDR. E. Coli and Enterococcus sp as well as E. Coli bacteremia PSH: Cleft palate surgery as child, tonsillectomy, [**11-3**] left hepatic lobectomy, CBD excision and RNY hepatojej for cholangiocarcinoma [**2117-5-19**] cholangiogram with exchange of PTC [**2117-5-26**] exchange of PTC [**2117-7-5**] exchange of PTC with stent placement [**2117-7-15**] new [**Month/Day/Year 19843**] placed thru biliary duct into collection Social History: lives in [**Location 2203**], MA with husband and daughter denies etoh, denies smoking, denies IVDU 2 cats Travel to [**Location (un) **] 2 yrs ago Family History: Mo - Parkinsons' disease Fa- HTN [**Last Name (un) **] - renal cancer Physical Exam: On Admission: VS: Temp: 97.5 B.P. 137/56 HR: 85 RR: 18 O2Sat 100RA General: Pleasant, NAD HEENT:PERRL, EOMI, sclerae anicteric OP: MMM, no ulcers/lesions/thrush, upper and lower dentures Neck: supple, no LAD, no thyromegaly Cardiovascular: RRR, normal S1, S2, no M/G/R Respiratory: CTA bilat w/o wheezes/rhonchi/rales Gastrointestinal: +bs, soft, distended, 3 R. catheters - no surrounding erythema/drainage, well bandaged, healing L. upper abd wound, L. J. tube without surrounding erythema/drainage. Musculoskeletal: moving all extremities Ext: Warm and well perfused, no edema. Skin: no rashes, no jaundice Neurological: aaox3, cn 2-12 Psychiatric: non-anxious, normal affect . On Discharge: Deceased Pertinent Results: [**2117-10-2**] 8:54 am BLOOD CULTURE Source: Line-PICC. **FINAL REPORT [**2117-10-11**]** Blood Culture, Routine (Final [**2117-10-11**]): [**Female First Name (un) **] PARAPSILOSIS. [**2117-10-2**] 10:10 am BLOOD CULTURE 2 OF 2. **FINAL REPORT [**2117-10-12**]** Blood Culture, Routine (Final [**2117-10-12**]): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. OF TWO COLONIAL MORPHOLOGIES. COLISTIN Susceptibility testing requested by AMI [**Doctor Last Name **] #[**Numeric Identifier 38652**] [**2117-10-4**]. COLISTIN = SENSITIVE AT <=2 MCG/ML. COLISTIN Sensitivities performed by [**Hospital1 **] laboratories. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- =>64 R CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 2 S MEROPENEM------------- =>16 R PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S [**2117-10-2**] 8:54 am BILE **FINAL REPORT [**2117-10-7**]** GRAM STAIN (Final [**2117-10-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [**2117-10-7**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. AMIKACIN REQUESTED BY AMI [**Doctor Last Name **] [**2117-10-5**] 9-0841. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. THIRD MORPHOLOGY. AMIKACIN REQUESTED BY AMI [**Doctor Last Name **] 9-0841 [**2117-10-5**]. YEAST. QUANTITATION NOT AVAILABLE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- <=2 S 16 S CEFEPIME-------------- =>64 R =>64 R CEFTAZIDIME----------- 32 R =>64 R CIPROFLOXACIN--------- 2 I 0.5 S GENTAMICIN------------ 2 S 8 I MEROPENEM------------- =>16 R =>16 R PIPERACILLIN---------- =>128 R =>128 R PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ <=1 S <=1 S [**2117-10-9**] 1:00 pm ABSCESS [**Month/Day/Year **] POCKET (HEPATIC ABSCESS). GRAM STAIN (Final [**2117-10-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- =>64 R CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S Brief Hospital Course: Admitted for failure to thrive and bilious output leaking from around drains. She underwent several [**Month/Day/Year 19843**] studies/manipulations on [**2117-9-30**] - exchange of three biliary catheters, [**2117-10-1**] - exchange of internal external biliary stent with pigtail formation in the abscess cavity and jejunum, [**2117-10-9**] - pigtail catheter placement into a new liver abscess. Upon admission she was restarted on TPN. Her clinical status deteriorated during her hospital course though her drains did appear to be functioning. [**2117-10-2**] Blood cultures grew out [**Female First Name (un) **] PARAPSILOSIS as well as multi-drug resistant PSEUDOMONAS AERUGINOSA. The ID service followed Ms.[**Known lastname **] closely during her hospital course and aided the primary team in adjusting her antibiotic course accordingly. The pt was transferred to the ICU twice during her hospital course for increasing lethargy, unresponsiveness and increased work of breathing. Blood cultures were drawn daily but the pt remained persistently bacteremic with MDR Pseudomas sepsis. A family discussion was held on [**10-12**] and it was decided to make the pt [**Name (NI) 3225**]. Antibiotics were stopped as well as TPN and Tube feeds. The pt expired during the evening of [**2117-10-12**] in the ICU. Medications on Admission: **Linezolid 600 mg po bid ([**8-31**] - **Erythromycin 250 mg po q 6 hrs **Meropenem 500 mg IV q 8 hrs ([**8-25**]- ([**7-25**] - [**8-13**])([**8-18**]) Vancomycin ([**8-11**], [**8-25**] - [**8-31**]) Clarithromycin ([**7-29**] - [**8-7**]) ([**8-10**] - [**8-14**]) Amoxicillin PO ([**7-29**] - [**8-7**], [**8-10**] -[**8-14**]) Levofloxacin PO ([**8-18**] - [**8-25**]) ______________________________ SC ISS levothyroxine 75 mcg po daily citalopram 20 mg po daily pantoprazole 40 mg po bid carvedilol 3.125 mg po bid MVI po daily ursodiol 300 mg po bid creon 12 mg po tid Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "112.5", "572.0", "996.59", "276.1", "038.43", "E878.2", "286.9", "272.0", "995.92", "785.52", "401.9", "576.8", "997.4", "244.9", "250.00", "287.5", "E879.8", "783.7" ]

icd9cm

[ [ [] ] ]

[ "54.91", "99.15", "87.54", "97.05", "50.91", "97.29" ]

icd9pcs

[ [ [] ] ]

8976, 8985

7005, 8319

328, 548

9037, 9047

2961, 6384

9100, 9234

2151, 2222

8947, 8953

9006, 9016

8345, 8924

9071, 9077

2237, 2237

2932, 2942

240, 290

6419, 6982

576, 1161

2251, 2918

1183, 1969

1985, 2135

21,525

173,208

20418+20419

Discharge summary

report+report

Admission Date: [**2103-3-13**] Discharge Date: [**2103-3-16**] Date of Birth: [**2053-7-1**] Sex: M Service: Medicine, [**Hospital1 139**] Firm NOTE: Day of discharge unknown. This Discharge Summary is dictated for his hospitalization course through [**2103-3-16**]. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old gentleman with a past medical history significant for terminal cirrhosis of the liver due to alcohol, pancytopenia, hepatitis C virus, and history of gastrointestinal bleed who presented [**Hospital1 69**] in [**Location (un) 620**] with a rash and hypotension. The patient initially presented to the outside hospital due to his rash on his hands and feet for two days that was painful and itchy. He also noted that his hands and feet were swelling and that they were cold. The patient was found to be hypotensive in the Emergency Department at the outside hospital and was given two liters of fluid and was started on a dopamine drip. On arrival to [**Hospital1 69**], the dopamine was weaned with blood pressures in the mid 80s to low 90s. He denied any fevers, chills, neck stiffness, mental status changes, sore throat, shortness of breath, chest pain, melena, bright red blood per rectum, hematemesis, abdominal pain, or increased abdominal girth. The patient received 2 grams of ceftriaxone as well as Flagyl, and 2 million units of penicillin for a question of syphilis. PAST MEDICAL HISTORY: 1. Hepatic encephalopathy. 2. Terminal cirrhosis of the liver due to alcohol. 3. Hepatitis C virus. 4. History of a gastrointestinal bleed. 5. Chronic anemia. 6. History of pancreatitis. 7. Pancytopenia. 8. History of urosepsis. MEDICATIONS ON ADMISSION: 1. Lasix 80 mg by mouth in the morning and 40 mg by mouth in the evening. 2. Spironolactone 40 mg by mouth every other day. 3. Folic acid 1 mg by mouth once per day. 4. Nadolol 20 mg by mouth once per day. 5. Protonix 40 mg by mouth once per day. 6. Lactulose twice per day. 7. Iron sulfate 325 mg by mouth once per day. 8. Thiamine 100 mg by mouth once per day. 9. Vitamin B12. 10. Vitamin C. ALLERGIES: No known drug allergies. FAMILY HISTORY: Family history significant for alcoholism in his father. SOCIAL HISTORY: The patient is single and lives with his mother and sister. [**Name (NI) **] works as a part-time contractor. He does have a history of alcohol and denied alcohol use in the past three months. He denied any tobacco use or intravenous drug abuse. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.1 degrees Fahrenheit, his blood pressure was 71/29, his heart rate was 76, his respiratory rate was 16, and his oxygen saturation was 96% on room air. In general, a thin Caucasian male, shivering under covers, but no diaphoresis. In no acute distress. Head, eyes, ears, nose, and throat examination the pupils were equal, round, and reactive to light. The sclerae were icteric. The conjunctivae were pink. Positive oropharyngeal petechiae. The mucous membranes were dry. Neck examination revealed there was no lymphadenopathy. Cardiovascular examination revealed a regular rate and rhythm. There were no murmurs, rubs, or gallops. Pulmonary examination revealed clear to auscultation bilaterally. The abdomen was soft, distended, and nontender. There were normal active bowel sounds. There was no hepatosplenomegaly. Extremity examination revealed no clubbing, cyanosis, or edema. No axillary or other lymphadenopathy. Skin revealed petechial rash with purpuric regions on the feet, 0.5-cm lesions on the Achilles tendon. No rash on the legs or thighs. Positive palmar on the dorsum of the hand. Skins and recurs on the elbows. Neurologically, the patient was alert and oriented times three. Cranial nerves II through XII were grossly intact. Strength was [**4-4**]. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 23.1 (with 90% neutrophils and 3 bands), his hematocrit was 31.1, and his platelets were 269. His sodium was 127, potassium was 4.4, chloride was 102, bicarbonate was 15, blood urea nitrogen was 64, creatinine was 2.3, and his blood glucose was 105. His calcium was 7.9, his magnesium was 1.8, and his phosphorous was 5.9. His alanine-aminotransferase was 19, his aspartate aminotransferase was 35, his alkaline phosphatase was 367, his total bilirubin was 4, his albumin was 2.4, his lipase was 22, and his amylase was 94. Prothrombin time was 17.6, his partial thromboplastin time was 43.3, and his INR was 2. His fibrinogen was 347. D-dimer was 5420. Urinalysis showed trace blood, but negative protein and otherwise negative. PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed atelectasis at the right base; otherwise was clear. IMPRESSION: The patient is a 49-year-old gentleman with a history of hepatitis C virus, cirrhosis, hepatic encephalopathy, alcohol abuse, and a history of gastrointestinal bleed who presented with a petechial rash on the hands, both his feet, elbows, and associated malaise. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL ISSUES: the patient had a paracentesis performed which revealed [**2098**] white blood cells, 425 red blood cells, 57% neutrophils, no microorganisms, 2+ polymorphonuclear leukocytes. The serum ascites albumin gradient was greater than 1; consistent with portal hypertension. Based on these results, even though the cultures were negative to date, the patient was diagnosed with having spontaneous bacterial peritonitis due to his history of chronic liver disease. For this reason, he was started initially on vancomycin, levofloxacin, and ceftriaxone for broad antibiotic coverage. However, the vancomycin and levofloxacin were discontinued on hospital day two, and he was just continued on the ceftriaxone 1 gram intravenously q.24h. An abdominal ultrasound revealed a main portal vein that was patent with thready anterior grade flow. No definite thrombus, and a large amount of ascites. No hydronephrosis, and a cirrhotic liver without a focal mass. The patient was continued on thiamine and folic acid supplements. He was on a low protein diet, and lactulose was given for prevention/aiding in treatment of hepatic encephalopathy. His Lasix, spironolactone, and nadolol were initially held due to his hypotension but were restarted on hospital day three without incident. The patient initially presented with hyponatremia which improved on 2 liters of free water restriction. 2. DERMATOLOGIC ISSUES: Dermatology was consulted for the patient's diffuse rash. A biopsy was performed which revealed no microorganisms, and the cultures were pending to date. This showed evidence of leukocytoclastic vasculitis; consistent with cryoglobulinemia. The cryoglobulinemia was in relation to his hepatitis C viral cirrhosis. The patient was treated symptomatically with betamethasone, Usaryn, and Bacitracin topical creams. 3. CARDIOVASCULAR ISSUES: The patient initially presented with hypotension. He was started on dopamine pressors which were discontinued on hospital day two. His heart rate and blood pressure stabilized, and he was thought stable to be restarted on his Lasix, spironolactone, and nadolol. A transthoracic echocardiogram was performed which revealed an ejection fraction of greater than 50%, and trivial mitral regurgitation. No effusion, no aortic regurgitation, and no vegetations. Poor visualization of the tricuspid and pulmonary valves. 4. GENITOURINARY ISSUES: The patient had a negative urine culture. He was found to be in acute renal failure; likely due to his dehydration. However, his creatinine had returned almost to baseline at the time of this dictation. 5. HEMATOLOGIC ISSUES: On hospital day three, the patient was found to have a hematocrit of 21.2. For this reason, he was consented and transfused 2 units of packed red blood cells in order to keep his hematocrit above 27. Iron studies were pending at the time of this dictation. 6. INFECTIOUS DISEASE ISSUES: Blood cultures times two were pending at the time of this dictation and were negative to date. The patient had a rise in white blood cell count but remained afebrile. He was continued on the ceftriaxone 1 gram intravenously q.12h. to be continued for a total of 10 days; to be discontinued on [**2103-3-22**]. The patient will need chronic ciprofloxacin for spontaneous bacterial peritonitis prophylaxis. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To a rehabilitation facility. MEDICATIONS ON DISCHARGE: 1. Multivitamin one tablet by mouth every day. 2. Folic acid 1 mg by mouth once per day. 3. Thiamine 100 mg by mouth once per day. 4. Protonix 40 mg by mouth once per day. 5. Usaryn cream apply topically twice per day. 6. Bacitracin 500 U/g ointment one application topically twice per day. 7. Betamethasone 0.05% cream one application topically twice per day. 8. Lactulose 30 mL by mouth three times per day. 9. Nadolol 20 mg by mouth once per day. 10. Spironolactone 25 mg by mouth every other day. 11. Furosemide 80 mg by mouth in the morning and 40 mg by mouth in the evening. 12. Ceftriaxone 2 grams intravenously q.12h. (to be stopped on [**3-22**]). DISCHARGE DIAGNOSES: 1. Cirrhosis of the liver; end-stage liver disease. 2. Spontaneous bacterial peritonitis. 3. Anemia. 4. Cryoglobulinemia. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to call his primary care physician (Dr. [**Last Name (STitle) **] in one to two weeks (telephone number [**Telephone/Fax (1) 6163**]) for a follow-up appointment. NOTE: Another dictation is to follow for the patient's hospitalization course beyond [**2103-3-16**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**] Dictated By:[**Name8 (MD) 6206**] MEDQUIST36 D: [**2103-3-16**] 17:30 T: [**2103-3-19**] 01:46 JOB#: [**Job Number 54717**] Admission Date: [**2103-3-13**] Discharge Date: [**2103-3-20**] Date of Birth: [**2053-7-1**] Sex: M Service: Medicine, [**Hospital1 139**] Firm ADDENDUM: Please refer to the prior dictated Discharge Summary from [**2103-3-13**] through [**2103-3-16**]. The following is a summary of the hospitalization course from [**2103-3-17**] through [**2103-3-20**]. HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 1. SPONTANEOUS BACTERIAL PERITONITIS ISSUES: The patient was on intravenous ceftriaxone 1 gram intravenously once per day from [**3-13**] through [**3-18**]. At that point, the patient was changed to oral ciprofloxacin 500 mg by mouth twice per day for treatment of spontaneous bacterial peritonitis. A repeat paracentesis performed on [**2103-3-19**] revealed an improvement in the spontaneous bacterial peritonitis with only 50 white blood cells, and 29% polys, as well as 44% lymphocytes in the setting of 725 red blood cells. The patient was discharged on maintenance therapy for spontaneous bacterial peritonitis to include ciprofloxacin 750 mg by mouth every week. 2. HEPATIC ENCEPHALOPATHY ISSUES: The patient was continued on his lactulose and titrated up to three to four bowel movements per day. His mental status improved significantly from admission. 3. HEPATITIS C CIRRHOSIS ISSUES: The patient was continued on his thiamine, folic acid, low-protein diet, lactulose, Lasix, spironolactone, and nadolol. His Lasix dose had been increased on [**3-18**] from 40 mg by mouth every day to 60 mg by mouth once per day for better diuresis. His weights remained stable, and he was continued on his 2-gram sodium diet. 4. RASH ISSUES: The Dermatology consultation noted that his rash was consistent with leukocytoclastic vasculitis; most likely cryoglobulinemia. The biopsy was negative for cryoglobulins. However, this was most likely because the biopsy was not performed during the exact acute phase of the cryoglobulinemia. The patient was continued on bacitracin and betamethasone creams with improvement of his rash. No intravenous steroids were utilized. 5. FEVERS/INFECTIOUS DISEASE ISSUES: By the time of discharge, the patient's white blood cell count had decreased and he was afebrile. His blood cultures were negative to date. His spontaneous bacterial peritonitis had been improving on a repeat paracentesis on [**2103-3-19**]. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was continued on his low-protein diet. He was restricted to 1500 mL of free water per day with improvement of his hypernatremia. His electrolytes were repleted as needed. 7. DIARRHEAL ISSUES: Likely due to lactulose. A Clostridium difficile toxin was negative. 8. NON-GAP METABOLIC ACIDOSIS ISSUES: This improved with time. It was thought likely to be due to the lactulose. 9. ANEMIA ISSUES: The patient was transfused 2 units of packed red blood cells on [**3-16**] with improvement of his hematocrit to 30. His iron studies were consistent for hepatic synthetic function. 10. THROMBOCYTOPENIA ISSUES: Likely due to his liver disease and was made worse with transfusion of the packed red blood cells. 11. COAGULOPATHY ISSUES: The patient had an INR of 1.8. He was administered vitamin K with improvement of his INR to 1.5. Therefore, the repeat paracentesis was performed without incident. 12. CARDIOVASCULAR ISSUES: The patient had a transthoracic echocardiogram which revealed mild mitral regurgitation, and an ejection fraction of greater than 50%, and poor visualization of the tricuspid and pulmonary valves. No vegetations, no effusions, or aortic regurgitation. The patient did have evidence of systolic failure which was compensated. The Lasix was continued as well as sodium restriction for adequate diuresis. 13. OTHER ISSUES: The patient was evaluated by Physical Therapy and felt to be adequate for discharge to home without the need for rehabilitation. However, he would be administered visiting nurse assistance. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: Home with services. DISCHARGE DIAGNOSES: 1. Cirrhosis of the liver. 2. Spontaneous bacterial peritonitis. 3. Anemia of chronic disease. 4. Cryoglobulinemia. MEDICATIONS ON DISCHARGE: 1. Multivitamin one capsule by mouth every day. 2. Folic acid 1 mg by mouth once per day. 3. Thiamine 100 mg by mouth once per day. 4. Protonix 40 mg by mouth once per day. 5. Petrolatum-mineral oil cream one application topically twice per day to affected area. 6. Bacitracin 500 U/g ointment one application topically twice per day to affected area. 7. Betamethasone dipropionate 0.05% cream one application topically twice per day to affected area. 8. Lactulose 30 mL by mouth q.6h. (to titrate up to three to four bowel movements per day). 9. Nadolol 20 mg by mouth once per day. 10. Spironolactone 25 mg by mouth once per day. 11. Ciprofloxacin 750 mg by mouth every week. 12. Furosemide 80 mg by mouth in the morning and 60 mg by mouth in the evening. 13. Albuterol 1 to 2 puffs q.6h. as needed (for wheezing). 14. Atrovent 1 to 2 puffs q.6h. as needed (for wheezing). DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in one to two weeks (telephone number [**Telephone/Fax (1) 6163**]). [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 2511**], M.D. Dictated By:[**Name8 (MD) 6206**] MEDQUIST36 D: [**2103-3-21**] 12:10 T: [**2103-3-21**] 12:43 JOB#: [**Job Number 54718**]

[ "584.9", "280.0", "287.5", "276.2", "273.2", "567.2", "571.2", "070.54", "789.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "54.91", "86.11" ]

icd9pcs

[ [ [] ] ]

2186, 2244

14143, 14264

14291, 15189

1718, 2169

15224, 15639

5102, 8509

14075, 14122

317, 1431

1453, 1691

2261, 5068

30,962

146,588

10561

Discharge summary

report

Admission Date: [**2198-6-11**] Discharge Date: [**2198-6-18**] Date of Birth: [**2141-12-31**] Sex: F Service: MEDICINE Allergies: Reglan / Bactrim / Univasc Attending:[**First Name3 (LF) 348**] Chief Complaint: nausea/vommiting Major Surgical or Invasive Procedure: none History of Present Illness: 56F h/o DM1, CRI, CAD s/p CABG presented to [**Hospital 34762**]Medical Center [**2198-6-4**] with 2 days abdominal pain, nausea, vomiting, and chills but no fever. She had also noticed an increase in her insulin requirement during this time. Noted to be afebrile but with diffuse abdominal pain on exam, positive [**Doctor Last Name 515**] sign, and leukocytosis of 17.6. LFTs were - AST 24, ALT 18, AP 62, Tbili 0.9; amylase and lipase normal. She was started on Unasyn for presumed cholangitis. RUQ ultrasound revealed cholelithiasis without cholecystitis. HIDA scan was negative. Noncontrast CT confirmed gallstones and could not r/o an obstructive CBD stone due to extensive calcification. ERCP performed with ?filling defect s/p CBD stenting and developed post-ERCP pancreatitis (amylase 811, lipase 405). Hydrated with IVFs and transfused 2 units pRBC for falling Hct 24->31. Changed to levo/flagyl on [**2198-6-9**]. Cre increased from 3.1->6.9 with oliguria prior to transfer for possible hemodialysis initiation. At presentation, her main complaints were vertigo, nausea and wretching. She had mild abdominal pain. She was admitted to the MICU. Past Medical History: 1. Coronary artery disease status post 4v CABG in [**Month (only) 1096**] of [**2190**]. 2. DM1 complicated by retinopathy, neuropathy, nephropathy, gastroparesis on insulin pump. 3. Hypertension. 4. Chronic renal insufficiency with a baseline creatinine of . 5. Hyperlipidemia. 6. Hypothyroidism. 7. Anemia. 8. Left lung decortication secondary to pleural effusion in [**2191-12-12**]. 9. Vancomycin resistant enterococcal infection. 10. Peripheral vascular disease. 11. C section x2. 12. Gout 13. h/o Peptic ulcer disease (EGD [**2196**] with erosive gastritis, hiatal hernia, gastroparesis) Social History: She lives with her son in [**Name (NI) **]. Unemployed. She quit tobacco in [**2190**], but has a 30 pack year smoking history. She does not drink. She has one dog at home. Family History: Diabetes, chronic renal insufficiency, coronary artery disease, asthma and thyroid disease. Physical Exam: VS: Tm 99.3 Tc 99.3 150/43 (130-178/40-58) HR 76 (72-83) RR17 O2 90%RA I: 1.7, O: 1.6 HEENT: NCAT, PERRL, EOMI, anicteric, OP clear, MMM Neck: no bruit/lad/thyromegally CV: S1 S2 RRR no m/r/g Chest: CTA bil no rales/rhonchi/wheeze Abd: +bs, soft, nd, epigastrium tender to deep palp, no rebound tenderness, no hsm Ext: RUE erythematous, Pitting edema of bil lower extremities. Pertinent Results: CXR [**6-11**]: Heart size is normal. Lungs are grossly clear. Widening of the superior mediastinum is unchanged over four years. In [**2193**] CT scanning showed it was due to a combination of adenopathy and fat deposition. . RENAL U/S [**6-12**]: The right kidney measures 11.3 cm. There is moderate hydronephrosis present. A 1.2 x 0.6 cm cyst is identified in the interpolar region. The left kidney measures 11 cm in maximum dimensions. There is normal corticomedullary differentiation without evidence of focal stones, mass, or hydronephrosis. Two relatively simple-appearing cysts are identified in the interpolar region of the left kidney. CONCLUSION: New onset moderate right hydronephrosis. This was not present in [**2193**]. . RENAL U/S [**6-14**]: The right kidney measures 11.1 cm in length and has a normal appearance. Again noted is a small cyst in the anterior portion of the right kidney. Color flow shows flow to the right kidney. The left kidney measures 11 cm in length. No stones, mass lesions, or hydronephrosis are noted in the left kidney. Color flow shows flow to the left kidney. Please note that the previously noted hydronephrosis in the right kidney has resolved. IMPRESSION: Resolution of right-sided hydronephrosis. Brief Hospital Course: A/P: Ms. [**Known lastname 34763**] is a 56 yo female with a h/o DM1, CRI, CAD s/p CABG presented to OSH with abdominal pain, nausea, vomiting s/p ERCP with pancreatitis and acute renal failure transferred for concern for need for intiating HD. . 1) Acute renal failure: On arrival in the MICU, the renal team was consulted. Her acute on chronic renal failure was attributed to ATN [**1-12**] poor renal perfusion in setting of pancreatitis. Diagnosis of ATN was supported by calculated FeNa=8.4%, suggesting intrinsic renal disease. PT found to have AG acidosis, which was managed with Bicarb GGT while in the MICU. She also had a renal ultrasound that revealed moderate right-side hydroneprhosis. With high-doses of diuril and lasix, her oliguria improved and creatinine steadily trended down from 7.2 to 2.6 at time of discharge. Due to this improvement, hemodialysis was never necessary. Renal ultrasound was repeated two days later and revealed interval resolution of hydroneprhosis. . 2) Pancreatitis: Patient is s/p ERCP at OSH for question of cholangitis. Her pancreatitis chemically improved, but patient continued to have pain and nausea, which was mangaged with Dilaudid prn, Zofran prn, and standing ativan for N/V. She was transferred on antimicrobial coverage with levofloxacin and flagyl. Although no evidence of pancreatic necrosis was visualized on imaging, she was empirically was started on 7 day course of Imipenem. Pancreas imaging discussed with radiology but since patient's clinical status was improving and she remained afebrile with downward trending WBC, further imaging was deferred. At time of discharge, patient had been advanced to a full diet which she was tolerating without difficulty. . 3) DM1: Complicated by retinopathy, neuropathy, nephropathy, gastroparesis on insulin pump at home. DM managed initially with insulin gtt titrated to blood glucoses of 80-120, then she was transitioned to home insulin pump. Of note, gastroparesis may be contributing to NV, but pt has reported allergy to reglan. . 4) Hypertension: managed with Nifedipine and Metoprolol. . 5) Vertigo: Chronic per patient. Continued meclizine for vertigo and Ativan and zofran prn nausea. . 6) CAD: Status post 4v CABG in 12/[**2190**]. No active issues during this hospitalizaiton. Continued ASA, plavix, and BB. . 7) Hypothyroidism: Continued levothyroxine. . 8) Anemia: Chronic. Likely [**1-12**] CRI. s/p 2 units pRBC at OSH with appropirate increase. Hct stable. Pastient to continue procrit every other week (last dosed at OSH [**6-11**]). Medications on Admission: MEDICATIONS AT HOME: Novolog pump Levoxyl 0.112mcg qSunTueThuSat, 0.125mcg QMonWedFri Metoprolol 50mg tid Omeprazole 20mg [**Hospital1 **] Lasix 80mg daily Lescol XL 80mg qhs Zetia 10mg daily Plavix 75mg daily Procrit 4000U every other week Colchicine 0.6mg prn Meclizine 25mg prnNitroQuik 0.4mg prn Claritin prn Feosol 200mg [**Hospital1 **] ASA 81mg [**Hospital1 **] MVI Fish oil 1200mg [**Hospital1 **] Calcium + D 600mg [**Hospital1 **] Tylenol prn . MEDICATIONS ON TRANSFER to MICU from OSH: ASA 81mg [**Hospital1 **] Omeprazole 20mg [**Hospital1 **] Procrit 10k units sc weekly (given [**2198-6-11**]) Norvasc 5mg daily Levoxyl 150mcg daily Flagyl 500mg IV q8h Levaquin 250mg IV daily Labetalol 10mg IV q8h Plavix 75mg daily Insulin gtt D5 1/2NS @ 150 cc/hr Zofran 4mg IV q4h prn Ambien 5mg po qhs prn Tylenol prn Dilaudid 1-2mg IV q3-4h prn . Medications on transfer from MICU to [**Location (un) **]. Sevelamer 800 mg PO TID Lorazepam 0.5-1 mg PO/IV Q4H:PRN nausea, anxiety Lorazepam 1 mg IV Q6H nausea, anxiety Metoprolol 75 mg PO TID HYDROmorphone (Dilaudid) 1-2 mg IV Q6H:PRN Meclizine 25 mg PO TID Heparin 5000 UNIT SC BID Insulin Pump SC (Self Administering Medication Imipenem-Cilastatin 250 mg IV Q12H Amlodipine 10 mg PO DAILY Docusate Sodium 100 mg PO BID Levothyroxine Sodium 112 mcg PO QSUNTUETHUSAT Pantoprazole 40 mg IV Q12H Acetaminophen 325-650 mg PO Q6H:PRN Ondansetron 4 mg IV Q8H:PRN Clopidogrel Bisulfate 75 mg PO DAILY Aspirin 81 mg PO BID Senna 1 TAB PO BID:PRN Bisacodyl 10 mg PO/PR DAILY:PRN Discharge Medications: 1. Procrit 4,000 unit/mL Solution Sig: One (1) syringe Injection q 2 weeks. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO QSUNTUETHUSAT (). 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Novolog 100 unit/mL Solution Sig: 1 unit/hour basal rate Subcutaneous QACHS: Patient to perform carb counting at lunch. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Pancreatitis Acute renal failure Diabetes Mellitus, Type I Metabolic acidosis Gout Anemia Hypertension Discharge Condition: Good. Creatinine improved to 2.6. Discharge Instructions: You were admitted to [**Hospital1 18**] for management of your acute pancreatitis and acute renal failure. Both of these conditions have resolved at the time of your discharge. You should be sure to be compliant with all medications exactly as prescribed. You should seek immediate medical attention if you are experiencing shortness of breath, chest pain, nausea/vomiting, fevers, poor glucose control, or other concerning symptoms. Followup Instructions: You should follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] immediately following your discharge from rehab. Please call [**Telephone/Fax (1) 26677**] to schedule your follow-up appointment.

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icd9cm

[ [ [] ] ]

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icd9pcs

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2649

Discharge summary

report

Admission Date: [**2169-8-16**] Discharge Date: [**2169-8-24**] Service: MEDICINE Allergies: Lopressor Attending:[**First Name3 (LF) 1148**] Chief Complaint: short of breath, fever, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname 13276**] is a Russian-speaking [**Age over 90 **] y/o F w/ CAD, CLL (baseline WBC's 20s), CHF who p/w increasing SOB, fever and cough. Per the pt's daughter, the pt began to complain of SOB 1 day PTA, with intermittent cough X 2 months. She was seen in the ED in [**Month (only) **], had a CXR performed which was negative for PNA. On the morning of admission, the daughter noted that her mother was not "acting like herself", refused to eat breakfast, and was complaining of feeling hot and not being able to breathe. On the day of admission, the pt continued to feel SOB and hot while standing, became pale, and fell to the floor. No head trauma or LOC. The daughter then called EMS. Denies recent sick contacts, increase in salt in diet. The daughter does report the pt's LEs have been more swollen over the past few days and called her PCP who instructed the pt to take 1 [**1-16**] pills of Lasix (for total of 120 mg po) on the morning of admission. At baseline, the pt experiences chest pain which is relieved by a nitro patch and is able to walk short distances slowly in her daughter's apt without feeling SOB. The pt was recently treated for a UTI with a 5 day Cipro course. ROS negative for recent headaches, dizziness, abdominal pain, n/v/d, dysuria, urinary frequency. . In ED, her vital signs were T104.3 BP 99/43 P138 R25 93% on RA. She appeared hypovolemic and was given 2L NS. CXR w/ CHF and ? pneumonia. Patient started on vanco/ceftriaxone/azithromycin. She was also found to have anemia and received 1u PRBC. She complained of chest pain, probably due to demand ischemia, with transient 1mm STD's noted on lateral leads of EKG, which resolved on f/u EKG, as did her CP within an hour. Past Medical History: CLL with anemia, on aranesp, refused chemo hypertension hx of a flutter s/p cardioversion copd ?CAD - refusing aggressive work up due to age CRI (baseline Cr 1.2- 1.4) Social History: Lives with daughter in [**Name (NI) 3146**]. Patient denied alcohol, drugs, tobacco use. She immigrated from [**Country 532**] about 10 years ago. Family History: Non-contributory Physical Exam: T 98.0 BP 120/80 P 80 RR 16 O2 sat on 2L NC 96% Gen - elderly Russian-speaking female, NAD, pleasant HEENT - PERRL, MMM, neck supple, no LAD, neck veins 8-10cm CV - RRR, + s1/s2, II/VI SEM URSB to apex Lungs - rales at lung bases b/l and worse on R, occasional diffuse wheezing b/l Abd - soft, NT, ND, normoactive BS, moderately obese Ext - +2 pitting edema to knees b/l, +1 dorsalis pedis pulses b/l Neuro - CN grossly intact, moves all 4 extremities spontaneously Pertinent Results: [**2169-8-16**] 06:36PM LACTATE-3.0* K+-4.0 [**2169-8-16**] 05:16PM COMMENTS-GREEN TOP [**2169-8-16**] 05:16PM LACTATE-4.6* K+-5.9* [**2169-8-16**] 04:55PM GLUCOSE-226* UREA N-34* CREAT-1.9* SODIUM-138 POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-21* ANION GAP-21* [**2169-8-16**] 04:55PM CK(CPK)-31 [**2169-8-16**] 04:55PM cTropnT-0.04* [**2169-8-16**] 04:55PM WBC-31.6* RBC-3.69* HGB-8.8* HCT-26.9* MCV-73* MCH-23.9* MCHC-32.8 RDW-18.3* [**2169-8-16**] 04:55PM NEUTS-15* BANDS-1 LYMPHS-77* MONOS-0 EOS-2 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [**2169-8-16**] 04:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG urine culture: klebsiella oxytoca blood cultures: no growth CXR: Stable appearance of the chest without acute pulmonary process TTE:Conclusions: 1. The left atrium is moderately dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. No MR seen. 7.There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2163-9-20**], the LV function appears to have improved. Renal ultrasound: CONCLUSION: Multiple bilateral renal cysts. No hydronephrosis or calculi. Markedly enlarged spleen with an area of increased echogenicity. Although IV contrast usage would likely be difficult in this patient with renal failure, but a CT scan or MRI suggested for delineating anatomy in the upper abdomen. EKG: sinus tachycardia, IVCD with poor R wave progession, [**Street Address(2) 11342**] depressions in I, avL, V6 that subsequently resolved 1 hr later. Brief Hospital Course: [**Hospital Unit Name 153**] course: Her blood pressure stabilized and her mental status improved, allowing transfer to the floor in stable condition [**8-17**] 9 PM. Echo [**8-17**] showed normal LVEF >55% with normal LV size and no significant valvular disease (some aortic valve leaflet thickening). [**Age over 90 **]yo female h/o CAD, CHF, CLL, CRI presented with fevers, lymphocytosis, cough, increased SOB, and hypotension. 1) SOB: On further eval of CXR, pt believed to have increased opacity in LLL. Blood cultures were no growth. Pt had lateral ST changes in ED but cardiac enzymes remained negative, so believed from strain. No other events. Pt given 9 days of antibiotics (levofloxacin 250mg qday as renal function improved) with plan to complete 10 days total. Pt continued to have cough. Given albuterol/atrovent nebs and cough suppression with some relief. 2) UTI: Pt's urine grew klebsiella. Treated with levofloxacin as well. 3) Hypotension: Believed secondary to dehydration and infection. Improved with hydration. BP medications initially held and eventually added back. 4) CLL: WBC elevated here to 30s. Baseline reportedly in the 20s. On aranesp as an outpatient. Pt's hematocrit was around 26. With h/o CAD goal Hct closer to 30. Pt consented and received 1 U PRBCs with increase to 28.6. Pt denied any symptomatic improvement. 5) Acute on chronic renal failure: Patient's baseline Cr 1.2-1.4; on admission was 1.9. Improved with hydration to 1.2. Renal ultrasound showed bilateral renal cysts, no evidence of obstruction or hydro. 6) Aflutter/CAD: Initially medications held. Now back on diltiazem, disopyramide, ASA. Pt also on lasix 80mg qday. BP well controlled with these agents. Spoke with patient's VNA who reported patient has had cough with lisinopril previously, so will not restart. Also will hold doxazosin as blood pressure well controlled. If patient does need another [**Doctor Last Name 360**] in the future, might consider [**First Name8 (NamePattern2) **] [**Last Name (un) **]. No beta blocker as has stimulated bronchospasm in past. 7) Derm: Pt has numerous moles over body; dermatology was asked to evaluate. Believed lesion in L lower abdomen was seborrheic keratosis. Lesion R lat upper calf: diff dx incls blue nevus, combined nevus, or possibly evoling neoplasm. Deep shave biopsy done; can follow up as outpatient. Also given Penlac for toenail fungus, to be applied once daily. 8) FEN: Patient's potassium was well maintained without supplement. DNR/DNI Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Klor-Con 20mg qday 4. Doxazosin 200mg [**Hospital1 **] 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 1* Refills:*2* 8. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 9. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 10. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Penlac 8 % Solution Sig: One (1) Topical once a day for 4 weeks. Disp:*1 * Refills:*0* Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 1* Refills:*2* 8. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 9. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 10. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Penlac 8 % Solution Sig: One (1) Topical once a day for 4 weeks. Disp:*1 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family and Children Services Discharge Diagnosis: Pneumonia Klebsiella urinary tract infection Prerenal azotemia (from dehydration) Discharge Condition: Good Discharge Instructions: Take your antibiotic until completion. Use the incentive spirometer 2-3 times per day to help with breathing. Call your doctor if you develop fevers, chills, sweats. Followup Instructions: Please make a follow up appointment in 2 weeks with Dr. [**First Name (STitle) 13277**] [**Name (STitle) **] (phone no [**Telephone/Fax (1) 13278**]). Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-10-19**] 10:40 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2169-10-19**] 10:40 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-10-19**] 11:00

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icd9cm

[ [ [] ] ]

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33317

Discharge summary

report

Admission Date: [**2131-7-10**] Discharge Date: [**2131-7-20**] Date of Birth: [**2093-2-10**] Sex: M Service: MEDICINE Allergies: Reglan / Lidocaine / Iodine Attending:[**First Name3 (LF) 2167**] Chief Complaint: gastroparesis, vomiting, abdominal pain, hyperglycemia Major Surgical or Invasive Procedure: PICC line placement Endoscopy with biopsies History of Present Illness: This is a 38 yo M with a h/o DMI complicated by gastroparesis/nephropathy/ retinopathy, h/o diastolic and systolic (EF 50-55%) CHF, h/o pancreatitis, HTN, CKD stage IV, schizophrenia, just discharged yesterday, who presents again with vomiting and abdominal pain c/w his typical gastroparesis. After he went home from the hospital yesterday, his abdominal pain began to worsen again. He has had 10 episodes of bilious emesis today with diffuse [**7-8**] crampy abdominal pain. He has had midsternal chest pain, but this is only associated with his vomiting. He has had no diaphoresis or shortness of breath. He also admits to feeling shaky, but denies chills or fevers. He has been unable to tolerate any food or water. He denies any dysuria. His last bowel movement was 2 days ago. His FS at home have been in the 100s. He was unable to take his home blood pressure medications today due to nausea. He admits to some nasal congestion for several days. . The pt was admitted from [**Date range (1) 77327**] for gastroparesis. He was treated with IV erythromycin, compazine, ativan, and zofran. He was started on pantoprozole 40 mg q 12 for h/o esophagitis and gastritis. His [**Last Name (un) **] and HCTZ were discontinued until outpt f/u with Dr. [**First Name (STitle) 805**] (renal) given he was admitted with ARF Cr 3.5 Bl [**12-31**]). He was discharged today with outpatient GI follow up. . In the ED, the pts vitals were: T 96.6, HR 91-106, BP 175-187/100-108, R 20, Sat 96% RA. . He received Zofran 4 mg IV x1, Dilaudid 1 mg IV x2, Regular insulin 16 U x1, Hydralazine 50 mg po x1, and metoprolol 50 mg po x1. Urine tox and serum tox were negative. Past Medical History: Type I DM, Insulin-requiring, dx at 20, currently seen at [**Last Name (un) **] - Diabetic gastroparesis (per patient, has had motility studies at OSH); was on reglan but developed EPS, now on erythromycin - Diabetic neuropathy and retinopathy # History of pancreatitis # HTN # Chronic Kidney Disease Stage IV, recently discovered # Thrombocytopenia NOS (resolving) # Hx of Esophageal ulcer and GIB # Schizophrenia # Depression / Suicidal ideation # CAD with CHF, EF nadir 25%, now improved to 50-55% on last ECHO in [**3-6**]. Diastolic dysfunction. # H/O C. difficile [**3-6**] # H/O elevated LFTs (ALT, alk phos) - negative RUQ u/s, hep serologies neg, autoimmune w/u negative Social History: Recently relocated from NH to [**Location (un) 86**], where he is living with his brother and brother's wife. Denies current ETOH use; admits to heavy drinking x 1 year about age 27. + Active tobacco use, about 1 pack every 3 days. Last marijuana use 15 days ago. No IVDU. Family History: +DM in sister, brother, father, and mother. Sister: died from diabetic complications/alcoholism in mother and father. Brother diagnosed with schizophrenia. Physical Exam: . ROS: -Constitutional: []WNL []Weight loss []Fatigue/Malaise []Fever []Chills/Rigors []Nightsweats [x]Anorexia -Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: []WNL [x]Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: []WNL [x]Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough -Gastrointestinal: []WNL [x]Nausea [x]Vomiting [x]Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria []DIscharge []Menorrhagia -Skin: [x]WNL []Rash []Pruritus -Endocrine: [x]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: [x] WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [x]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [x] WNL []Seasonal Allergies . Physical Exam: Appearance: appears fatigued, ill, NAD Vitals: T: 97.4 BP: 192/131 HR: 93 RR: 22 O2: 95 % RA FS 297 Eyes: EOMI, PERRL, conjunctiva clear but pale, noninjected, anicteric, no exudate ENT: dry MM Neck: No JVD, no LAD Cardiovascular: tachycardic, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, diffusely tender to palpation without rebound or guarding, mildly distended, hypoactive bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, [**12-31**]+ pitting in BL LE up to knees Neurological: Alert and oriented x3Integument: warm, no rash, no ulcer Psychiatric: appropriate Pertinent Results: [**2131-7-10**] 10:12PM URINE HOURS-RANDOM [**2131-7-10**] 10:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2131-7-10**] 08:20PM COMMENTS-GREEN TOP [**2131-7-10**] 08:20PM LACTATE-1.5 [**2131-7-10**] 08:00PM GLUCOSE-424* UREA N-48* CREAT-3.2* SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 [**2131-7-10**] 08:00PM ALT(SGPT)-31 AST(SGOT)-28 ALK PHOS-109 TOT BILI-0.2 [**2131-7-10**] 08:00PM LIPASE-43 [**2131-7-10**] 08:00PM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-1.9 [**2131-7-10**] 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2131-7-10**] 08:00PM URINE HOURS-RANDOM [**2131-7-10**] 08:00PM URINE GR HOLD-HOLD [**2131-7-10**] 08:00PM WBC-6.0 RBC-3.28*# HGB-10.3*# HCT-29.8* MCV-91 MCH-31.2 MCHC-34.4 RDW-15.0 [**2131-7-10**] 08:00PM NEUTS-70.3* LYMPHS-13.8* MONOS-5.7 EOS-9.8* BASOS-0.3 [**2131-7-10**] 08:00PM PLT COUNT-177 [**2131-7-10**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2131-7-10**] 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2131-7-10**] 08:00PM URINE RBC-[**1-31**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 Brief Hospital Course: This is a 38 yo M with a h/o DMI complicated by gastroparesis/nephropathy/ retinopathy, h/o diastolic and systolic (EF 50-55%) CHF, h/o pancreatitis, HTN, CKD stage IV, schizophrenia, who was only out of the hospital 24 hours before he represented with the same symptoms of N/V, thought to be due to gastroparesis. On the evening of [**7-12**] he was found unresponsive and transferred to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] the patient was awake, alert and oriented x3. His IV compazine, zofran and dilaudid were held for concern for delerium/oversedation. He was given ativan for N/V and he was placed on a CIWA protocol. Patient was also noted to have tachycardia, rigors and hypothermia, so blood cultures and urine cultures sent and on [**7-12**] pt. He was started on vancomycin, ceftazidime, and zosyn given a positive culture for GPC. The vancomycin was eventually discontinued given that the blood culture grew only coagulase negative staphylococcus. He was then switched to levofloxacin and metronidazole for a total 7 day course for aspiration pneumonia. He remained stable on room air. . For his nausea, vomiting, and abdominal pain, he was placed on IV erythromycin and Ativan and Dilaudid. He had an EGD performed which showed no evidence of bezoar. Biopsies were taken and were negative for infectious organisms. He was transitioned to oral erythromycin for discharge. At time of discharge he was tolerating pos. He was kept on pantoprazole 40 mg twice daily for esophagitis seen on EGD. . He was noted to have anemia and thrombocytopenia. He was guaiac negative. He received 2u pRBC. DIC labs and a HIT antibody were negative. His hematocrit and platelet count stabilized and improved after his acute illness. . He was extremely hypertensive during his stay. His medications were changed, with the addition of furosemide, valsartan, and labetalol and increases were made in his doses of hydralazine and clonidine. At time of discharge, his SBPs were 150s. He was also diuresed with IV lasix, with good urine output and improvement in his scrotal and peripheral edema. . DM type I, uncontrolled, with complication. His blood sugars remained under good control during his inpatient stay. . For his kidney failure, he was followed by the renal service. He had Stage IV kidney disease. His creatinine was stable during his admission, but began to rise slightly on day of discharge which will need to be followed as an outpatient. Medications on Admission: Norvasc 10 mg daily ASA 81 mg daily Hydralazine 50 mg every 8 hrs Colace 100 mg twice daily Simvastatin 20 mg daily MV Metoprolol 100 mg twice daily Clonidine 0.3 mg twice daily Prochlorperazine Maleate 10 mg every 6 hrs as needed for nausea Dilaudid 2 mg every 6 hr as needed Sucralfate 1 gram twice daily Senna twice daily as needed 70/30 12 units in AM and 6 units in PM Protonix 40 mg twice daily Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 3. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours): THIS DOSE IS INCREASED FROM BEFORE. [**Month/Year (2) **]:*270 Tablet(s)* Refills:*2* 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO twice a day: THIS iS A NEW MEDICATION. TAKE THIS IN PLACE OF METOPROLOL. . [**Month/Year (2) **]:*180 Tablet(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Month/Year (2) **]:*60 Capsule(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. [**Month/Year (2) **]:*30 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Month/Year (2) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): THIS IS A NEW MEDICATION. [**Month/Year (2) **]:*60 Tablet(s)* Refills:*2* 11. Insulin 70/30 Insulin 70/30 12units qam, 6units qpm. Sliding scale. 12. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours): THIS IS A NEW MEDICATION. [**Month/Year (2) **]:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): THIS IS A NEW MEDICATION. [**Month/Year (2) **]:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Hypertensive urgency 2. Altered mental status 3. Diabetic gastroparesis 4. Esophagitis 5. Multilobar aspiration pneumonia 6. Coagulase negative staphylococcus contaminant in blood culture 7. Diabetes type I uncontrolled with complications 8. Chronic kidney disease Stage IV 9. Schizophrenia 10. Depression 11. Thrombocytopenia 12. Anemia Discharge Condition: Stable Discharge Instructions: You were admitted with nausea and vomiting. You were also found to have very high blood pressures. If you develop nausea and vomiting, fevers, or chills, chest pain, shortness of breath, please call your primary care doctor or go to the emergency room. Followup Instructions: Please follow up with GI on Wednesday [**8-1**] at 2pm in the [**Hospital Unit Name **]. Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2131-8-1**] 2:00 Please follow up with Dr. [**Name (STitle) 26842**] for on Monday [**8-6**] at 3pm at [**Hospital6 733**] in the South Suite. [**Telephone/Fax (1) 250**].

[ "530.10", "536.3", "584.9", "507.0", "285.9", "403.00", "585.4", "250.43", "287.5", "250.63", "337.1", "295.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.16" ]

icd9pcs

[ [ [] ] ]

11125, 11183

6411, 8892

343, 389

11568, 11577

5129, 6388

11879, 12270

3091, 3250

9346, 11102

11204, 11547

8918, 9323

11601, 11856

4432, 5110

249, 305

417, 2078

2101, 2784

2800, 3075

29,305

138,308

53584

Discharge summary

report

Admission Date: [**2104-12-2**] [**Month/Day/Year **] Date: [**2104-12-10**] Date of Birth: [**2037-3-8**] Sex: F Service: MEDICINE Allergies: Bactrim / Tetracyclines / Erythromycin Base / Optiray 350 / Lisinopril / Diltiazem / Bee Sting Kit / Citrus Derived / Fish Product Derivatives / Shellfish Derived / Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 4975**] Chief Complaint: Atrial fibrillation Major Surgical or Invasive Procedure: DC cardioversion x1 History of Present Illness: Ms. [**Known lastname 110101**] is a 67 year old female with history of paroxysmal atrial fibrillation on coumadin, CAD, HTN, prior CVA ([**10-17**]), asthma, DM2 who awoke with acute onset of stabbing chest pain, shortness of breath, and presyncopal this AM. She had some associated pain in her bilateral shoulders and throat. The pain came in three discreet episodes lasting 1.5hrs total, unclear how long for each episode. She denied any palpitations at the time and states that she is unable to feel her atrial fibrillation at baseline. She presents with a detailed medical record of HR and BPs and appears that baseline HR is 50-60s, likely sinus (last [**11-22**]). In the ED, vital signs were T 101.5, BP 149/84, HR 170s irregular, O2sat 96% on RA. EMS gave 5mg IV lopressor x 2 and 325mg aspirin. In the ED, patient was given metoprolol 10mg IV x 1, metoprolol 25mg PO x 1 in ED with IVF (approx 1.5L), rate improved to 130-150 with stable BP. However, given that patient had persistent chest pain decision was to cardiovert patient. Cardioversion was successful, and patient is now in NSR 60-70s. BPs 100-110 systolic. CXR unremarkable. Vitals prior to transfer were 105/53, 60s, 19, 97% 2L. On arrival to the floor the patient is complaining of chest pain worse with movement. She no longer has any jaw, shoulder or neck pain. Breathing is improved. Past Medical History: 1) ?Sjogrens syndrome-being worked up by PCP 2) Spinal stenosis 3) Hypothyroidism on levoxyl 4) Type 2 DM 5) CAD 6) Atrial fibrillation on coumadin 7) Hypertension 8) Mitral valve regurgitation 9) Neuropathy 10) s/p R TKR 11) s/p R cataract and retinal surgery [**07**]) Arthritis 13) Asthma 14) Acne 15) CVA: [**10/2103**] with some residual stutter and left sided weakness. Social History: Social history is significant for the absence of current tobacco use. She has never smoked. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. The patient lives alone and tends to own ADLs. Wheelchair bound. Physical Exam: VS T 98.6, BP 114/76, HR 72, RR 18, O2sat 99% on 2L. Gen: WDWN elderly female 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 3-4cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles appreciated at right base, no wheezes or rhonchi. Reproducible chest wall tenderness below left breast. 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: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN II-XII intact, L sided weakness 4/5 upper and lower extremities, [**4-14**] on right. . 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: Labs on Admission: [**2104-12-2**] 09:15AM BLOOD WBC-14.4*# RBC-4.73 Hgb-14.3 Hct-39.7 MCV-84 MCH-30.1 MCHC-35.9* RDW-13.9 Plt Ct-152 [**2104-12-2**] 09:15AM BLOOD Neuts-88.0* Lymphs-7.9* Monos-3.2 Eos-0.5 Baso-0.4 [**2104-12-2**] 09:15AM BLOOD PT-32.9* PTT-39.1* INR(PT)-3.4* [**2104-12-2**] 09:15AM BLOOD Plt Ct-152 [**2104-12-2**] 09:15AM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-140 K-4.1 Cl-103 HCO3-26 AnGap-15 [**2104-12-2**] 09:15AM BLOOD ALT-28 AST-27 CK(CPK)-139 AlkPhos-84 TotBili-0.4 [**2104-12-2**] 09:15AM BLOOD Lipase-26 [**2104-12-2**] 09:15AM BLOOD CK-MB-5 proBNP-6416* [**2104-12-2**] 09:15AM BLOOD cTropnT-0.01 [**2104-12-2**] 05:20PM BLOOD CK-MB-4 cTropnT-0.01 [**2104-12-3**] 12:40AM BLOOD CK-MB-4 cTropnT-0.06* [**2104-12-3**] 09:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9 [**2104-12-2**] 09:15AM BLOOD TSH-4.0 [**2104-12-2**] 09:15AM BLOOD Digoxin-0.9 [**2104-12-2**] 10:38AM BLOOD Lactate-2.1* Studies: [**12-2**] CXR: FINDINGS: The lungs are clear with no signs of pneumonia or congestive heart failure. No pleural effusions or pneumothorax is seen. The cardiac and mediastinal contours are stable in appearance with the heart appearing top normal in size. The visualized osseous structures are stable with thoracic spondylolysis again observed. FINDINGS: No acute intrathoracic process. [**12-3**] VQ scan:INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate a small nonsegmental ventilation defect at the right base on the right posterior oblique image. Perfusion images in the same 8 views show a small matched nonsegmental defect at the right base. Perfusion is otherwise normal. Chest x-ray shows mild hydrostatic edema and patchy bibasilar opacities. IMPRESSION: Very low probability for pulmonary embolus. [**12-3**] CXR: Portable AP chest radiograph: mild increase in cardiomegaly, prominent pulmonary vasculature, perihilar haziness, Kerley B lines are all findings suggestive of increased fluid overload. Retrocardiac opacity likely represent atelectasis. [**12-5**] KUB: No evidence of bowel obstruction. [**12-5**] TTE: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 40-45%). Right ventricular chamber size is normal with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild global biventricular systolic dysfunction. Brief Hospital Course: Ms. [**Known lastname 110101**] is a 67 year old female with history of paroxysmal atrial fibrillation on coumadin, CAD, HTN, prior CVA ([**10-17**]), asthma, DM2 who awoke with acute onset of stabbing chest pain and shortness of breath on [**12-2**] and presented to ED. In the ED she was found to be in AF with RVR (ventricular rates in the 150s-160s). They attempted to treat her with beta blockers without success. Given persistent chest discomfort the decision was made to cardiovert her in the ED. She arrived to the floor in NSR. # Rhythm: History of AF on coumadin. INR on admission was 3.4. On arrival to the floor the patient was in NSR. Initially there was an unclear precipitant for AF - TSH 4.0, CXR without acute process. She was maintained on her home dose of Metoprolol 25mg [**Hospital1 **], titrated up to 50mg [**Hospital1 **] and coumadin was continued at 5mg daily. Of note, she did have some elevation in CK and troponin however this was attributed to cardioversion and not felt likely related to ischemia. However, on the morning of [**12-4**] she went back into atrial fibrillation with ventricular rates in the 150s. She was given IV metoprolol and increased doses of PO metoprolol without improvement in rate. She was then started on a diltiazem gtt, however it was later noted that this is an allergy for her. She complained of scratchy throat and was given IV benadryl and prednisone. The AM of [**12-4**] rates persisted in the 150s-160s, BP stable and pt reported no symptoms. She was started on IV amiodarone 150mg bolus followed by 1mg/min x 6 hours and 0.5mg/min for 18hours with plan for cardioversion as she was still in AF with rapid response on [**12-5**] AM. Digoxin was discontinued. An echo was ordered for evaluation of valvular abnormalities and chamber size however this was deferred on [**12-5**] due to rapid rates and therefore likely poor image quality. She developed hypotension on [**12-5**] and was transferred to the unit for closer monitoring. It was decided not to acutely cardiovert her as it was felt that her hypotension was related to an infectious source and not related to atrial fibrillation. In the ICU, beta blocker was titrated up for improved rate control. Her HR continued to range into the 130s at times, particularly with movement. Her BB was increased to 100mg tid and her amio was increased to 400mg tid. She was given a trial of verapamil 5mg IV x1 while in the ICU which she tolerated (had ? allergy to dilt) and was then started on PO verapamil. She was transferred back to the floor given she remained hemodynamically stable in the ICU. On the floor her verapamil was uptitrated to 80mg tid. She remained in afib on tele, however her rate was much better controlled at 80s-110s with activity. The patient's INR remained supratherapeutic and was 4.2 on he day of [**Month/Year (2) **]. Her coumadin was held during this time. Her elevated INR was felt to be [**1-12**] antibiotic and poor nutrition. Her INR should be monitored on [**Month/Day (2) **] and her coumadin can be restarted when her INR is < 2.5. She had no evidence of bleeding during her stay. Her amiodarone will need to be tapered. She should continue on 400mg [**Hospital1 **] for a week, then this should be decreased to 400mg daily. She will follow up with her cardiologist in 2 weeks. # Hypotension: On the morning of [**12-5**] the patient became hypotensive with SBPs in the 70s and HR remained stable in the 110s-140s range. She received 1L IVF with improvement in her BP to 90s which then drifted down to the 80s. Although she was febrile on presentation to the ED, she has had only low grade temps on the floor to 100.4. WBC count had risen to 21K. Urine culture from [**12-2**] showed 1000 enterococcus. Blood cultures were neg. CXR from [**12-3**] shows volume overload but no infiltrate, however levofloxacin was started on [**12-3**] out of concern for new O2 requirement (had been on 3L NC since admission). In the setting of her new O2 requirement, V/Q scan was performed which showed low prob for PE, also INR has been therapeutic-supratherapeutic since presentation. Lactate was mildly elevated to 2.1. She was transferred to the ICU, however she did not require pressors and her BP quickly stabilized. Etiology was felt to be multifactorial with increasing beta-blockade, tachyarrythmia and infection contributing. She was also amio loaded which may have contributed as well. All blood cx neg. thus far. CXR was concerning for LLL and right middle lobe opacification concerning for pneumonia; ? aspiration during cardioversion. She was treated with levofloaxacin for a 10 day course and is currently day 9. During time of ICU transfer the patient was complaining of RUQ pain, however LFTs were normal and KUB was negative for obstruction. Her BP has remained stable with systolics in 100-110 range since tranfer to the floor. # Coronaries: Patient with history of CAD per medical records but no documentation of prior stress or cath. She presented with chest pain on admission which was initially attributed to atrial fibrillation. She was continued on aspirin. She triggered on [**12-3**] for [**8-20**] acute onset crushing chest pain. ECG was unchanged. A VQ scan was ordered for ? PE and was very low probability. Enzymes were borderline and likely related to DCCV. Plan was for pMIBI for evaluation of ischemia as etiology however this was also deferred given rapid rates. Exam also notable for reproducible chest wall tenderness s/p cardioversion. # Pump: EF normal in [**2102**] however with elevated BNP and O2 requirement on presentation. Likely volume overloaded and was given IV lasix on [**12-3**] with good output. She had a repeat TTE on [**12-5**] which showed decreased EF of 45%. She appeared euvolemic and did not require additional diuresis. her home dose of lasix was held while in the hospital and can be restarted as an outpatient as needed. # Pneumonia: Patient had a temperature of 101.5 in the ED with elevated WBC count. Blood and urine cultures obtained were without growth. LFTs within normal limits on admission. She was treated with Levofloxacin empirically for PNA for fever and O2 requirement. She has remained afebrile since the day of admission. # Musculoskeletal chest pain: The patient developed reproducible chest pain during admission that initially involved the left and right chest and was aggravated with motion and palpation. It was not thought to be related to cardiac ischemia, given its positional qualities and the absence of EKG changes or cardiac enzyme elevation. The left sided chest pain gradually resolved and the patient's right sided chest pain was still present on the day of [**Month/Year (2) **] but improving. # Folliculitis and right wrist thrombophlebitis with overlying cellulitis: Patient was found to have small, pustular lesions on the right side of her back that were initially concerning for zoster. She was started on acyclovir but this was discontinued as her lesions were not felt to be consistent with zoster. She was then treated with vancomycin for presumed folliculitis. Vancomycin was discontinued because MRSA was not a concern and she was transitioned to cephalexin. She will complete a five day course of antibiotics. Cephalexin is also being used to treat overlying cellulitis in the patient's left wrist, which developed after thrombophlebitis from peripheral IV insertion. # Diabetes mellitus type 2: Patient's oral hypoglycemics were held and she was maintained on an insulin sliding scale and a diabetic diet. Her oral hypoglycemics can be restarted at rehabilitation. Of note, she should be on an angiotensin receptor blocker but is not currently (allergy to lisinopril). Initiation of this is deferred to the outpatient setting. # Hypertension: Patient had episodes of hypotension, as described above. She remains on metoprolol and verapamil. # Asthma: Patient was continued on advair and nebs prn. # CVA: Patient has a history of CVA but had a stable neuro exam, with chronic left-sided weakness. # Hypothyroidism: Patient was continued on levoxyl and had a TSH of 4.0. Medications on Admission: Glipizide 5mg daily Advair diskus 250/50 1 puff [**Hospital1 **] Lanoxin 0.25mg tablets daily Lasix 20mg daily Hydroxyzine PRN Metoprolol 25mg [**Hospital1 **] Aspirin 81mg daily Levoxyl 50mcg daily Vitamin D daily Omeprazole 20mg [**Hospital1 **] Colace 100mg [**Hospital1 **] Tylenol PRN Coumadin 5mg on Tu/Th, 6mg on MWF Sertraline 50mg daily Flonase 1 spray NU daily [**Hospital1 **] Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] [**Location (un) **] Diagnosis: Primary: Atrial fibrillation with rapid ventricular response Pneumonia Thrombophlebitis Musculoskeletal chest pain Secondary: Hypertension Diabetes Hypothyroidism [**Location (un) **] Condition: Good [**Location (un) **] Instructions: You were admitted because of chest pain. We diagnosed you with atrial fibrillation and a rapid heart rate. To treat you for this, we shocked your heart, which was only briefly successful, and then started you on medications to control your heart rate. We also diagnosed you with pneumonia and an infection of your skin, for which we treated you with antibiotics. You were started on two new medications to help control your heart rate, amiodarone and verapamil. The amiodarone will be tapered by your doctors [**First Name (Titles) **] [**Last Name (Titles) **]. 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: Scheduled Appointments : Provider [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2104-12-19**] 10:45 Provider [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2104-12-24**] 2:20 Provider [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], [**Name Initial (PRE) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-1-7**] 8:30 Test for consideration post-[**Month/Day/Year **]: Tryptase Completed by:[**2104-12-10**]

[ "250.00", "707.05", "427.31", "707.22", "414.01", "244.9", "424.0", "401.9", "041.04", "493.90", "410.81", "599.0", "451.84", "V58.61", "486", "704.8", "427.1" ]

icd9cm

[ [ [] ] ]

[ "99.61", "88.72" ]

icd9pcs

[ [ [] ] ]

6695, 14877

493, 514

3677, 3682

16508, 17078

2470, 2617

14903, 15276

2632, 3658

15423, 15589

434, 455

15621, 15628

15306, 15391

15663, 16485

542, 1906

3696, 6672

1928, 2306

2322, 2454

77,804

102,018

6652

Discharge summary

report

Admission Date: [**2102-6-16**] Discharge Date: [**2102-6-24**] Date of Birth: [**2055-9-8**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESLD in need of liver transplant Major Surgical or Invasive Procedure: [**2102-6-16**]: Orthotopic liver transplant History of Present Illness: 46y man with liver failure secondary to HCV and alcoholic cirrhosis, portal hypertension, and HCC who presents for liver transplant. He has been feeling well and denies fever, chills, abdominal pain, shortness of breath, or chest pain. Past Medical History: Cirrhosis [**3-20**] HCV/EtOH dx [**2095**] s/p failed pef-interferon tx for HCV h/o variceal hemorrhage [**5-21**] Social History: former EtOH - dry x 4 years, h/o IVDU but currently clean Family History: NC Physical Exam: VS: 99.2 78 122/69 20 98%RA Wt 87.8KG Gen: NAD Heart: regular, S1 S2 Lungs: CTA B/L, no wheeze or rales Abd: soft, mild tenderness at umbilical hernia, non-distended, bowel sounds present Extr: warm, well perfused, no edema Pertinent Results: On Admission: [**2102-6-16**] WBC-4.4# RBC-4.45* Hgb-14.6 Hct-42.3 MCV-95 MCH-32.8* MCHC-34.6 RDW-14.8 Plt Ct-46* Glucose-94 UreaN-13 Creat-0.9 Na-135 K-3.7 Cl-101 HCO3-26 AnGap-12 PT-25.5* PTT-39.4* INR(PT)-2.5* Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-1.7 Brief Hospital Course: 46 y/o male admitted for liver transplant. The donor liver was from a 33-year-old 110 pound woman who died from a combination of an asthma attack and snorting heroin. The patient was made aware of the nature of the donor death. Hepatitis C and HIV testing were negative. The patient was taken to the OR on [**2102-6-17**] by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for liver transplant. He received induction immunosuppression consisting of Cellcept and Solumedrol. Significant portal hypertension was noted, and the liver was found to be quite adherent. Prior to surgery the patient was on coumadin for portal vein thrombus. At time of surgery there seemed to be a small clot in the portal vein, however, the vein itself was open. Once opened it appeared to be a cavernous transformation of the vein and there was an excellent flow. The liver pinked up immediately and made bile on the table. The patient tolerated the procedure well and was transferred to the SICU, intubated. He was extubated on postop day 1, and transferred out of the SICU on postop day 2. Prograf was initiated on POD 1, steroid taper continued and cellcept [**Hospital1 **] without notable side effect. Urine output was appropriate and foley was removed without incident. JP drains outputs averaged 1-2 Liters total daily requiring IV fluid replacements. JP drain bilirubins were 1.5 and 1.8. JP drainge decreased allowing for removal of the lateral drain was d/c'd on POD 6. He was seen and cleared by PT, ambulating without difficulty. He had return of bowel function and was tolerating diet without any issues. [**Last Name (un) **] was consulted for hyperglycemia. NPH (10 units)was addded in addition to sliding scale humalog insulin with improved glucose control. He received instructioin on glucose management and self administration. He was discharged to home in stable condition. Medications on Admission: Lasix 40 mg once a day, lactulose titrated to [**4-19**] bowel movements per day, nadolol 20 mg once a day, Protonix 40 mg 1 twice a day, Aldactone 100 mg once a day, Carafate 10 cc by mouth 4 times a day, Coumadin as directed (2.5 daily Discharge Medications: 1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day: AM Dose. Disp:*2 bottles* Refills:*2* 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper. 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times 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. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) as needed for s/p liver transplant. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day: at breakfast. Disp:*1 vial* Refills:*2* 12. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day. Disp:*1 vial* Refills:*2* 13. One Touch Ultra System Kit Kit Sig: One (1) Miscellaneous four times a day. Disp:*1 kit* Refills:*2* 14. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* 15. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: liver failure secondary to HCV and alcoholic cirrhosis, portal hypertension now s/p orthotopic liver transplant Discharge Condition: Stable/good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you fever greater than 101, chills, nausea, vomiting, diarrhea, constipation. Monitor the incision for redness, drainage or bleeding Drain and record JP drain output as often as needed. Do not allow the bulb to become more than half full. Bring a copy of the drain outputs to your clinic visit. Labs to be drawn every Monday and Thursday. Fax results to transplant clinic at [**Telephone/Fax (1) 673**]. No heavy living You may shower, allow water to run over incision, pat incision dry. PLace new drain sponge following your shower or daily. No driving if taking narcotic pain medication Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-6-29**] 8:30 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-7-6**] 9:30 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2102-7-6**] 10:30 Completed by:[**2102-6-27**]

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Discharge summary

report

Admission Date: [**2128-7-27**] Discharge Date: [**2128-8-4**] Date of Birth: [**2085-9-29**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2518**] Chief Complaint: transfer from OSH for R pontine hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 42yo man with PMH significant for hypertension, right eye enculeation, h/o traumatic brain injury with resultant memory loss, presents as a transfer from [**Hospital3 **] with a right pontine hemorrhage on head CT. History is per the patient and the OSH notes, but is limited as he cannot hear much and is illiterate. He reports being at the bar (where he or his girlfriend works?) and after taking a smoking break, he walked back inside; while walking, maybe carrying trays, he had acute onset of left hemisensory loss, facial droop, weakness, dysarthria, and deafness. He presented to [**Hospital6 **], where he was found to have a 12x16mm pontine hemorrhage just to the right of midline. BP at presentation was 190/110; he received labetolol 10mg x 1 and zofran 2mg x 1 and was transferred to [**Hospital1 18**] ED. Here, his BP was 209/128. Neurosurgery was consulted. He was started on a labetolol gtt. Notably, he had presented to [**Hospital6 **] on [**7-20**] with headache; at that time he had a normal head CT. He reported to the OSH drinking 2 alcoholic drinks today and using marijuana. Past Medical History: hypertension TBI in [**2110**] with residual memory loss deficits GSW to the chest right eye enucleation Social History: +tobacco, EtOH, marijuana, unsure about other drugs Family History: Unknown Physical Exam: VS: T 99.9, BP 209/128, HR 74, RR 17, SaO2 98%/2L Genl: sitting in bed, coughing up thick phlegm, speaking very loudly HEENT: NCAT other than old right eye enucleation, dry MM Chest: CTA bilaterally CV: RRR, nl S1, S2, no m/r/g appreciated Abd: soft, NTND, BS+ Ext: warm and dry Neurologic examination: Examination limited by pt's inability to hear and illiteracy preventing writing as a form of communication. Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person and year, unable to communicate further orientation questions. Seems grossly attentive. Speech is fluent with normal comprehension; naming intact. +dysarthria. Cranial Nerves: Unable to appreciate L fundus due to pupillary constriction. Left pupil round and reactive to light, 2 to 1.5mm. Visual fields were not tested; blinks to threat. Unable to adduct left eye, with abduction on upgaze as well. Left beating nystagmus at rest. Sensation decreased on left V1-V3. Facial movement decreased on left. Hearing severely diminished bilaterally - cannot hear in left ear and have to shout into right hear. Palate elevation symmetric but seems somewhat decreased. Sternocleidomastoid and trapezius full strength bilaterally. Tongue appears midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. Left drift downwards. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5- 5 5 5 4+ 5 4 5 5 5 5 5 ?slight weakness of other left-sided muscles, but mostly incoordination - he is able to give good strength briefly with repeated testing. Sensation: Decreased to light touch and pinprick in left arm, absent in left leg. Unable to test vibration, proprioception, and cold sensation. Reflexes: Hyperreflexic on right. Right toe downgoing, left toe mute. Coordination: finger-nose-finger, fine finger movements, and [**Doctor First Name **] significantly dysmetric on the left. Gait: not tested Pertinent Results: [**2128-8-3**] 06:30AM BLOOD WBC-10.2 RBC-4.39* Hgb-14.9 Hct-43.0 MCV-98 MCH-33.9* MCHC-34.7 RDW-13.4 Plt Ct-247 [**2128-7-27**] 03:12PM BLOOD WBC-14.9* RBC-4.63 Hgb-15.7 Hct-43.7 MCV-94 MCH-33.8* MCHC-35.8* RDW-14.0 Plt Ct-195 [**2128-8-3**] 06:30AM BLOOD Plt Ct-247 [**2128-8-3**] 06:30AM BLOOD Glucose-109* UreaN-23* Creat-1.0 Na-138 K-4.2 Cl-100 HCO3-29 AnGap-13 [**2128-7-27**] 03:12PM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-24 AnGap-15 [**2128-7-27**] 03:12PM BLOOD ALT-23 AST-22 LD(LDH)-193 AlkPhos-72 Amylase-69 TotBili-0.4 [**2128-7-27**] 03:12PM BLOOD Lipase-33 [**2128-7-29**] 02:50AM BLOOD CK-MB-3 cTropnT-<0.01 [**2128-7-27**] 03:12PM BLOOD cTropnT-<0.01 [**2128-8-3**] 06:30AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.3 [**2128-7-27**] 03:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2128-7-29**] 03:01AM BLOOD Type-ART pO2-100 pCO2-42 pH-7.44 calTCO2-29 Base XS-3 Brief Hospital Course: Mr. [**Known lastname 11041**] is a 42-year-old man with a h/o HTN who presented with tingling, diminished hearing, and difficulty speaking and who was found to have a right pontine hemorrhage. His mechanism was felt to be secondary to HTN as he was found to be very hypertensive in the ED. He was admitted to the ICU for monitoring. During his course he remained hypertensive and required PRN medications to keep the MAP <130. He was also started on Mannitol to prevent intracranial edema. He was transfered to the step down for further treatment and monitoring. There he was also gradually titrated off Mannitol w/o complications. He remained hypertensive therefore Metoprolol, Lisinopril and later HCTZ were started for treatment. The 3 drug regimen was effective in lowering his BP to SPB of 120's. During episodes of exertion his SBP became elevated and was a limiting factor for his ability to participate in PT/OT. His goal SPB is < 140 at rest and <160 during exertion. Mr. [**Known lastname 48504**] hearing gradually improved however he remained dysarthric and ataxic. On discharge he had persistent dysarthria; R eye was unable to adduct past the midline. He had improved but persistent decreased hearing; ataxia on L; L pronator drift; decreased sensation on L face; arm and leg; non-sustained clonus in bilateral LE. Given the fact that blood was obscuring the pons during the initial MRI/MRA, he should undergo a followup vascular imaging study at approximately 6 weeks after the event to rule out an underlying malformation. [**7-27**] HCT IMPRESSION: Right pontine hemorrhage; old studies not available to assess for interval change.down for further care where he underwent evaluation with [**7-27**] X-ray Skull: IMPRESSION: No radiopaque foreign bodies. Unremarkable x-rays. [**7-28**] HCT IMPRESSION: Perhaps slight increase in transverse measurement of previously identified right pontine hemorrhage as described above. [**7-29**] MRI/MRA IMPRESSION: 1. No evidence of AV malformation within the region of the right pontine hemorrhage or elsewhere throughout the visualized portions of the brain and neck. 2. Scattered white matter T2 hyperintensities, most likely consistent with chronic small vessel infarction given the patient's history of hypertension/tobacco abuse. 3. Attenuated segments of the distal right posterior cerebral artery as well as in the ascending frontal branch of the left middle cerebral artery. These findings may be artifactual as they are on the edge of the field of view. However, given the patient's presenting symptoms and history, atherosclerotic stenoses need to be considered. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Stroke Hypertension Dysarthria Ataxia R eye blindness abnormal gait Sensory loss Discharge Condition: Stable: Persistent dysarthria; R eye unable to adduct past the midline Improved but persistent decreased hearing; ataxia on L; L pronator drift; decreased sensation on L face; arm and leg; non-sustained clonus in bilateral LE Discharge Instructions: Please keep all scheduled appointments and take all medications as prescribed. . . PLEASE MAINTAIN A SBP <140 AT REST AND <160 WITH EXERTION Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2128-9-6**] 4:30 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-8-25**] 4:40 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

[ "V45.78", "401.9", "434.91", "303.01", "305.21" ]

icd9cm

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icd9pcs

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41663

Discharge summary

report

Admission Date: [**2148-10-11**] Discharge Date: [**2148-10-15**] Date of Birth: [**2086-5-2**] Sex: F Service: MEDICINE Allergies: ibuprofen / lisinopril / hydrochlorothiazide Attending:[**First Name3 (LF) 602**] Chief Complaint: presyncope, palpitations Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 406**] is a 62 y/o F with recently diagnosed pancreatic adenocarcinoma (last dose of chemo three days ago) as well as Htn, T2DM, who presented to the ED from her oncologist's office with postural palpitiations and lightheadedness since this morning. Her HR as recorded from her clinic note was 153 bpm. She has no history of any tachycardias in the past. She had chills last evening, but no other localizing infectious symptoms. Denies cough, dyspnea, dysuria/polyuria, abdominal pain, diarrhea, nausea/vomiting, or neck stiffness. She has bilateral calf edema that is stable. Her oncologist checked outpatient labs, which showed hematocrit 25, leukocytosis of 18, and glucose > 300. In the oncologist's office, a peripheral IV was placed and NS infusion was started, then discontinued on transfer to [**Hospital1 18**] ED. . In the ED inital vitals were 97.5, 150, 103/63, 16, 100% on room air. Exam notable for normal mentation, sinus tachycardia and symmetric bilateral calf edema. Labs revealed elevated WBC count with left shift but no bandemia, stably low hct, mildly elevated creatinine to 1.1 and bicarbonate of 19. Troponin was negative and BNP was > 4000. She was given 2L NS for BP support. ECG was initially thought to be sinus tachycardia, but repeat ECG was c/w atrial flutter with 2:1 conduction. Cardiology was consulted for possible cardioversion, but her HR converted to sinus rhythm with 20 mg IV and 30 mg PO diltiazem. She was also given 325 mg aspirin and 8 units humalog. . CXR x2 showed pulmonary edema, and CTA showed no PE but +small airways disease or atelectasis; note made of stale pancreatic mass and diverticulosis. She developed hypoxia to the high 80s, and was placed on Bipap. Given pulmonary edema and need for Bipap, she was given 20 mg IV furosemide; O2 sats improved to 97% on 4L NC. Bedside cardiac ultrasound showed a non-circumferential pericardial effusion, and "good squeeze." She was also given vancomycin and cefepime out of concern for septic etiology for hypotension and tachycardia. She had two 18 gauge PIV's and foley catheter placed. Prior to transfer to the ICU, her vitals were 88, 105/69, 18 97% on 4L NC. She had no fevers in the ED. . On the floor, the patient reports feeling tired and weak, but denies any dyspnea, chest pain, palpitations, fevers, chills, sweats, or abdominal pain. . Review of systems: (+) Per HPI (-) Denies recent weight loss or gain, headache, rhinorrhea or congestion, cough, wheezing, nausea, vomiting, diarrhea, constipation, arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Locally advanced pancreatic adenocarcinoma - s/p 2 cycles of gemcitabine (started on [**2148-9-3**], last dose was on [**10-8**] - C2D8 Gemzar), plans for radiation -Type 2Diabetes - requiring insulin -PVD -HTN -Neuropathy -Hip pain and Discomfort -Sciatica -Herniated disk -Hysterectomy -spinal surgery -back surgery -subclavian bypass for subclavian stenosis syndrome Social History: Lives in [**Location 1468**] with her husband and son. She is a retired medical coder. Currently smokes 1 ppd for the past 40 years. No alcohol or illicits. Family History: A sister had breast cancer with metastasis to the brain. Another sister had breast cancer. An uncle with [**Name2 (NI) 500**] cancer and aunt with lung cancer. Sister has atrial fibrillation, and mother had CHF. Physical Exam: PE on Admission: Vitals: T:98.5 BP:143/66 P:95 R:21 O2:92% 4L General: Well nourished adult female appears fatigued but alert, oriented, no acute distress. HEENT: No conjunctival icterus/injection/pallor. OP clear, face symmetric, MMM Neck: JVP @ 8 cm H20. Supple, no LAD Lungs: Mild crackles at bilateral bases, no wheezes, rhonchi CV: RRR, normal S1/S2, no M/R/G Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley catheter in place Ext: Symmetric 1+ edema to mid shins, bilaterally. No cyanosis or clubbing. Symmetric 2+ PT/DP/radial pulses bilaterally Neuro: AAOx3, speech fluent, thought process clear. [**4-25**] strength upper/lower extremities, proximally and distally. Sensation to light touch grossly intact throughout. Discharge Exam: VS: Tm 99.2 Tc HR 80s-90s BP 140-170s/70-80s RR 18-20 SaO2 98% RA I/O last 8h: [**Telephone/Fax (1) 90566**] Last 24 1000/350+ GENERAL: [x] NAD [] Uncomfortable Eyes: [x] anicteric [] PERRL ENT: [x] MMM [] Oropharynx clear [] Hard of hearing NECK: [] No LAD [x] JVP: 6cm CVS: [x] RRR [x] loud s1 s2 [x] no MRG [x] no edema LUNGS: [x] No rales [x] No wheeze [x] comfortable. ABDOMEN: [x] Soft [x]nontender [x]bowel sounds present []No hepatosplenomegaly SKIN: [x]No rashes [x]warm [x]dry [] decubitus ulcers: LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [x] Oriented x3 [x] Fluent speech Psych: [x] Alert [x] Calm [x] Mood/Affect: appropriate Pertinent Results: Labs on Admission: [**2148-10-11**] 02:25PM WBC-16.5*# RBC-2.95* HGB-8.5* HCT-25.9* MCV-88 MCH-28.9 MCHC-33.0 RDW-16.7* [**2148-10-11**] 02:25PM NEUTS-91.9* LYMPHS-6.6* MONOS-0.3* EOS-1.0 BASOS-0.2 [**2148-10-11**] 02:25PM PT-12.9 PTT-25.6 INR(PT)-1.1 [**2148-10-11**] 02:25PM proBNP-4309* [**2148-10-11**] 02:25PM cTropnT-<0.01 [**2148-10-11**] 02:25PM GLUCOSE-254* UREA N-29* CREAT-1.1 SODIUM-134 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-20 [**2148-10-11**] 02:39PM GLUCOSE-233* LACTATE-3.3* K+-4.4 [**2148-10-11**] 04:04PM LACTATE-2.8* Notable studies [**2148-10-11**] 02:25PM BLOOD proBNP-4309* Microbiology: [**2148-10-12**] URINE URINE CULTURE-FINAL INPATIENT [**2148-10-11**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2148-10-11**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Reports: [**2148-10-11**] Radiology CTA CHEST W&W/O C&RECON and CT ABD & PELVIS WITH CO 1. No pulmonary embolism. 2. Pulmonary edema with small bilateral effusions and atelectasis. 3. Coronary artery disease with small pericardial effusion. 4. Stable appearance to pancreatic mass. Fullness of the left adrenal gland suspicious for metastasis. 5. Extensive atherosclerotic disease of the abdominal aorta with diminished flow within the left external iliac artery. 6. Sigmoid diverticulosis without diverticulitis. [**2148-10-11**] Radiology CHEST (PORTABLE AP) No significant interval change from study obtained two hours previously. Continued mild pulmonary edema and bibasilar atelectasis. [**2148-10-11**] Radiology CHEST (PA & LAT) Cardiogenic pulmonary edema. Recommend repeat radiography after appropriate diuresis to assess for underlying infection. [**10-15**] Echocardiogram: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Increased PCWP. Small circumferential pericardial effusion. Mild PA systolic hypertension. Labs on Discharge: [**2148-10-15**] 06:00AM BLOOD WBC-14.2* RBC-3.17* Hgb-9.7* Hct-27.6* MCV-87 MCH-30.6 MCHC-35.2* RDW-16.4* Plt Ct-150 [**2148-10-15**] 06:00AM BLOOD Glucose-132* UreaN-24* Creat-1.1 Na-139 K-3.8 Cl-102 HCO3-24 AnGap-17 Studies Pendig on Discharge: None Brief Hospital Course: 62 yo F with locally advanced pancreatic cancer undergoing gemcitabine chemotherapy admitted with rapid atrial flutter and pulmonary edema. #Acute diastolic heart failure: Patient developed pulmonary edema and was initially admitted to the ICU. She received BIPAP and IV diuresis with improvement in symptoms. It is unclear the exact cause of heart faiulre but was likely due to rapid atrial flutter and exacerbated by 2L NS she received in the emergency department for an initial concern for sepsis. Her echocardiogram showed mild LVH with EF>65% and no focal WMA and mildly elevated PASP. Given her rapid improvement and that her probable inciting factor was corrected prior to discharge she was not discharged on maintenance diuretic therapy. The patient was instructed to call her doctor if she experienced weight gain at which time maintenance diuretic regimen could be discussed. #Atrial flutter: Patient presented with atrial flutter with ventricular rate at 150bpm. Patient was treated with Diltiazem with reduction in heart rates and return to sinus rhythm with PACs. Diltiazem was uptitrated with good control of heart rates and she was discharged to continue Diltiazem. On discharge patient had HR ~110 with stable blood pressure and without symptoms during ambulation with physical therapy. Given the rapid return to sinus rhythm and symptomatic palpitations with her atrial flutter, the decision was made after discussion with oncology to hold off on initiation of Coumadin, but re-consider if she has recurrence of her symptoms. Patient was discharged on long acting Diltiazem. #Locally advanced pancreatic cancer: Patient had an abdominal CT which showed stable pancreatic mass, but new fullness of the left adrenal potentially consistent with adrenal metastasis. The patient's covering Oncologist was made aware of this finding and this will be addressed by the patient's primary Oncologist following discharge as overall tumor markers are falling with chemotherapy. #Diabetes 2, controlled without complications: Patient was continued on her home dose Lantus insulin with sliding scale insulin. Metformin was held during hospitalization as she received IV contrast as part of a PE protocol CT. Metformin was held on discharge given the recent CTA until her PCP appointment and recheck of BUN/Cr to make sure stable as she had good blood sugar control off metformin in house. #Disposition: Home with PCP and Oncology followup of atrial flutter, heart rate, blood pressure, heart failure, and anemia. Medications on Admission: From last discharge summary (updated more recently than OMR) 1. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for anxiety: 1 tab every morning PRN panic attacks, two tab at bedtime . 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Zofran 8 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 13. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 14. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: Per sliding scale Subcutaneous four times a day: Breakfast, lunch, dinner, bedtime. [**Month/Day/Year **]:*1 bottle* Refills:*2* Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO once a day. 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 5. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for anxiety: 1 tab in the evening prn for panic attacks and 2 at bedtime. 6. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 7. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for back pain. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty (30) units Subcutaneous at bedtime. 11. Humalog 100 unit/mL Solution Sig: as directed units Subcutaneous breakfast, lunch, and dinner: per sliding scale. 12. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 14. Medication Changes ADDITIONS: CHANGES: 1) Please do not take your metformin until you have seen your PCP to make sure that your kidney function remains normal 15. diltiazem HCl 180 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO once a day: If you feel dizzy or lightheaded while taking this medication, please call your doctor. [**Last Name (Titles) **]:*60 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atrial flutter Heart failure/pulmonary edema Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of an abnormal heart rhythm (atrial flutter) and a fast heart rate, which was likely the cause of your lightheadedness and palpitations. You were also found to have heart failure as a result of your high heart rate. You were admitted to the intensive care unit and given diuretic medications and your heart rate was reduced with a medication called Diltiazem. You should continue to take Diltiazem as directed upon discharge. Also, please monitor your weight daily and if you note an increase in your weight by more than 3 lbs over a [**1-25**] day period, please call your PCP as this may be a sign of increased fluid that can be treated with diuretics. Also, please call your doctor if you experience recurrence of palpitations, dizziness, lightheadedness, or feel as if you are going to pass out. You should also follow up with your doctors as noted below. Followup Instructions: Please follow up with your Oncologist as previously scheduled. Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31017**], MD Specialty: Internal Medicine Location: [**Location (un) 2274**]-[**Location (un) **] Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**] Phone: [**Telephone/Fax (1) 31019**] We are working on a follow up appointment for you to see Dr. [**Last Name (STitle) **] within 1 week of your discharge from the hospital. You will be called at home with the appointment. If you have not heard within 2 business days, please call the number above.

[ "250.02", "356.9", "428.0", "198.7", "427.32", "276.51", "428.31", "285.9", "276.2", "157.0", "V58.67", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13326, 13332

7594, 10116

330, 337

13428, 13428

5311, 5316

14493, 15124

3556, 3771

11594, 13303

13353, 13407

10142, 11571

13579, 14470

3786, 3789

4612, 5292

7565, 7571

2766, 2970

266, 292

7316, 7551

365, 2747

5331, 7296

13443, 13555

2992, 3365

3381, 3540

25,225

156,702

3956

Discharge summary

report

Admission Date: [**2178-4-2**] Discharge Date: [**2178-4-10**] Date of Birth: [**2147-8-13**] Sex: F Service: SURGERY Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[**First Name3 (LF) 695**] Chief Complaint: Fever Major Surgical or Invasive Procedure: [**2178-4-2**] RUE AVG excision History of Present Illness: 30-year-old woman with previous hemodialysis access graft which had been revised. The graft Has become exposed and infected and she is now febrile to 104, the decision has been made to remove it. Past Medical History: - SLE diagnosed [**2166**] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - h/o MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [**2166**]. In [**2173**], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [**8-/2175**] complicated by rejection and capsule rupture 11/[**2174**]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [**2177-6-24**]. Complicated by wound./Hardware infection requiring BKA [**2177-11-21**] -[**2178-4-2**] RUE AVG excision Social History: No smoking, occasional alcohol, no drug use. Originally from [**Country **], now lives in [**Location 2268**]. Used to work at [**Hospital1 18**]. Family History: Noncontributory Physical Exam: In the SICU: T: 97.6 P: 93 R: 19 BP: 104/62 General: Intubated HEENT: MMM, neck supple, no LAD Card: Regular, S1 S2 only with II/VI systolic murmur to axilla Lungs: Few basilar crackles bilaterally Gastrointestinal: Soft, NT, ND Musculoskeletal: BKA of right lower extremity Skin: No generalized rashes. Extr: Right arm with dressing in place, no edema noted Pertinent Results: On Admission: [**2178-4-2**] WBC-9.1 RBC-3.06* Hgb-8.7* Hct-26.6* MCV-87 MCH-28.4 MCHC-32.8 RDW-20.7* Plt Ct-121* PT-18.0* PTT-92.5* INR(PT)-1.6* Glucose-99 UreaN-13 Creat-5.0*# Na-138 K-4.3 Cl-100 HCO3-28 AnGap-14 Calcium-8.8 Phos-3.0 Mg-1.7 On Discharge: [**2178-4-9**] WBC-6.9 RBC-3.19* Hgb-8.8* Hct-27.7* MCV-87 MCH-27.8 MCHC-31.9 RDW-19.8* Plt Ct-150 Glucose-84 UreaN-12 Creat-5.2*# Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 Albumin-2.6* Calcium-8.8 Phos-3.2 Mg-1.8 [**2178-4-8**] %HbA1c-5.0 Brief Hospital Course: Temperature was 104 in the ED. She was taken to the OR for excision of the exposed RUE AVG that was infected. Postop, she was sent to the SICU for pressor support for hypotension, temperature of 105 and CVVHD. She continued to be febrile and was pan cultured. R tunneled dialysis catheter was removed and tip sent for Cx. The exposed graft from [**4-2**] grew MRSA. IV vanco and gent were started. Blood cultures and tunnelled line tip (Present at time of admission) were negative. Blood cultures sent from her HD unit prior to admit grew methicillin sensitive staph aureus. Subsequent cultures were sent and have been negative to date. ID was consulted and a TTE was recommended for persistent fevers. The TTE showed moderate mitral annular calcification with probable small, calcified vegetation/mass on the posterior leaflet of the mitral valve. Preserved biventricular systolic function. Moderate tricuspid regurgitation. A TEE was then done confirming moderate-sized vegetation on the posterior leaflet of the mitral valve. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Depressed right ventricular function. EF was >55%. Cardiac surgery recommended medical treatment with antibiotics with follow up serial cardiac echo as an outpatient in conjunction with a cardiac consult. EKG on [**4-8**] showed sinus rhythm with lateral T wave abnormalities ,atrial premature complex and Left atrial abnormality with prolonged Q-Tc interval. These findings were nonspecific. SBP continued to be on the low side in the 90's. HR ranged between 70-80. She experienced sob with ambulation requiring 1 liter/NC while ambulating otherwise, she did not complain of cp/sob/palpitations. A left groin temporary hemodialysis line was initially placed. A right femoral vein tunnelled HD line (55-cm cuff-to-tip 14.5 French double lumen)was placed on [**4-6**] after she was afebrile x 48 hours. The tip of the catheter was in the right atrium. The left temporary line was removed. This was used without problems on [**4-9**]. [**Name2 (NI) **] usual HD schedule was to continue on Tues-Th-Sat. ID recommended vancomycin per HD protocol x 6wks (stop [**2178-5-14**]) and Gentamicin dosed per HD using dose of gent of 80 mg IV for a trough of less than two; goal peaks would be in the range of [**3-14**]. Recommended goal vancomycin troughs are 15-17. Discontinuation of gent could occur whith clearance of blood cultures. Care Group VNA (1-[**Telephone/Fax (1) 14297**]) was set up for right upper arm graft excision site. The incision appeared clean. Wicks were removed and no futher packing was required. She did complain of right hand pain and numbness. Radial pulse was strong (2+). Hand felt warm and there was no edema. PT and OT were consulted recommending continuation of home PT/OT. The plan was for a f/u echo and close f/u with cardiology (Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4022**]) in 2 weeks. She did not need to f/u with CT surgery unless cardiology felt that this was indicated. Medications on Admission: Amitryptilline 100 hs, Calcitriol 0.25', Epogen 10,000 units at HD, Fentanyl Patch 75 q72 hrs, Folic Acid 1', Hydromorphone 4-8mg q4-6 prn, Omeprazole 40', Percocet 5/325 [**12-10**] prn, Prednisone 5', Renagel 800''', Tizanidine 2''', Tylenol PRN, Aspirin 81', B complex vitamin, Bisacodyl 5mg 2tabs daily prn, Colace 100'', Senna 8.6'' PRN, ibuprofen 600 PRN, Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 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). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 15 doses: Give at hemodialysis through [**2178-5-14**] for endocarditis. Disp:*15 * Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Epogen at hemodialysis 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*0* 14. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: infected RUE AV graft, MRSA Endocarditis (Mitral valve vegetation) esrd on hemodialysis Discharge Condition: good Discharge Instructions: Please call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fever > 101, chills, shortness of breath, chest pain, right arm has increased swelling, redness/bleeding/drainage or increased numbness/altered sensation Visiting Nurse arranged for right arm dressing changes twice daily. PT/OT ordered as well Resume usual hemodialysis schedule. IV vancomycin to be given at hemodialysis through [**2178-5-14**] per Infectious disease recommendations. Cardiology to follow. They will schedule follow-up ECHO prior to clinic visit. PLease call [**Telephone/Fax (1) 4022**] with questions or concerns. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-4-13**] 11:40 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-4-13**] 1:00 [**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2178-4-13**] 1:30 [**Hospital 17547**] Clinic ([**Telephone/Fax (1) 7236**] ([**Hospital Ward Name 23**] building, [**Hospital Ward Name **]) [**2178-4-22**] at 1:40 [**Doctor Last Name **]-CC7 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] CC7 CARDIOLOGY (SB) They will schedule ECHO prior to appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2178-4-14**]

[ "E878.2", "458.29", "V42.0", "287.31", "582.81", "790.7", "585.6", "998.32", "397.0", "518.89", "V45.89", "285.9", "V49.75", "282.5", "996.62", "041.11", "421.0", "710.0", "401.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.43", "39.95", "96.04", "88.72" ]

icd9pcs

[ [ [] ] ]

7379, 7437

2550, 5571

346, 380

7569, 7576

2034, 2034

8233, 9056

1621, 1638

5986, 7356

7458, 7548

5597, 5963

7600, 8210

1653, 2015

2291, 2527

301, 308

408, 606

2048, 2277

628, 1440

1456, 1605

27,362

172,544

33062

Discharge summary

report

Admission Date: [**2179-4-27**] Discharge Date: [**2179-4-29**] Date of Birth: [**2158-5-11**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Codeine Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Ms. [**Known lastname 76867**] is a 20yo female with PMH significant for idioathic MPGN s/p living donor transplant in [**2175**] followed by reoccurrence of her disease and HTN who presents with hypertensive urgency. Per patient, she has been having migraine headaches for the past week. She describes these as her "typical" migraines associated with nausea, vomiting, and photophobia. She has been using Excedrin with mild relief. The patient was scheduled for a pharmacological stress test today as part of pre-op evaluation for kidney transplant and evaluation. Her blood pressure was significantly elevated at 240/140. She was immediately transported to the ED. She has been compliant with her anti-hypertensive medications over the past week. She denies any fevers, chills, chest pain, shortness of breath, dizziness, abdominal pain, or hematuria. Last dialyzed yesterday. In the ED initial vitals were T 99.2 BP 232/138 RR 18 O2 sat 96% RA. She received Clonidine 0.1mg PO, Isradipine 15mg PO, Hydralazine 20mg IV, Morphine 4mg IV, Labetolol 120mg IV, Zofran 4mg IV, and Labetolol 40mg IV. She was started on a nitro gtt and then transferred to the MICU for further management. Also, potassium elevated to 6.2. Received Kayexalate 30g PO, Insulin 10 units IV, and dextrose. Past Medical History: 1)MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post transplant pt was doing well, but had rising Cr for two year. In [**6-/2178**] pt presented with uncontrolled BP requiring ICU admission for Isradipine drip. Repeat biopsy showed a type 1 MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed stable AVF. Her creatinine peaked to 4's and she was started on steroids, prograf and cellcept. In [**1-/2179**], she required 3 sessions of HD through a right upper chest catheter. Creatinine slowly recovered to 3.2. Plasmapheresis was then initiated with plan to then treat with Rituximab. She only underwent 3 sessions of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **] at [**Hospital1 18**] to an adult clinic. 2)Peripheral edema and abdominal striae [**1-9**] steroids 3)HTN [**1-9**] steroids and renal disease, multiple admissions for Hypertensive emergency. 4)Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**] to malignant hypertension. 5)Migraines Social History: Lives at home with [**Month/Day (2) **], brother and sister, college student at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit drugs, tobacco. Family History: No history of kidney disease, malignancy, heart disease, or diabetes. Physical Exam: vitals T BP 210/138 AR 83 RR 14 O2 sat 98% RA Gen: Patient appears tired, responsive to questions [**Name (NI) 4459**]: MMM, anicteric sclera Heart: RRR, no m,r,g Lungs: CTAB, no crackles Abdomen: soft, NT/ND, +BS Extremities: No LE edema, 2+ DP/PT pulses bilaterally Pertinent Results: [**2179-4-27**] 03:00PM BLOOD WBC-6.0 RBC-4.26# Hgb-12.1# Hct-39.1# MCV-92 MCH-28.4 MCHC-31.0 RDW-21.2* Plt Ct-195 [**2179-4-27**] 03:00PM BLOOD Neuts-73.9* Lymphs-13.9* Monos-6.1 Eos-5.6* Baso-0.5 [**2179-4-27**] 03:00PM BLOOD PT-12.9 PTT-26.1 INR(PT)-1.1 [**2179-4-27**] 03:00PM BLOOD Glucose-123* UreaN-28* Creat-6.7*# Na-141 K-6.2* Cl-99 HCO3-28 AnGap-20 [**2179-4-28**] 05:29AM BLOOD Calcium-9.4 Phos-7.2*# Mg-1.6 Relevant Imaging: 1)Cxray ([**4-27**]): There is stable cardiomegaly with a spade-shaped configuration and may be seen with pericardial effusion. There is no new pulmonary vascular congestion. No pleural effusion or other evidence of CHF. No focal consolidation is seen. A right-sided large-bore dual-lumen venous access device terminates in the high right atrium. 2)CT scan head ([**4-27**]): No evidence of acute bleed. Brief Hospital Course: Ms. [**Known lastname 76867**] is a 20yo female with PMH significant for MPGN on HD who presents with hypertensive urgency. 1)Hypertensive urgency: Patient presents with significantly elevated BPs~200/100's. She has been admitted multiple times to [**Hospital1 18**] for similar presentation. Usually occurs in the setting of migraine headaches when she is unable to tolerate PO and unable to take her blood pressure medications. This is not the case during this admission. No evidence of significant fluid overload. She received multiple doses of Labetolol in the ED with minimal response. No evidence of end organ damage; no ECG changes, cxray with no pulmonary edema, and CT head with no evidence of acute bleed. She was started on a nitro gtt in the ED and upon transfer to the MICU she was also started on a labetolol gtt as well. The next day her outpatient regimen was restarted and both the drips were eventually weaned off. She is being discharged on home regimen which includes Losartan, Metoprolol, Hydralazine, Clonidine, Isradipine, and Lisinopril. 2)Migraine HA: Patient presents with headaches over the past week associated with nausea, vomiting, and photophobia. No red flag symptoms like fevers, chills, etc. Also, usually occurs before or after HD. Her pain was controlled with Dilaudid. Headaches resolved at time of discharge. 3)ESRD/MPGN: s/p failed renal transplant with reoccurence of her disease. Currently on HD; last HD was day prior to admission. She did not appear volume overloaded on exam. She was dialyzed once during her stay. Her medications were renally dosed. She was continued on Mycophenalate and Prednisone. Lasix was stoppped per renal team recommendations. The patient did not complete her stress test; it was prematurely stopped given her extreme hypertension. After discussion with her nephrologist, the decision was made to postpone the stress test for now. Medications on Admission: Prednisone 5mg PO daily Mycophenolate Mofetil 250mg PO BID Furosemide 80mg PO BID B Complex-Vitamin C-Folic Acid 1mg PO daily Calcium Acetate 667mg PO TID Clonidine 0.3 mg/24 hr patch QMon Losartan 100mg PO BID Metoprolol 100mg PO BID Hydralazine 100mg PO TID Clonidine 0.1mg PO TID Isradipine 15mg PO TID Lisinopril 40mg PO daily Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO Q8H (every 8 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 10. Losartan 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1)Hypertensive urgency 2)Migraine headache 3)End stage renal disease 4)Membranoproliferative glomerulonephritis Discharge Condition: Stable, blood pressure at baseline Discharge Instructions: 1)You were admitted to the hospital with very high blood pressures. You initially required IV blood pressure medications which have been stopped. You are doing well on your home regimen. 2)Please take all medications as listed in the discharge instructions. You have been started on a new medication called Nephrocaps; a prescription has been provided. 3)Please attend all appointments as listed below. Since you were admitted to the hospital, you missed part of your stress test. Please talk with your kidney doctor as to when this should be done. 4)If you experience any fevers, chills, chest pain, shortness of breath, dizziness or any other concerning symptoms please seek immediate medical attention. Followup Instructions: 1)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-6-17**] 1:20 2)Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-7-22**] 9:40

[ "583.1", "283.19", "345.90", "782.3", "429.3", "585.6", "V45.1", "346.90", "701.3", "996.81", "E932.0", "443.89", "E849.9", "403.01", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7272, 7278

4168, 6073

313, 328

7453, 7490

3300, 3720

8247, 8539

2926, 2997

6455, 7249

7299, 7432

6099, 6432

7514, 8224

3012, 3281

253, 275

3738, 4145

356, 1638

1660, 2713

2729, 2910

436

114,621

47231

Discharge summary

report

Admission Date: [**2147-6-19**] Discharge Date: [**2147-6-26**] Date of Birth: [**2099-1-26**] Sex: F Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is a 48 year old female with past medical history of ethanol abuse, hypertension, chronic pancreatitis, narcotic abuse, recurrent falls. On [**2147-6-19**], she was found at home on the floor unresponsive with agonal breathing and diffuse bleeding. She was brought to the Emergency Department where she was intubated for airway protection and treated for possible drug overdose. On head CT she was found to have a subarachnoid hemorrhage, subdural hemorrhage with midline compression and a large intraparenchymal pontine hemorrhage. PHYSICAL EXAMINATION: On examination on admission, she was found to be unresponsive to verbal stimuli. Head, eyes, ears, nose and throat examination revealed a left facial and periorbital edema, left subconjunctival hemorrhage. The pupils are 2.0 millimeters, fixed and nonreactive, no doll's eyes, positive corneal reflex, slight gag reflex. Neurologically, she had posturing of bilateral arms plus left lower extremity to painful stimuli. Toes were bilateral upward. Left ankle clonus greater than right ankle clonus. Cardiovascular - regular rate and rhythm. Respiratory was clear to auscultation bilaterally. The abdomen was soft. LABORATORY DATA: Her laboratories were unremarkable. Serum ethanol 136. Positive urine benzodiazepine. The rest of the toxicology screen was negative. HOSPITAL COURSE: Neurosurgery was consulted and it was determined that there were no therapeutic options at this time. Family decided that under the circumstances, this patient should be made comfort measures only, no fluids, no blood draws, will keep comfortable. Her hospital course was uneventful. The patient was comfortable throughout hospitalization. Over the course of days, she was in the MICU in the beginning and transferred from the MICU to the floor. She was kept comfortable with intravenous Morphine. She also had a Scopolamine patch placed q72hours for reduction of airway secretions. On [**2147-6-25**], her respirations started to slow and on [**2147-6-26**], this patient passed away. The family was present. The attending was notified. CAUSE OF DEATH: Respiratory arrest secondary to dehydration and sepsis and renal failure. The precipitating cause of death was severe brain injury secondary to fall and/or seizure at home. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-398 Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2147-8-14**] 14:22 T: [**2147-8-21**] 19:52 JOB#: [**Job Number **]

[ "852.20", "E885.1", "401.9", "518.81", "303.90", "577.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

1551, 2721

757, 1533

185, 734

59,918

157,056

39998

Discharge summary

report

Admission Date: [**2147-12-11**] Discharge Date: [**2147-12-29**] Date of Birth: [**2097-2-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: This is a 50-year-old gentleman with a pmhx. of alcohol dependence who is transferred from [**Hospital 8**] Hospital for uncontrolled UGI bleed despite endoscopic intervention. Per OSH report, patient was admitted on [**12-7**] for hematemesis and melanotic stools. He underwent EGD on [**12-7**], which revealed non-bleeding grade II esophageal varicies and 2 duodenal ulcers, which were thought to be the cause of patient's symptoms. Ulcers were injected with epinepherine and patient remained stable with hematocrits around 30 for about 72 hours. On day of admission, hct dropped to 23 and patient had repeat endoscopy. Duodenal ulcers did not appear to be rebleeding, and five bands were placed around esophageal ulcers. Patient was noted to have BRBPR and colonoscopy was subsequently performed. Scope was advanced to cecum however, only finding was copious bright red blood. Patient subsequently developed massive hematemesis and a repeat EGD was performed. Four out of five bands were noted to be in place, but endoscopist did not advance further to avoid disloding bands or causing additional trauma. Patient remained intubated for airway protection. There was question of aspiration during this episode of hematemesis. . Of note, patient was febrile to 103 on admission to OSH. CXR and urine cultures were reportedly unremarkable. Patient was started empirically on vanc/zosyn/flagyl for broad coverage. There was also report of DTs during OSH admission. Patient had been placed on CIWA scale for withdrawal. On [**12-9**] scored 20 and 18, on [**12-10**] scored 7, 7, 5, and 4. . The decision was made to transfer patient to facility with IR capabilities. Upon arrival to [**Hospital1 18**] MICU, HR was 80, BP 107/77, SPO2 99% on CMV with FIO2 70%. Patient was intubated and sedated with propofol. He has had no subsequent episodes of hematemesis since EGD. Past Medical History: --Alcohol abuse --HTN Social History: Patient is married with 2 children. Came from [**Country 6257**] in [**2120**]. Works in construction/maintenance. [**First Name8 (NamePattern2) 122**] [**Known lastname 15655**] is his eldest son and the person making healthcare decisions. Unknown alcohol use history of tobacco use. Family History: Lung cancer in maternal uncle, mother with CHF. Physical Exam: UPON ADMISSION: VS: Temp: BP: 92/68 / HR: 79 RR: O2sat GEN: Intubated and sedated HEENT: Pupils reactive, does not respond to commands RESP: Coarse breath sounds throughout but with good air movement CV: RR, S1 and S2 wnl, no m/r/g ABD: +BS, mildly distended, mild fluid wave SKIN: Spider angiomas below neck and over clavicular area NEURO: Sedated RECTAL: Melena . UPON DISCHARGE: pertinent changes only Oriented x3, no asterixis Abdomen non-tender, no distention, no ascites No melena/hematochezia No wheezes/rhonchi/rales, respirations unlabored Pertinent Results: Labs upon admission: [**2147-12-11**] 08:54PM PLT SMR-LOW PLT COUNT-81* [**2147-12-11**] 08:54PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL BURR-OCCASIONAL [**2147-12-11**] 08:54PM NEUTS-82* BANDS-0 LYMPHS-12* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2147-12-11**] 08:54PM WBC-11.2* RBC-3.38* HGB-11.1* HCT-33.4* MCV-99* MCH-32.7* MCHC-33.1 RDW-20.5* [**2147-12-11**] 08:54PM CALCIUM-7.0* PHOSPHATE-1.8* MAGNESIUM-1.9 [**2147-12-11**] 08:54PM CK-MB-2 cTropnT-<0.01 [**2147-12-11**] 08:54PM CK(CPK)-114 [**2147-12-11**] 08:54PM estGFR-Using this [**2147-12-11**] 08:54PM GLUCOSE-111* UREA N-16 CREAT-0.7 SODIUM-137 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-25 ANION GAP-6* [**2147-12-11**] 09:00PM FIBRINOGE-204 [**2147-12-11**] 09:00PM PT-16.2* PTT-28.6 INR(PT)-1.4* [**2147-12-11**] 09:00PM PLT SMR-VERY LOW PLT COUNT-79* [**2147-12-11**] 09:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL TARGET-OCCASIONAL BURR-1+ [**2147-12-11**] 09:00PM NEUTS-76* BANDS-2 LYMPHS-13* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2147-12-11**] 09:00PM WBC-10.6 RBC-3.11* HGB-10.8* HCT-30.4* MCV-98 MCH-34.6* MCHC-35.4* RDW-20.3* [**2147-12-11**] 09:00PM ALBUMIN-2.2* CALCIUM-7.0* PHOSPHATE-1.8* MAGNESIUM-1.9 [**2147-12-11**] 09:00PM CK-MB-2 cTropnT-<0.01 [**2147-12-11**] 09:00PM LIPASE-19 [**2147-12-11**] 09:00PM ALT(SGPT)-31 AST(SGOT)-78* LD(LDH)-251* CK(CPK)-110 ALK PHOS-74 TOT BILI-3.1* [**2147-12-11**] 09:00PM GLUCOSE-111* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-25 ANION GAP-6* [**2147-12-11**] 09:19PM freeCa-0.96* [**2147-12-11**] 09:19PM TYPE-[**Last Name (un) **] PH-7.44 [**2147-12-11**] 09:48PM URINE RBC-21-50* WBC-[**2-17**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2147-12-11**] 09:48PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-SM [**2147-12-11**] 09:48PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.029 . Labs upon discharge: . [**2147-12-29**] 05:40AM BLOOD WBC-5.6 RBC-2.90* Hgb-9.5* Hct-29.2* MCV-101* MCH-32.7* MCHC-32.4 RDW-18.4* Plt Ct-159 [**2147-12-29**] 05:40AM BLOOD Neuts-54 Bands-0 Lymphs-31 Monos-15* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2147-12-29**] 05:40AM BLOOD PT-19.0* INR(PT)-1.7* [**2147-12-29**] 05:40AM BLOOD Glucose-99 UreaN-20 Creat-0.7 Na-136 K-3.9 Cl-105 HCO3-23 AnGap-12 [**2147-12-29**] 05:40AM BLOOD ALT-42* AST-84* AlkPhos-75 TotBili-0.9 [**2147-12-29**] 05:40AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8 [**2147-12-13**] 04:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2147-12-13**] 04:10AM BLOOD AFP-4.4 [**2147-12-13**] 04:10AM BLOOD HCV Ab-NEGATIVE . TTE: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are indeterminate for left ventricular diastolic function. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Indeterminate indices for diastolic function assessment. No intra-cardiac shunt seen - cannot excluded PFO/small ASD as bubble study not performed adequately. Borderline pulmonary artery systolic hypertension. . Abdominal ultrasound with dopplers 1. Patent hepatic vasculature. 2. Echogenic and nodular hepatic architecture. An ill-defined hypoechoic structure seen adjacent to the main portal vein could represent fatty sparing, however a lesion at this location cannot be excluded. A CT or MRI is suggested to further evaluate for possible lesions. 3. Small amount of sludge within the gallbladder. 4. Trace of ascites in the perihepatic space . CXR [**2147-12-27**]: Previous areas of pulmonary opacity, in the left suprahilar and right juxtahilar lung have cleared. A relatively small region of peribronchial opacification persists in the right lower lobe medially, but this is not a new finding. There is no pleural effusion. Stomach is distended with fluid and retained material. Heart size is normal. Azygos remains distended. . US abd limited [**2147-12-27**]: no ascites . [**2147-12-28**]: LENI: No evidence of DVT in right or left lower extremity. . Microbiology: Blood cultures: [**12-27**]: negative Urine cultures: [**12-27**]: negative Peritoneal cultures: [**2147-12-23**]: negative Stool cultures/Cdiff: [**12-22**], [**12-23**], [**12-27**]: negative Brief Hospital Course: Mr. [**Known lastname 15655**] is a 50 year old gentleman with ETOH abuse admitted for an UGIB with hospital course complicated by newly diagnosed cirrhosis and hypoxemic respiratory failure. . # Hypoxemic respiratory failure: Initially thought to be secondary to pulmonary edema, possible PNA, restriction from abdominal distention. Was intubated while receiving diuresis initially with lasix gtt and received 8 day course of vancomycin/zosyn for potential VAP. Found to have one day of hypotension thought to be secondary to overdiuresis of 3L in 24 hours; pressures stabilized with small fluid boluses and administration of albumin. Extubated successfully on [**2146-12-18**]. Respiratory status continued to improve with diuresis on floor, oxygen weaned, and repeat CXR showed improvement in pleural effusions and no new consolidation. . # UGI BLEED: Likely due to duodenal ulcer (injected with epi on [**12-7**]) and esophageal varicies (5 bands placed on [**12-10**]). Hct stable since transfer from OSH. Patient found to be H.pylori positive, treated for 10 days ([**Date range (3) 87971**]) with amoxicillin/clarithromycin/PPI. He was continued on pantoprazole 40mg [**Hospital1 **], sucralafate, and nadolol upon discharge. His heart rate remained in the 70s, but nadolol could not be further uptitrated because of SBP 90-100. He received EGD [**2147-12-29**] which showed one varix band in place, no new varices, no bleeding. Counseled to avoid heavy lifting. He will need repeat EGD in 6 months for varices surveillance. . # Alcoholic cirrhosis: His hepatic vasculature was patent, he was started on lactulose, rifaximin, furosemide. He has a hypoechoic lesion noticed on RUQ US, likely focal fatty sparing. AFP 4.4, making hepatoma less likely, however MRI of liver should be completed as an outpatient. . # Hepatic encephalopathy: Likely due to GI bleed and sedation. Intermittently required haldol and seroquel for agitation. Did not exhibit signs of withdrawl on the floor. Mental status cleared when GI bleed resolved. . # Fever: unclear source, presumed to be due to intra-abdominal translocation of bacteria during . He was full code for this admission. Medications on Admission: --Atenolol Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. 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* 3. sucralfate 100 mg/mL Suspension Sig: Ten (10) ml PO four times a day. Disp:*300 mL* Refills:*2* 4. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ML PO three times a day: titrate for 3 bowel movements daily. Disp:*1 bottle (960 mL)* Refills:*2* 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. nadolol 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 8. nadolol 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer Esophageal varices Acute blood loss anemia Hypoxemic respiratory Failure Ventilator-associated pneumonia H. pylori infection Alcoholic cirrhosis Hepatic encephalopathy Hypertension Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: You were admitted to the hospital with GI bleeding from an ulcer in the small intestine and abnormal blood vessels (varices) in the esophagus. Your blood counts remained stable after transfer to [**Hospital1 18**] from [**Hospital 8**] Hospital, and you did not require additional blood transfusions. You were treated for pneumonia, as well as for an infection in the stomach called H. pylori. You likely have cirrhosis, scarring of the liver due to excessive alcohol use. This underlying liver problem almost certainly contributed to the episodes of bleeding. It is absolutely necessary that you never drink alcohol again to avoid further damage to the liver. Please make sure that you attend all of your outpatient alcohol rehabilitation sessions. Please follow up with one of our liver specialists, Dr. [**Last Name (STitle) 7033**], on Wednesday, [**1-3**] at 3:40 PM. The following medication changes were recommended: - STOP Atenolol - START thiamine 100mg daily - START pantoprazole 40mg twice daily - START sucralafate 100 mL four times daily - START lactulose 15mL three times daily - you can increase or decrease this as need to have 3 bowel movements daily - START furosemide 40mg daily - START rifaximin 550mg twice daily - START nadolol 20mg every morning and 40mg every evening Followup Instructions: Department: LIVER CENTER When: WEDNESDAY [**2148-1-3**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2147-12-29**]

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icd9cm

[ [ [] ] ]

[ "45.13", "54.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11529, 11535

8314, 10502

322, 328

11775, 11865

3245, 3252

13248, 13585

2610, 2659

10563, 11506

11556, 11754

10528, 10540

11926, 13225

2674, 2676

268, 284

5375, 8291

356, 2243

3267, 5359

11880, 11902

2265, 2288

2304, 2594

19,052

100,199

51114+59310

Discharge summary

report+addendum

Admission Date: [**2185-11-11**] Discharge Date: [**2185-11-17**] Date of Birth: [**2110-10-25**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old female with a history of Alzheimer's dementia, coronary artery disease status post coronary artery bypass graft in [**2174**] with a history of five myocardial infarctions, the last in [**2185-7-28**] as well as congestive heart failure with an ejection fraction of 30%, hypertension, dyslipidemia. On [**2185-11-11**], she experienced transient episodes of left arm weakness associated with slow speech. Her husband called the patient's doctor who recommended she present to the emergency room. On arrival her vital signs were stable. Labs were unremarkable. Cardiac enzymes were negative initially. She was admitted to the Neurology for work up of a question of TIA or stroke. She underwent MRI of the head upon admission that was negative for an acute process. While on the floor on [**2185-11-11**], she was noted to become tachycardic in a sinus rhythm to 150 and was noted to have rales on exam. She was given 40 mg of IV Lasix without significant response; she received a second dose of 40 mg IV Lasix and then a code was called when she subsequently was noted to drop her oxygen saturation to the mid 80s on 100% nonrebreather. She also became hypotensive with a systolic blood pressure in the 70s. She was intubated and briefly required Dopamine to maintain her blood pressures. She was then transferred to the Coronary Care Unit for further management of congestive heart failure. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2174**]. 2. Diabetes mellitus. 3. Dyslipidemia. 4. Congestive heart failure, ejection fraction 30%. 5. Alzheimer's dementia. Her primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1537**]. Her neurologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. MEDICATIONS AT HOME: 1. Lisinopril 50 mg p.o. q.d. 2. Imdur 60 mg p.o. q.d. 3. Prilosec 20 mg p.o. q.d. 4. Lasix 40 mg p.o. q.d. 5. Potassium chloride 10 mEq p.o. q.d. 6. Coreg 6.25 mg p.o. q. AM and 3.125 mg p.o. q. PM. 7. Colestid with breakfast and supper. 8. Aspirin 325 mg p.o. q.d. 9. Folate 1 mg p.o. b.i.d. 10. Lanoxin 0.125 mg p.o. q. Monday, Wednesday and Friday and 0.25 Tuesday, Thursday, Sunday. ALLERGIES: 1. Sulfa. 2. Iodine. SOCIAL HISTORY: She lives with her husband. She does not smoke or drink. PHYSICAL EXAMINATION: Upon admission to the Coronary Care Unit, she was intubated and sedated. She had pink, frothy sputum suctioned from her G tube. Her lungs had audible rales at the bases. She had a regular rate and rhythm audible upon precordial exam with no audible extra heart sounds. Her abdomen was benign with positive bowel sounds. She had no edema with 1+ distal pulses. She was responding to stimuli, but was sedated. LABORATORY: Upon admission to the Coronary Care Unit had a sodium 134, potassium 4.4, chloride 97, bicarbonate 25, BUN 20, creatinine 0.7, glucose 124, INR 1.1. White count 7, hematocrit 33, platelets 211. EKG normal sinus rhythm at 90 beats per minute with a left axis, left bundle branch block. There was no comparison available at the time. Chest x-ray with patchy vascular markings consistent with congestive heart failure. HOSPITAL COURSE: The initial impression on admission to the Coronary Care Unit was that the patient was a 75 year-old female with severe coronary artery disease who developed symptoms of left arm discomfort on the day prior to admission. It may or may not have represented anginal type symptoms. She was now admitted directly from the floor in apparently decompensated congestive heart failure in the setting of elevated systolic blood pressure (as high as 200). The patient was able to be weaned off of Dopamine expeditiously upon admission to the Coronary Care Unit. She was diuresed aggressively and successfully with IV Lasix. She had a PA catheter placed upon admission in order to guide her management with initial pulmonary artery pressures of 35/10 and pulmonary capillary wedge pressure of 10. Of note, this was following aggressive diuresis. The patient did well with subsequent titration up of after load reduction with Captopril and initiation of Isordil. She was able to be extubated successfully on [**2185-11-14**]. She underwent a transthoracic echocardiogram which revealed a severely depressed LV function with ejection fraction of 20 to 30% and akinesis of the inferior row posterior walls and moderate hypokinesis at the LV as well as 1+ AR and MR. The patient subsequently did well and at the time of this dictation on [**2185-11-17**], she is awaiting transfer to the General Medical Floor where she will await eventual disposition most likely to short term rehab. TRANSFER STATUS: Stable. DISCHARGE STATUS: Pending. MEDICATIONS AT TIME OF DISCHARGE FROM CORONARY CARE UNIT: [**Unit Number **]. Lasix 100 mg p.o. q.d. 2. Isordil 30 mg p.o. t.i.d. 3. Heparin 5000 units subcutaneous b.i.d. 4. Captopril 75 mg p.o. t.i.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Regular insulin sliding scale. 9. Levaquin 250 mg p.o. q.d. to be discontinued on [**2185-11-22**]. 10. Flagyl 500 mg p.o. t.i.d., last dose to be given on [**2185-11-22**]. DISCHARGE DIAGNOSES AT THE TIME OF TRANSFER FROM THE CORONARY CARE UNIT: [**Unit Number **]. Decompensated congestive heart failure. 2. Hypertension. 3. Alzheimer's dementia. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 25313**] MEDQUIST36 D: [**2185-11-17**] 14:32 T: [**2185-11-17**] 14:45 JOB#: [**Job Number 106144**] Name: [**Known lastname 17278**], [**Known firstname **] Unit No: [**Numeric Identifier 17279**] Admission Date: [**2185-11-11**] Discharge Date: [**2185-11-23**] Date of Birth: Sex: F Service: Cardiology The patient is a 75-year-old female with a past medical history of Alzheimer's dementia, coronary artery disease, status post coronary artery bypass grafting, multiple myocardial infarctions, ischemic cardiomyopathy with an ejection fraction of 20-30% and hypertension. The patient was admitted for episodes of left arm weakness and developed flash pulmonary edema and tachycardia in the hospital. She was transferred to the CCU for medical management and diuresis. The patient responded to treatment well and, on [**2185-11-17**], she was transferred to the floor for further medical care prior to discharge to rehabilitation. The patient was stable throughout her course of hospitalization on the medical floor. She was restarted on her preadmission medications. Her congestive heart failure was not an acute issue. She was kept euvolemic throughout the hospitalization and suffered no additional shortness of breath, pulmonary edema or tachycardia. Her blood pressure did drop on occasion to 80-90/40. The patient was asymptomatic during these episodes and blood pressure elevated spontaneously to greater than 100/50. The patient had fevers in the CCU with negative blood cultures. She was started empirically on Levofloxacin and Metronidazole. On the hospital floor, she was noted to have one bloody stool. Hematocrit was stable. The patient's family notes that the patient has been having bloody stools on occasion over the past few years. They have related to her congestive heart failure exacerbations. The patient underwent an abdominal CT which showed evidence of proctitis to a very mild degree with some thickening of the bowel wall and stranding. The CT also noted an abnormally thickened and calcified gallbladder wall with a question of worrisome gallbladder. The patient was referred go Gastroenterology. She underwent a liver/gallbladder ultrasound which revealed cholelithiasis and evidence of adenomyomatosis, a benign non-premalignant condition for which no follow up is necessary. Due to the patient's age and presentation, late onset of ulcerative colitis was suspected for the occasional bloody stools. On flexible sigmoidoscopy, the patient was shown to have multiple non-bleeding rectal ulcers. The appearance was consistent with ulcerative colitis. Biopsies were taken and the results are pending. Due to the patient's very mild disease activity without pain and only occasional bloody stools without a drop in hematocrit, it is not clear at this time whether treatment with steroids or 5-ASA enemas is indicated. The patient will follow up with Gastroenterology for these issues. The patient's hematocrit was stable throughout the admission. The patient's diet was advanced and she took p.o. well. The patient is discharged in good condition to long term rehabilitation. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Congestive heart failure. 3. Pulmonary edema. 4. Diabetes mellitus. 5. Hypercholesterolemia. 6. Alzheimer's dementia. 7. Hypertension. 8. Ulcerative colitis. 9. Adenomyomatosis. DISCHARGE MEDICATIONS: 1. Digoxin 0.25 mg q Monday, Wednesday and Friday. 2. Digoxin 0.125 mg q Tuesday, Thursday, Saturday and Sunday. 3. Lisinopril 20 mg p.o. q day. 4. Coreg 6.25 mg b.i.d. 5. Folate. 6. Prilosec 20 mg p.o. q day. 7. Aspirin 325 mg p.o. q day. 8. Colestid 5 mg p.o. b.i.d. 9. Regular insulin sliding scale. 10. Tylenol. 11. Fosamax 75 mg p.o. q Sunday. 12. Isosorbide Dinitrate 30 mg p.o. t.i.d., hold for systolic blood pressure of less than 100. 13. Furosemide 10 mg p.o. q day, hold for systolic blood pressure of less than 100. 14. Levofloxacin 250 mg p.o. q day until [**2185-11-25**]. 15. Metronidazole 500 mg p.o. t.i.d. until [**2185-11-25**]. 16. Miconazole 2% cream to buttock sore q day until healed. The patient is to follow up with Dr. [**First Name8 (NamePattern2) 890**] [**Name (STitle) 690**]. She is discharged in good condition. [**Name6 (MD) **] [**Last Name (NamePattern4) 8732**], M.D. [**MD Number(1) 8733**] Dictated By:[**Last Name (NamePattern1) 580**] MEDQUIST36 D: [**2185-11-23**] 10:35 T: [**2185-11-23**] 10:53 JOB#: [**Job Number **]

[ "556.3", "518.81", "427.89", "428.0", "578.1", "780.6", "331.0", "250.00", "280.0" ]

icd9cm

[ [ [] ] ]

[ "48.24", "89.64", "96.04", "96.6", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

9031, 9250

9273, 10394

3458, 9010

2060, 2493

2592, 3440

168, 1597

1619, 2039

2510, 2569

27,400

162,594

21843

Discharge summary

report

Admission Date: [**2118-7-9**] Discharge Date: [**2118-7-30**] Date of Birth: [**2058-3-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: Febrile neutropenia Major Surgical or Invasive Procedure: PICC placement [**2118-7-11**] Bone Marrow Biopsy [**2118-7-24**] History of Present Illness: 60yo woman with mantle cell lymphoma s/p RICE (day 1 [**6-29**]) who presented to the ED with approximately 24h of nausea,vomiting, fever to 102 and loose stools. She also had fatigue and poor PO intake. No cough or SOB. She denied any photophobia, neck pain or visual changes. In ED her temp 102. HR 130, SBP 130s -> 85 after 2L but then increased to 90s. Patient received total of 3 L of IVF and electrolyte repletion for Magnesium and POtassium. At time of admission to [**Hospital Unit Name 153**] she felt very tired. She denied SOB, CP, photophob, abd pain, or new skin rashes. Past Medical History: Oncologic Hx: - dx mantle cell lymphoma in [**2114**] - completed four cycles of R-CHOP followed by Zevalin by [**4-9**] - progressed by [**7-11**] -> began velcade/rituxan ** had L cervical LN - again progressed by 5th cycle velcade/rituxan/dex in L cervical LN - admitted for [**Hospital1 **] on [**2117-12-11**], [**2118-1-10**] and R-[**Hospital1 **] on [**2118-2-4**] - PET showed good response initially - planned for autoSCT on [**2118-3-15**] but CT on admit showed progressive dz - received ESHAP w/ plans for autoSCT if dz stable post ESHAP - PET on [**2118-4-11**] reported progression of her disease - BMB on [**2118-3-15**] showed a mildly hypocellular marrow with trilineage hematopoiesis, no evidence of mantle cell, NL cytogenetics - admitted for 2nd cycle of ESHAP [**Date range (1) 57305**] - given rituxan on [**5-6**] and 3rd cycle ESHAP [**Date range (1) 57306**] - C1D1 Rituxan/Bendamustine on [**2118-6-6**] - CT showed disease progression [**2118-6-28**] . Other PMHx: - lyme [**2117**] - herpes zoster [**2117**] Social History: Patient lives with her husband. She is a computer teacher in an elementary school, but took a leave of absence recently. She has two sons, both married. She lives in [**Location 57307**]. She does not drink alcohol, smoke tobacco, or use illicit drugs. Family History: Mother had [**Name2 (NI) 499**] cancer. Uncle with stomach cancer. Physical Exam: Temp: 102.2 106 96/60 22 100% RA Gen: dry, pale, NAD Neuro: AAO x3. Able to follow commands. Good alertness. Toes down bilat. Hand strength symmetric. EOMI PERRLA. No nuchal rig or photophob HEENT: JVP flat. MM very dry Cards: RRR, [**3-10**] early systolic murmur Resp: Clear bilat Abd: BS+ NT ND Soft, no masses, no rebound or guarding Ext: no edema or rashes Pertinent Results: EKG: sinus tachy, NA NI, no acute ST T changes CXR: NAD (my read) ua neg . 127 90 9 -----------------< 142 3.2 24 0.9 Ca: 9.1 Mg: 1.2 P: 2.5 ALT: 12 AST: 19 Lip: 17 AP: 55 Tbili: 0.5 Alb: . WBC: 0.1 HCT: 27 (baseline low 30s) PLT: 23 (down from baseline) N:13 Band:13 L:38 M:25 E:0 Bas:13 . PT: 12.9 PTT: 29.1 INR: 1.1 [**2118-7-11**] ECHO: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior wall. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: regional LV systolic dysfunction. Mild mitral regurgitation. Small pericardial effusion without echo evidence of tamponade. [**2118-7-12**] Pelvic Ultrasound: No evidence of a fluid collection. Moderate amount of subcutaneous edema in the left labial region. [**2118-7-13**] CXR: As compared to the previous radiograph, the pre-existing pulmonary edema has almost completely cleared. On today's examination, small bilateral pleural effusions are seen. Also clear is the preexisting partial retrocardiac atelectasis. The overall size of the heart is unchanged. The right-sided central venous access line is in standard position. [**2118-7-15**] CT ABD/PELVIS: 1. No acute intra-abdominal process identified. 2. Non-specific stranding within the anterior subcutaneous tissues of the lower abdomen, compatible with given history of cellulitis. No abscess identified. 3. Small bilateral pleural effusions, new from [**2118-6-28**]. 4. Resolution of pericardial effusion. [**2118-7-18**] ECHO: The left atrium and right atrium are normal in cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior wall. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. 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. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Moderate regional LV systolic dysfunction. Small to moderate circumferential pericardial effusion without evidence of tamponade. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2118-7-11**], the pericardial effusion is slightly larger. There is still no clear-cut echo evidence of tamponade. The wall motion abnormalities and ejection fraction are similar. CT CHEST [**2118-7-22**]: 1. Interval progression of the large mediastinal mass has considerably increased in size since the previous examination of [**2118-3-21**]. 2. Newly occurred pericardial effusion. 3. Newly occurred pleural effusions. 4. Mild increase in size of pre-existing paraaortic lymph nodes. CT Neck [**2118-7-29**]: Larynx appears obliterated on the axial scan due to adduction of left vocal cord. Mediastinal mass continues to enlarge. Bone Marrow Biopsy [**2118-7-24**]: Final Results Pending Brief Hospital Course: 1)Febrile Neutropenia: Pt admitted to the ICU for febrile neutropenia. Blood cultures from admission were positive for 4/4 bottles pansensitive pseudomonas, with most likely source being gut translocation versus labial eschar/cellulitis. She was treated with a 14 day course of Meropenem. Patient remained afebrile from [**7-16**] to time of discharge and has remained hemodynamically stable. At time of discharge she is no longer neutropenic, afebrile and feeling well. Patient was continued on her outpatient regimen of prophylactic Acyclovir. She was started on Atovaquone 1500mg PO daily for PCP prophylaxis and discharged on both of these medications. 2)Mantle cell lymphoma: s/p RICE (day 1 [**6-29**]). Patient initially pancytopenic but counts nearly have recovered. Platelets have remained low. A Chest CT scan on [**7-22**] did not show a significant change compared to her Chest CT on [**2118-6-28**] indicating that her lymphoma was resistant to the RICE she received. Patient was given a dose of Rituxan on [**7-26**] when it was thought that she would undergo another cycle of chemotherapy. However, on [**7-29**] she had an acute episode of stridor/dysphagia that resolved after steroids and benadryl. A Neck CT on [**7-29**] showed approx 90% compression of her esophagus by her mediastinal mass. ENT saw patient and noted right vocal cord paralysis, which has been known. Radiation oncology was consulted and the new plan was for XRT rather than proceeding with more chemo. Given patient's respiratory status was stable and she could swallow soft solids and thin liquids, as per speech and swallow, emergent XRT was not done. At time of discharge patient was able to eat soft solids and thin liquids without no issues. Her respiratory status was stable and she felt generally well. The plan is for patient to return to outpatient [**Hospital Ward Name 1826**] 7 Clinic on Monday, [**8-1**] to discuss XRT with radiation oncology team and decide on when this therapy will begin. She was discharged with a two day course of Prednisone 40 mg PO daily and received one dose prior to discharge. Dr. [**Last Name (STitle) 410**] and Rad Onc can decided whether further steroid therapy is necessary. 3)NSTEMI - on [**2118-7-11**] she had 19 beat run of VT with associated dyspnea, also with bump in cardiac enzymes. Her troponin peaked at 0.23, and her CK and CKMB remained normal. She had and echocardiogram [**7-11**] which showed moderate hypokinesis of the anterior and septal walls that was new compared with prior from [**2118-3-9**]. She was evaluated by cardiology who did not feel that diagnostic cath was indicated in the setting of her recent chemo. They advised medical management with atorvastatin, beta-blockade as tolerated by her blood pressure. In addition they recommend stress testing once she is medically stable. Patient was discharged with Atorvastatin and Metoprolol. These medications should continue to be managed as an outpatient and pt should follow up with her primary care physician regarding stress test. 4) L Labial cellulitis: She had a cellulitis extending from her lower abdomen to her left labia and peri-rectal area. Initially patient had moderate pain to palpation of area. A translabial U/S on [**2118-7-11**] showed no evidence of abscess or fluid collection. Abd/Pelvic CT on [**7-15**] also did not show an evidence of abscess or fluid collection. Pt followed by ID during hospital course. Cellulitis made significant improvement as patients white cell count improved. Patient received a 16 day course of Vancomycin. At time of discharge cellulitis appeared was completely resolved. 5) L labial and L peri-rectal ulcer: Ulcers noted upon admission at which time they were covered by black eschars. They are painless punched out ulcers down to the dermis. Seem to be c/w ecthyma gangrenosum. Ulcers were followed by ID, Ob-gyn and Derm. Ulcers continue to improve with daily [**Last Name (un) **] baths and bacitracin/gauze dressings. According to derm, these ulcers could take weeks to fully heal. At time of discharge ulcers looked clean and seemed to be forming increased granulation tissue. Patient was instructed how to care for ulcers and actively cared for them herself as an inpatient. Ulcers should continue to be monitored for continued resolution. 6) Electrolyte Repletion: Patient was continued on Potassium and Magnesium replacement which were determined based on her needs as an inpatient. She is scheduled to have her labs drawn on [**2118-8-1**] at 7 [**Hospital 1826**] Clinic and her dosages of these electrolytes should be adjusted accordingly. Medications on Admission: Allopurinol 300 daily ativan 0.5 q6h prn compazine 10 q8h prn Potassium 20 daily mag oxide 800 [**Hospital1 **] albuterol prn benzonatate 100 tid acyclovir 400 tid Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 5. Atovaquone 750 mg/5 mL Suspension Sig: 10 mL PO DAILY (Daily). Disp:*300 mL* Refills:*0* 6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: 20 mEq PO twice a day. Disp:*60 * Refills:*0* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Pseudomonas bacteremia Secondary: cellulitis, mantle cell lymphoma Discharge Condition: good Discharge Instructions: You were admitted with nausea/vomitting and fever and found to have an infection in your blood. We gave you antibiotics and the infection resolved. During your admission we determined that you had injury to your heart. The Cardiologists who saw you felt that medical management of this problem would be appropriate at the present time. We started you on two new medications for you heart. It is recommended that you have a cardiac stress test as an outpatient. We also found that you had a skin infection on your lower abdomen and genital area. We treated you with antibiotics and this infection improved, as well. You still have ulcers in your genital and rectal area which you should continue treating with daily [**Last Name (un) **] baths and application of bacitracin covered by gauze. We monitored your blood cell counts closely during you hospital stay since you were neutropenic upon admission. Your blood counts have risen and you are no longer neutropenic. In regards to your mantle cell lymphoma, we rescanned chest and scanned your neck and found the the mass in your neck has enlarged. This is likely contributing to your difficulty swallowing. You were seen by the radiation oncologists who along with your primary oncologist feel that radiation would be an appropriate treatment. You were seen by speech and swallow who recommended that you eat soft solids and thin liquids, take sips after each bite, and tuck your chin when swallowing. You were started on the following new medications; 1) Metoprolol: This medication helps to control heart rate and will help protect your heart muscle. 2) Atorvastatin: This medication reduces cholesterol and also helps to protect your heart function. 3) Atovaquone: This is prophylaxis against pneumonia. 4) Prednisone: You should take this for the next two days. Dr. [**Last Name (STitle) 410**] will decide whether you need to continue taking this 5) Omeprazole: This is to help with reflux You should follow up on Monday at the [**Hospital Ward Name 1826**] 7 outpatient clinic. During this visit we will have you meet with the Radiation Oncology team and decide on plans for radiation therapy. If you should have fevers, chills, night sweats, significant nausea or vomitting, chest pain, shortness of breath or dizziness please go to your local emergency room. Followup Instructions: 7 [**Hospital Ward Name 1826**] Heme/[**Hospital **] Clinic: Monday, [**8-1**] at 12:30 pm Completed by:[**2118-7-31**]

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icd9cm

[ [ [] ] ]

[ "99.25", "31.42", "88.77", "38.93", "41.31" ]

icd9pcs

[ [ [] ] ]

12332, 12338

6561, 11188

334, 402

12458, 12465

2840, 6538

14834, 14956

2370, 2438

11402, 12309

12359, 12437

11214, 11379

12489, 14811

2453, 2821

274, 296

430, 1021

1043, 2082

2098, 2354

82,188

198,890

50919

Discharge summary

report

Admission Date: [**2111-5-14**] Discharge Date: [**2111-5-15**] Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 99**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Sigmoidoscopy with rectal tube decompression History of Present Illness: The pt is a 86 yo female with history of EEE with residual aphasia, seizure disorder, previous stroke in [**2104**] with residual left sided weakness, and mild dementia who developed abdominal pain yesterday overnight. Her last BM was 2 days ago. She ate normally last night. Nursing reported no fever or chills. A KUB was done at [**Hospital 100**] rehab with severe dilatation of bowel loops. She is normally do not hospitalize (last hospitalized in [**2104**]) but given her pain and bowel loop distention she was brought to the [**Hospital1 **] ED. In the ED, initial vs were 97.6 135/80 107 20 100% on 4L. A KUB was done which showed markedly distended bowel loops. Her CT abd with contrast was consistent with sigmoid volvulus. She received vancomycin 1g IV, zosyn 4.5mg IV, and morphine 2mg IV x2. Exam was notable for no stool in the rectal vault/guaiac negative. After the second dose of morphine her oxygen saturation decreased. Vitals prior to transfer were 103 156/80 32 95% amount of liters not documented. On the floor, the patient said no when asked whether she was in pain. She did have apparent waves of pain with grasping her abdomen. Review of systems: unable to obtain Past Medical History: -EEE as an infant left her with expressive aphasia -Previous stroke in [**2104**] with left sided weakness -seizure disorder, sounds like absence -previous aspiration PNA -gait disorder -mild dementia -RA -Mild dementia with cognitive deficits, does understand and can respond yes and no -osteoporosis -cellulitis of shin last week Social History: Lives at [**Hospital 100**] rehab. Wheel chair bound. Never smoker, no illicits, very occasional beer. Family History: Mother with ileostomy in her 80s from colon cancer. Multiple other sisters with likely colon cancer. Physical Exam: Vitals: 98.3 162/96 100HR 93% on 2L General: able to answer yes when I said her name and that we were at the hospital, answered no when asked if at a school HEENT: Sclera anicteric, pupils equally round, end of tongue missing, very dry mm Lungs: Poor air movement especially at the bases but otherwise CTA posteriorly CV: tachycardic, no murmurs, rubs, gallops Abdomen: decreased bowel sounds, very distended, mod tender to palpation did not further access to minimize discomfort Ext: warm, well perfused, 1+ radial and DP pulses, + healing lesion on right LE with bruising with mild erythema below bruise Pertinent Results: ADMISSION LABS: [**2111-5-14**] 02:00PM WBC-11.4* RBC-4.83# Hgb-14.6# Hct-44.0# MCV-91 Plt Ct-357# [**2111-5-14**] 02:00PM Neuts-86.2* Lymphs-8.4* Monos-4.3 Eos-1.0 Baso-0.1 [**2111-5-14**] 02:00PM Gluc-142* UreaN-28* Creat-0.6 Na-141 K-3.9 Cl-105 HCO3-21* [**2111-5-14**] 02:00PM ALT-35 AST-28 AlkPhos-212* TotBili-0.2 [**2111-5-14**] 02:00PM Lipase-14 [**2111-5-14**] 02:00PM cTropnT-<0.01 [**2111-5-14**] 02:00PM Albumin-4.6 [**2111-5-14**] 03:00PM Lactate-2.0 MICRO: [**2029-5-13**] BCx: NGTD OTHER PERTINENT LABS: [**2111-5-14**] 08:50PM BLOOD CK(CPK)-56 [**2111-5-15**] 02:40AM BLOOD CK(CPK)-72 [**2111-5-14**] 02:00PM BLOOD cTropnT-<0.01 [**2111-5-14**] 08:50PM BLOOD CK-MB-8 cTropnT-0.04* [**2111-5-15**] 02:40AM BLOOD CK-MB-7 cTropnT-0.03* STUDIES: [**5-14**] CXR: 1. Nonspecific retrocardiac opacity which may represent atelectasis, scarring, or infectious process. 2. Markedly dilated gas-filled loops of bowel without evidence of perforation. [**5-14**] CT abd/pelvis: 1. Findings compatible with sigmoid volvulus. 2. No pneumatosis or free air. 3. Extensive degenerative change of the spine, of indeterminate chronicity. 4. Bibasilar atelectasis, with additional probable chronic interstitial abnormality at the left base. [**5-14**] Sigmoidoscopy: - The volvulus was visualized at about 20 cm. The sigmoidoscope passed beyond the obstruction and we advanced the scope up 55 cm. We were able to suction out the gas. A colonic decompression tube was placed over a guide wire that was placed endoscopically. - Otherwise normal colonoscopy to 55 cm DISCHARGE LABS: [**2111-5-15**] 02:40AM WBC-7.0 RBC-3.59* Hgb-10.8* Hct-32.8* MCV-91 Plt Ct-287 [**2111-5-15**] 02:40AM PT-14.1* PTT-27.5 INR(PT)-1.2* [**2111-5-15**] 02:40AM Gluc-106* UreaN-21* Cr-0.5 Na-145 K-3.0* Cl-114* HCO3-23 [**2111-5-15**] 02:40AM Calcium-7.7* Phos-3.3 Mg-1.9 Brief Hospital Course: Ms. is an 86 yo female with EEE as an infant with expressive aphasia, old stroke in [**2104**], seizure disorder, and recent cellulitis who presented with volvulus. Volvulus: The patient presented with volvulus that was seen on CXR and CT abd/pelvis. The patient underwent sigmoidoscopy by GI and was decompressed with a rectal tube. She was initially started on antibiotics for concern of possible translocation of bacteria given the volvulus and possible ischemic bowel - however, these were discontinud as there was no e/o fever or increased WBC count. The patient's rectal tube was taken out several hours after the procedure. She was restarted on oral intake. In the event of a recurrent volvulus (which is a likely possibility), the patient should be treated with a gastrograffin enema. If this does not work, the patient's care should be focused on comfort and pain control, and hospice care should be offered to the patient. NOTE: Gastrograffin enemas are not available in the middle of the night at [**Hospital 100**] Rehab per discussion with HR Geriatrics fellow. Recommendation is to discuss with family comfort measures AT REHAB if abdominal pain recurs and not to hospitalize. Option to come to [**Hospital1 18**] for gastrograffin enema in ED is available, but if this does not work (and is likely not to work given the patient needed extreme measures including sigmoidoscopy and elective intubation this admission to treat the volvulus) then the recommendation is to offer the patient comfort care and return to [**Hospital 100**] Rehab. Please attempt to avoid hospitalization in this patient. Elective intubation: The patient was electively intubated prior to the sigmoidoscopy and rectal tube decompression. She was extubated the following morning with no complications. Her code status was returned to DNR/DNI after extubation. EKG changes: Most likely related to demand ischemia in the setting of tachycardia in the ED. CE remained negative x3. ASA was kept at 81 mg daily. Hypotension: The patient was hypotensive likely [**1-20**] to sedating medications. She was started on Dopamine, which was weaned off prior to discharge. The patient's home metoprolol was held [**1-20**] to hypotension. SBP on discharge was ~100-110. Seizure disorder: Continued home phenytoin. Previous stroke in [**2104**]: ASA continued. Previous aspiration PNA: restarted on thick liquids and pureed solids after extubation RA: continued tylenol for pain LE wound: Erythema below wound likely due to bandage not cellulitis. Will monitor erythema given recent cellulitis per daughter. Code: DNR/DNI, focus on comfort HCP: [**Name (NI) 105829**],[**Name (NI) 8031**] [**Telephone/Fax (1) 105830**] Medications on Admission: tylenol 650mg po BID tylenol 975mg qhs and 8am ASA 81mg daily senna 8.6mg daily famotidine 20mg po bid fexofenadine 60 mg [**Hospital1 **] prn phenytoin 300mg po qpm metoprolol xl 25mg daily hydroxyzine 25mg po q6 hr prn miconazole 1 application [**Hospital1 **] simethicone 80mg po TID lotrisone cream 1 application [**Hospital1 **] Discharge Medications: 1. Tylenol 325 mg Tablet Sig: Three (3) Tablet PO qAM and qPM. 2. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO twice a day. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. 6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 7. Phenytoin 125 mg/5 mL Suspension Sig: Three Hundred (300) mg PO QPM (once a day (in the evening)). 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day as needed for gas. 9. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: Topical twice a day. 10. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary Diagnosis: Sigmoid volvulus Hypotension . Secondary Diagnosis: Seizure disorder Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname 79**], . You were admitted to the hospital with a volvulus. This was decompressed by the gastroenterologists. If this happens again, you should try a gastrograffin enema for decompression. If that does not work, measures should be taken to ensure that you are made comfortable. . The following changes have been made to your medications: #. Please hold your Metoprolol while your blood pressure is low. This can be restarted if your blood pressure is elevated. #. Please hold your Senna and any other bowel regimen for the next few days. . It was a pleasure meeting you and taking part in your care. Followup Instructions: Please follow with your doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.

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icd9cm

[ [ [] ] ]

[ "96.04", "96.08", "38.91", "46.85", "96.71" ]

icd9pcs

[ [ [] ] ]

8547, 8612

4610, 7319

228, 275

8744, 8744

2736, 2736

9531, 9629

1993, 2095

7703, 8524

8633, 8633

7345, 7680

8880, 9508

4317, 4587

2110, 2717

1482, 1501

174, 190

303, 1463

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2752, 3235

8652, 8683

3257, 4301

8759, 8856

1523, 1856

1872, 1977

26,320

133,354

5559+5587

Discharge summary

report+report

Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-12**] Date of Birth: [**2072-12-7**] Sex: M Service: BLUE SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 22371**] is a 75 year-old man with a history of hypertension, coronary artery disease, hypercholesterolemia and peptic ulcer disease who had vague abdominal pain for approximately one month. On [**7-4**] he noticed having many episodes of loose stools that were mostly composed of blood. He also reported at that time having some lightheadedness while walking. He denied having any shortness of breath or chest pain. Denied fevers or chills, but had some nausea. No vomiting or abdominal pain. He had a little bit of tenderness on rectal examination. In the Emergency Department he had nasogastric lavage, which produced bright red clots that cleared after about 100 cc of saline flushing. He also had maroon melena stool approximately 200 cc approximately two times. He was admitted to the hospital for gastrointestinal bleeding. PAST MEDICAL HISTORY: Significant for coronary artery disease status post left anterior descending stent in [**2146**] and a recent catheterization, which showed an ejection fraction of 50%. Hypertension, hypercholesterolemia, type 2 diabetes mellitus. Three cerebrovascular accidents, which left him with a left hemiparesis and right sided weakness. Prostate cancer status post prostatectomy. He had a laminectomy in the past, gout, peptic ulcer disease with gastrointestinal bleed secondary to aspirin or non-steroidal anti-inflammatory use in [**2132**]. Depression and delayed gastric emptying secondary to his diabetes. MEDICATIONS ON ADMISSION: Allopurinol 100 mg once a day, Atenolol 100 mg once a day, Celexa 20 mg once a day, enteric coated aspirin two aspirin per day 325 mg, Glucophage 500 mg three times a day, Imdur 300 mg once a day, Lipitor 40 mg once a day, Hydrochlorothiazide 25 mg once a day. Aciphex 20 mg once a day, Protonix 40 mg once a day, potassium chloride 10 mg once a day and Plavix 75 mg once a day. SOCIAL HISTORY: Significant for the fact that he worked as an archaeologist. He lives with his wife and daughter. [**Name (NI) **] quit smoking approximately forty years ago and drinks alcohol socially. ALLERGIES: No known drug allergies. FAMILY HISTORY: Significant for diabetes mellitus in his mother and brother. Brother suffered from a stroke at age 76. PHYSICAL EXAMINATION: Blood pressure 118/68. Heart rate 74. Respiratory rate 18. Oxygen saturation of 98% on room air. He was generally ill appearing African American man who did not appear to be in any acute apparent distress. His sclera were clear. Oropharynx mucous membranes are moist. His lungs were clear to auscultation bilaterally with no crackles or wheezes. His heart was regular with a normal S1 and S2. No murmurs. Abdomen showed decreased bowel sounds. It was soft, nontender with no rebound or guarding. Rectal showed no external hemorrhoids or gross blood. Extremities no lower extremity edema. His right arm was slightly cachectic as well as was his hand flexed. Neurological examination he was alert and oriented. He had 5 out of 5 strength in all extremities, except for the right arm, which was 0 out of 5. STUDIES AND LABORATORIES ON ADMISSION: Electrocardiogram showed normal sinus rhythm at 60 beats per minute. He had a left axis deviation negative 40 degrees with normal intervals. He had no ST T elevations or changes. Chest x-ray showed no infiltrate. No evidence of congestive heart failure. CAT scan of his head showed no acute bleed. Laboratories, white count was 12.1, hemoglobin 9.0, hematocrit 27.1, platelet count 187, PTT 28.9, INR 1.2, sodium 139, potassium 4.9, chloride 105, bicarb 23, BUN 24, creatinine 1.2, glucose 180. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Doctor Last Name 22372**] MEDQUIST36 D: [**2148-7-12**] 12:27 T: [**2148-7-12**] 12:41 JOB#: [**Job Number 22373**] Admission Date: [**2148-7-3**] [**Year (4 digits) **] Date: [**2148-7-12**] Date of Birth: [**2072-12-7**] Sex: M Service: BLUE SURGE HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 22371**] is a 75-year-old male with a past medical history significant for hypertension, coronary artery disease, hypercholesterolemia, diabetes mellitus type 2 and history of three major prior cerebrovascular accidents. The patient presented to the hospital with vague abdominal pain for one month. At the time of admission on that day, the patient had many episodes of loose stools that were composed of bright red blood. The patient also had experienced some lightheadedness while waking, but denied having any shortness of breath, chest pain, fevers of chills. The patient did report some nausea, but denied any vomiting or abdominal pain. He did have some rectal tenderness. He underwent nasogastric lavage in the emergency room, which produced bright red clots, which cleared after about 300 cc normal saline flush. He was also noted to have maroon melanocolic stool, approximately 200 cc times two. He was, at that time, started on Protonix and a gastrointestinal consultation was called. PAST MEDICAL HISTORY: Mr. [**Name13 (STitle) 22448**] past medical history is significant for coronary artery disease, status post a left anterior descending stent placement in [**2148-4-15**]; hypertension; hypercholesterolemia; diabetes mellitus type 2; cerebrovascular accidents with resulting left hemiparesis and extreme right-side weakness; prostate cancer status post prostatectomy; gout; peptic ulcer disease with past gastrointestinal bleed secondary to nonsteroid anti-inflammatory use in [**2132**]; depression; and delayed gastric emptying. MEDICATIONS ON ADMISSION: 1. Atenolol 100 mg once a day. 2. Allopurinol 100 mg once a day. 3. Celexa 20 mg once a day. 4. Enteric coated aspirin 325 mg twice a day. 5. Glucophage 500 mg three times a day. 6. Hydrochlorothiazide 25 mg once a day. 7. Imdur 30 mg once a day. 8. Lipitor 40 mg once a day. 9. Protonix 40 mg once a day. 10. Aciphex 20 mg once a day. 11. Potassium chloride 10 mg once a day. 12. Plavix 75 mg once a day. 13. Arthrotek 75 mg once a day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: History is significant for the fact that he worked as an archaeologist and lived with his wife and daughter. [**Name (NI) **] quit smoking approximately 40 years ago. He now only drinks alcohol socially. FAMILY HISTORY: History is significant for diabetes mellitus in his mother and his brother, who suffered a stroke at the age of 76. PHYSICAL EXAMINATION: On admission, the blood pressure was 118/68, heart rate 74, respiratory rate 18, oxygen saturation 98% on room air. GENERAL: The patient was an ill-appearing African-American man in no acute distress. Sclerae are clear. Oropharynx and mucous membranes were moist. HEART: Heart was regular with a normal S1 and S2, no murmurs ausculted. CHEST: Chest was clear to auscultation bilaterally with no crackles or wheezing. ABDOMEN: Abdominal examination had decreased bowel sounds. Abdomen was soft, nontender, without any signs of rebound or guarding. RECTAL: Examination showed no external hemorrhoids or gross blood. EXTREMITIES: Lower extremities demonstrated no lower extremity edema. Right arm was seen to be cachectic with his hand in the flexed position. NEUROLOGICAL: Examination revealed that the patient was alert and oriented with 5/5 strength in all extremities save for the right arm, which was rated 0 out of 5 strength. LABORATORY DATA: Initial studies revealed EKG done which showed normal sinus rhythm at 60 beats per minute. There was LAD found to be approximately -40 degrees with normal intervals and no ST-T segment changes. Chest x-ray was done, which showed no infiltrates or evidence of congestive heart failure. Head CT was also performed, which showed no evidence of an acute bleed. Labs on admission revealed the following: White blood cell count 4.1, hematocrit 9.0, hematocrit 27.1, platelet count 187,000, PTT 28.4, INR 1.2, sodium 139, potassium 4.9, chloride 105, bicarbonate 23, BUN 24, creatinine 1.2, glucose 180. HOSPITAL COURSE: Mr. [**Known lastname 22371**] was admitted to the Medical Intensive Care Unit, where he underwent further gastric lavage, which returned bright red fluid. Subsequent EGD revealed melena with gastritis with a short segment of [**Doctor Last Name 15532**] esophagus, but no active bleeding was noted. However, the patient continued to pass bright red blood per rectum and subsequently a bleeding scan was obtained, which revealed a blush of bleeding at the ascending colon. At the time the patient was sent to Interventional Radiology, where superior mesenteric artery angiogram revealed active bleeding from a branch of the ileocolic artery. Attempts at vasopressin injection with increment doses failed to stop the bleeding and coil embolization was performed two times, which stopped the extravasation into the right colon. However, the patient continued to pass bright red blood per rectum and the hematocrit showed a drop from 30.8 to 22.2. The patient received 15 units of packed red blood cells and was taken to the operating room on [**7-6**]. In the operating room the patient underwent total colectomy for intractable bleeding from colonic diverticula and ileostomy site was created and stoma was brought out in the right lower quadrant of the abdomen. The patient was subsequently admitted to the surgical Intensive Care Unit, where he was monitored for blood pressure control and stabilization of hematocrit for which he received multiple transfusions. By postoperative day #4, the patient's hematocrit had stabilized and blood pressures were under good control with the patient's previous oral medications and the patient was transferred to the floor. He continued to progress well from that point forward remaining afebrile with progressively decreasing white blood cell counts and stable hematocrit. He tolerated serial advances in his diet from clear liquids to soft solids to a regular house diet and he showed good wound healing with good stoma function, gas, and stool output into his ileostomy bag and there was no further need for IV fluid hydration. CONDITION ON [**Month (only) 894**]: The patient is hemodynamically stable. He is afebrile. He is taking good nourishment orally and is feeling quite comfortable with no abdominal pain. The patient is being discharged to the [**Hospital3 7**] care facility in order to overcome decompensation, which occurred from his recent severe illness and multiple days in the Intensive Care Unit at which time he remained bed bound. Dr. [**Last Name (STitle) 957**] and the Department of Surgery at the [**Hospital1 346**] would like Mr. [**Known lastname 22371**] to followup with him in approximately 10 to 14 days. Mr. [**Known lastname 22371**] may place a phone call to Dr.[**Name (NI) 6275**] office to schedule this appointment. Mr. [**Known lastname 22449**] [**Known lastname **] medications will be the same as his admission medications with the change that he will no longer be taking Plavix. Mr. [**First Name (Titles) 22448**] [**Last Name (Titles) **] diagnoses are as follows: [**Last Name (Titles) 894**] DIAGNOSES: 1. Intractable bleeding from multiple colonic diverticula status post total colectomy and creation of ileostomy. 2. History of prior strokes. 3. History of coronary artery disease. 4. Diabetes mellitus type 2. 5. Hypercholesterolemia. 6. Hypertension. 7. History of prostate cancer. 8. History of weakness and hemiplegia secondary to cerebrovascular accidents and peptic ulcer disease with past gastrointestinal bleeding. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Dictator Info 22450**] MEDQUIST36 D: [**2148-7-12**] 12:54 T: [**2148-7-12**] 13:14 JOB#: [**Job Number 22451**]

[ "438.20", "530.2", "285.1", "535.50", "562.12", "250.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "46.20", "38.48", "88.47", "45.13", "39.79", "45.72", "38.93" ]

icd9pcs

[ [ [] ] ]

6602, 6719

5859, 6361

8327, 12101

6742, 8309

173, 1036

3323, 5278

5301, 5833

6378, 6585

65,710

163,487

42376+58521

Discharge summary

report+addendum

Admission Date: [**2169-6-16**] Discharge Date: [**2169-6-30**] Date of Birth: [**2110-8-20**] Sex: M Service: MEDICINE Allergies: Unasyn Attending:[**First Name3 (LF) 3021**] Chief Complaint: Hemoptysis post-EGD. Major Surgical or Invasive Procedure: Endoscopy on [**2169-6-16**], [**2169-6-18**], and [**2169-6-23**]. History of Present Illness: Mr. [**Known lastname **] is a 58yo [**Known lastname 8230**]-speaking M with a PMH of stage IIIc esophageal CA on warfarin for Hx of PEs who presents after an outpatient EGD done today because of inability to swallow secretions and concern of progressive disease after XRT and 4 cycles of cisplatin/5-FU. EGD revealed an area of friable and necrotic tissue, concerning for residual disease and a biopsy was taken. After the procedure, pt had an episode of hemoptysis, approx 75cc of BRB per nurse [**First Name (Titles) 1023**] [**Last Name (Titles) **] it. Labs were found to be significant for INR 4.5. Pt was transferred to the [**Hospital Unit Name 153**] for close monitoring. . On arrival to [**Hospital Unit Name 153**], VS: Hr 84, BP 115/42, RR 21, 92% RA. Pt is coughing up small amounts of blood-tinged sputum.Pt remained in teh [**Hospital Unit Name **] and was transferred to the oncology floor. Past Medical History: Oncologic History: - Stage IIIC or IV (cT4b cN1 Mx) squamous esophageal cancer, Initially presented with 6 month history of ~40 pound weight loss, dysphagia, worsening nausea/emesis with up to 6 episodes of emesis per day,and PO intolerance. He had been able to tolerate liquids and well-chewed solids, with larger pieces of food getting stuck in his throat. - [**2169-1-10**] EGD done with pathology showing SCC, also revealing esophageo-pulmonary fistula. Stent placed at that time. - PET CT without evidence of mets, underwent [**Month/Day/Year 74384**] treatment, planned for 28 days, 2050 grays total. - Started chemo-rad on [**2169-1-21**], Past Medical History: RLL abscess in setting of esophageal rupture. Multiple PE's diagnosed in [**2-5**]-on coumadin Gout Latent TB Social History: [**Date Range 8230**] speaking only. Understands some Mandarin. Lives with daughter and son-in-law. Drank and smoked heavily when younger. Denies illicits. Family History: No family h/o cancer. Physical Exam: Physical Exam on Admission: General: Alert, conversing appropriately with aid of an interpreter. NAD, appears comfortable. HEENT: Sclera anicteric, moist mucus membranes, oropharynx clear Lungs: Diffuse expiratory crackles, more pronounced at the bases. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, hyperactive bowel sounds, mild distention, no rebound tenderness or guarding Ext: Warm, well perfused . Physical Exam on Transfer out of ICU: General: Alert, conversing appropriately with aid of an interpreter. NAD, appears comfortable. HEENT: Sclera anicteric, moist mucus membranes, oropharynx clear Lungs: Diffuse expiratory crackles, more pronounced at the bases, especially present on R>L. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, hyperactive bowel sounds, mild distention, no rebound tenderness or guarding Ext: Warm, well perfused. No cyanosis, clubbing, or edema Pertinent Results: ADMISSION LABS: [**2169-6-16**] 02:00PM BLOOD WBC-9.3 RBC-3.33* Hgb-10.3* Hct-31.8* MCV-96 MCH-31.0 MCHC-32.5 RDW-16.1* Plt Ct-286 [**2169-6-23**] 07:15AM BLOOD Neuts-74.7* Lymphs-12.2* Monos-9.2 Eos-3.6 Baso-0.4 [**2169-6-16**] 12:05PM BLOOD PT-46.0* INR(PT)-4.5* [**2169-6-16**] 02:00PM BLOOD UreaN-32* Creat-0.7 Na-144 K-4.0 Cl-105 HCO3-30 AnGap-13 [**2169-6-16**] 02:00PM BLOOD ALT-41* AST-43* AlkPhos-148* Amylase-152* TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2169-6-18**] 08:52AM BLOOD Calcium-8.6 Phos-2.4*# Mg-1.7 . [**2169-6-16**] EGD: The previously placed partially covered metal stent was seen from 29 cm to 39 cm from the incisors. The lumen at the upper end of the stent was narrowed but was able to be traversed by the regular gastroscope. The stent was patent. Friable tissue and necrotic tissue were seen at the distal end of the stent suspicious for residual cancer. The lumen was partially obstructed. The regular gastroscope did not traverse. Cold forceps biopsies were performed from the friable tissue at the distal end of the stent for pathology. . [**2169-6-16**] BIOPSY OF ESOPHAGEAL MASS: Active esophagitis with ulceration; stain for fungi will be sent as an addendum; multiple levels taken (see note). Note: The squamous epithelium shows atypicality which is considered to be reactive. ADDENDUM: Stains for fungi (A) are negative; controls satisfactory. . [**2169-6-17**] CXR: Left lower lobe opacities have increased worrisome for aspiration. Cardiomediastinal contours are unchanged. Right lower lobe and right mid lung opacities are more chronic and stable. There is no pneumothorax or pleural effusion. A catheter projects in the left upper quadrant. . [**2169-6-18**] EGD: A large bulk of friable tissue was seen within the stent at the distal end. It suggested cancer tissue. Some blood clots were also seen. The lumen was near complete obstruction. The blood clots were fragmented with combination of snare and spiral basket. They were completely aspirated out. An Argon-Plasma Coagulator was applied for the tumor tissue destruction with majority of tissue within the stent successfully coagulated. More than half circumference of the stent was patent. Friable tumor tissue and necrotic tissue was also seen distal to the metal stent. The lumen was partially obstructed. The lumen at the upper end of the stent was narrowed but was able to be traversed by the regular gastroscope. . [**2169-6-18**] LLE DOPPLER U/S: IMPRESSION: No evidence of deep vein thrombosis in the left lower extremity. The patient reported intense knee pain during the study, exacerbated by flexion. [**2169-6-20**] BARIUM ESOPHOGRAM: IMPRESSION: 1. No obstructing mass. 2. Opacification of the trachea with barium indicating either aspiration or tracheoesophageal fistula at the level of the carina (proximal end of the stent), as described above. . [**2169-6-20**] VIDEO SWALLOW: IMPRESSION: No evidence of aspiration. . [**2169-6-22**] CXR: Interval appearance of the left lower lobe consolidation and left pleural effusion concerning for pneumonia . [**2169-6-23**] EGD: Impression: The old stent seen from 30 cm to 39 cm from the incisors. Two large pieces of tumor-appearing tissues seen within the stent. retrieved with [**Doctor Last Name **] net for pathology. Near complete obstruction by malignant-appearing tissues, suggesting remaining cancer, at the distal end of the stent. A 153 mm x 18 mm fully covered WallFlex esophageal metal stent successfully placed under fluoroscopic guidance. The proximal end of the new stent was at 24 cm, 7 cm proximal to the fistular opening. It was patent. . DISCHARGE LABS: Brief Hospital Course: 58yoM with Stage III esophageal CA and PEs on warfarin s/p EGD and Bx of mass [**2169-6-16**] in the setting of supratherapeutic INR who was admitted to the ICU for observation after he vomitted 75cc of BRB post-procedure. S/P Vitamin K 10units IV x1 and 2 units FFP, stable and transferred to the floor on the evening of [**6-17**]. . # Hematemsis: Pt had one episode post-procedure in the setting of supratherapeutic INR and was HD stable. Had 2 PIVs placed and received IVFs in GI suite.He was given 3 additional units of FFP on [**6-18**], prior to repeat EGD adn again 2 units of FFP prior to EGD on [**2169-6-23**]. he had no recurrent episodes of hematemesis or melena.H/H remained overall stable .Given evidence of esophagitis on biopsy of esophagus , pt was started on IV protonix [**Hospital1 **] . . # Hx of PEs: Multiple PEs seen on CTs in [**2169-1-25**]. Has been therapeutically anticoagulated for at least three months.Warfarin was initially held, and after the EGD on [**2169-6-23**] pt was restarted on coumadin after cleared by the GI-ERCP service. . # Esophageal CA: Pt underwent an EGD on [**6-16**] because of inability to swallow his saliva or liquids. EGD showed evidence of a mass causing near complete obstruction. Biospies were aobtained and showed esophaigitis and atypical cells. Repeat EGD done on [**2169-6-18**] and mass in the stent was coagulated. Pt underwent a third EGD on [**2169-6-23**] and a new stent was placed to cover the TE fistula and new biopsies obtained. Repeat biopsies show.....Case was reviewed by thoracic surgery and pt not a surgical candidate. . # PNA /TE fistula: Pt with cough after drinking post EGD on [**2169-6-18**].Barium esophogram shows evidence of TE fistula. New stent placed [**2169-6-23**] to cover fistula ( old stent migrated). CXR on [**2169-6-22**] showed evidence a new lll infiltrate and pt started on cefepime/vancomycin and flagyl. He completed..... . #Gout : Pt with gout flare with knee pain and rt shoulder, bilateral toe pain. Rheumatology consulted and . pt started on colchicine , given 1.2 mg laoding dose 6/28 and then 0.6mg [**Hospital1 **] for 3-5 days. Low dose allopurinol was continued.. . #Anemia: Stable. Likely due to chemotherapy/inflammation. Anemia panel c/w ........ . # Hx of latent TB: Con't INH/B6 . Medications on Admission: - oxycodone 5 mg PO Q6H prn pain - isoniazid 300 mg PO DAILY - allopurinol 100 mg PO DAILY - pyridoxine 50 mg PO DAILY - ondansetron 4-8mg Rapid Dissolves PO q8HR PRN nausea - Nepro 0.08-1.80 gram-kcal/mL Liquid [**Hospital1 **]: One can PO q6HR: Please flush with 250 cc of water after each feeding. Check for residuals >200 cc. - senna 1 tab PO BID - warfarin 2mg PO daily Discharge Medications: 1. tube feeds Nepro tube feeds 4 cans per day ( 240cc) free water flushes 50cc pre and post each can 2. oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) mg PO Q6H (every 6 hours) as needed for pain. 3. isoniazid 300 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. pyridoxine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. prochlorperazine maleate 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*1* 7. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: [**12-26**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*1* 8. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 11. colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*5* 13. tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Esophageal cancer Gastrointestinal bleeding Tracheo-esophageal fistula (connection between airway and esophagus) Aspiration pneumonia Gout flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], you were admitted to the hospital after vomiting blood after an upper endoscopy. The endoscopy was done because of diffulty swallowing and showed an obstructuion of your esophagus. After the procedure you bled, so you were transferred to the intensive care unit for close monitoring. A barium esophogram showed a possible connection (fistula) between the trachea (airway) and your esophagus. You had two repeat endoscopies in which biopsies were taken and a new stent was placed. You also developed a left lower lobe pneumonia, possibly due to aspiration from the fistula. This pneumonia was treated with IV antibiotics. . Change in medications: 1. Colchicine once a day until seen by your Rheumatologist. 2. Increase warfarin dose to 3mg daily. 3. Lansoprazole 30mg 2x a day (this medication takes the place of omeprazole (Prilosec) because it dissolves in your mouth and avoids having to swallow another pill that might have difficulty passing the esophageal stent). Followup Instructions: PCP [**Name Initial (PRE) **]: Tuesday, [**7-4**] at 1pm With:[**Name6 (MD) **] [**Name8 (MD) 91770**],MD Location: [**Hospital3 8233**] Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**] Phone: [**Telephone/Fax (1) 8236**] ** Be sure to get INR checked at this appointment . Hematology/Oncology: PENDING With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**0-0-**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) **] for the week of [**7-3**]. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**0-0-**]. . Department: RHEUMATOLOGY When: WEDNESDAY [**2169-8-9**] at 3:00 PM With: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . PLEASE CALL [**Hospital Ward Name **] ONCOLOGIST DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT ([**Telephone/Fax (1) 54862**] FOR A FOLLOW-UP APPOINTMENT. Name: [**Known lastname **],[**Known firstname 11840**] [**Doctor Last Name **] Unit No: [**Numeric Identifier 14448**] Admission Date: [**2169-6-16**] Discharge Date: [**2169-6-30**] Date of Birth: [**2110-8-20**] Sex: M Service: MEDICINE Allergies: Unasyn Attending:[**First Name3 (LF) 4148**] Addendum: HOSPITAL COURSE REVISED/UPDATED: 58yo man with Stage III esophageal CA and PEs on warfarin s/p EGD and biopsy of mass [**2169-6-16**] in the setting of supratherapeutic INR who was admitted to the ICU after 75cc hematemesis post-procedure. He was given vitamin K and 2 units FFP. Transferred to the floor [**2169-6-17**]. . # Hematemesis: One episode post-EGD in the setting of supratherapeutic INR. Hemodynamically stable. Given IV fluids, FFP 2U after bleeding, 3U prior to repeat EGDs. GI okay with restarting warfarin [**2169-6-23**]. Changed PPI from IV to PO: pantoprazole IV BID to lansoprazole PO BID for esophagitis seen on biopsy. . # Chronic PEs: Multiple PEs seen on CT 2/[**2168**]. Restarted warfarin per GI. Monitor INR. Increase warfarin from 2 to 3mg given subtherapeutic INR. . # Esophageal CA: Likely has residual disease after XRT and 4 cycles of 5-FU/cisplatin based on EDG. Biopsy [**2169-6-16**] showed esophagitis and atypia. Barium esophagogram suggested a tracheo-esophageal fistula. Not a surgical candidate due to location of tumor/fistula. Dysphagia likely due to near complete obstruction from blood clots in tracheal stent; improved post-EGD. - PENDING biopsy [**2169-6-23**]. . # Pneumonia/tracheo-esophageal fistula: Cough after drinking post-EGD [**2169-6-18**]. Barium esophogram [**2169-6-20**] suggested tracheo-esophageal fistula. New stent placed [**2169-6-23**] to cover fistula (old stent migrated). Blood cultures negative. Albuterol nebs PRN. Levofloxacin and metronidazole Day #1 [**2169-6-17**], switched to metronidazole, vancomycin, and cefepime for nosocomial/aspiration pneumonia [**2169-6-22**]. Plan to complete 8 days [**2169-6-30**]. No positive culture data and with evidence of fistula, risk of GI flora supercedes MRSA; D/C'd vancomycin [**2169-6-25**]. Sputum cx contaminated; no additional sputum was produced. . # Gout acute: Knee, right shoulder, bilateral toe pain. Rheumatology consulted. Started colchicine, given 1.2mg loading dose [**2169-6-22**] and then 0.6mg [**Hospital1 **], changed to once daily dosing [**2169-6-26**]. Pain improved. Continued allopurinol and colchicine. Continued tramadol and oxycodone PRN. . # Anemia: Likely due to chemotherapy/inflammation, suggested by iron panel. Stable. . # Hx of latent TB: Continued outpatient INH/B6 and current presentation was unrelated. Continued isoniazid/pyridoxine (vitamin B6). . # Constipation: Resolved. Bowel regimen as needed. . # Pain: Due to gout. Started colchicine. Continued scheduled tramadol and oxycodone PRN as above. . # FEN: Tube feeds. GI okay with advancing to liquid diet as tolerated. Repleted hypophosphatemia. . # GI PPx: PPI [**Hospital1 **] for hematemesis. Bowel regimen for constipation. . # DVT PPx: Restarted warfarin for PEs. . # Access: Peripheral IV. . # Code: FULL. Discharge Disposition: Home with Service [**Name6 (MD) **] [**Last Name (NamePattern4) 4150**] MD [**MD Number(2) 4151**] Completed by:[**2169-6-30**]

[ "150.9", "564.00", "285.3", "530.3", "998.11", "V12.55", "795.51", "274.01", "E878.8", "507.0", "V15.82", "V44.4", "530.84", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "98.02", "96.6", "42.33", "42.24", "42.81" ]

icd9pcs

[ [ [] ] ]

17135, 17293

6996, 9302

288, 357

11520, 11520

3332, 3332

12696, 17112

2292, 2315

9727, 11290

11353, 11499

9328, 9704

11670, 12673

6973, 6973

2330, 2344

228, 250

385, 1296

3348, 6956

2358, 3313

11535, 11646

1988, 2099

2115, 2276

46,793

161,403

4130

Discharge summary

report

Admission Date: [**2121-8-25**] Discharge Date: [**2121-8-30**] Date of Birth: [**2052-10-4**] Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing Attending:[**First Name3 (LF) 1515**] Chief Complaint: ches discomfort and worsening shortness of breath Major Surgical or Invasive Procedure: CoreValve aortic valve replacement History of Present Illness: Pt is a 68yo caucasian male who presented with c/o worsening shortness of breath limiting activities, and chest discomfort at rest. PMHx significant for Hodgkins disease treated with high dose radiation to the chest in the [**2070**]'s, CAD s/p CABG and redo, severe aortic stenosis,PPM, DM, lupus. He was transferred to [**Hospital1 18**] [**7-24**], underwent cardiac cath, was found to have 80%LCX stenosis and was treated with bare metal stent. His echo confirmed severe aortic stenosis, [**Location (un) 109**] 1.0cm2, mean gradient 45mmHG, peak velocity 4.3mm/sec. Mr [**Known lastname **] reports he has noted SOB over the past year, however significantly worsening over the past few weeks. He was walking 1.5 miles daily, now limited due to near syncopal episodes. He was experiencing chest pain daily prior to his last intervention. He feels his worsening shortness of breath is severely limiting his ADLs and is seeking aortic valve treatment options. Patient reports no admissions since last seen. No medication changes. Noticing decline in functional status, now only able to ambulate about 75 feet prior to experiencing blurred vision, lightheadedness. Past Medical History: -CAD -bare metal stent to left circumflex ([**2121-7-24**]) -Multiple coronary angioplasties and stents (?19) -CABG (x3, [**2091**]), (SVG-LAD, SVG-RCA/OM) -redo CABG ([**2101**]), (LIMA-LAD, SVG-RCA, ligation of old SVG RCA) -Left inframammary AV fistula -known aortic stenosis - s/p PM for AV block -[**2101**] - insulin dependent DM - HTN - hyperlipidemia - left internal carotid stenosis (50-69%) - Hodgkin's dz (sp XRT neck, mediastinum) - Lupus anticoagulant (on coumadin-subtherapeutic INR secondary to bleeding) - COPD - asthma - sleep apnea - peptic ulcer disease - papillary thyroid cancer s/p thyroidectomy - BPH - hematuria s/p left ureteropyeloscopy (cytology neg) - spinal stenosis - degenerative joint disease of the hips, knees and shoulders - left shoulder fx/pinning secondary to MVA - right wrist fx secondary to fall - right carpal tunnel surgery - back surgery x 2 (disc fusions) - choleycystectomy - tonsillectomy - appendectomy Social History: Lives with wife. Denies current tobacco, etoh, drug use. Family History: Father deceased, 64yo, CVA. Mother deceased, age [**Age over 90 **] CAD. Sister deceased, age 62, breast Ca. Bother, age 78, A+W. Son,age 45, parkinsons dz. Daughter, A+W. Physical Exam: Admission physical exam: Pulse:69 B/P: Left 123/78 Resp:16 O2 Sat: 96(RA) Temp:98.4 Height: Weight: 200.5 lbs General:NAD A&O. Skin: Dry/intact. Tan. Right medial knee two scratches secondary to ?chicken vs. fence. Trace erythema, well approx., dry. HEENT: NCAT. Edentulous. Neck: Supple, trachea midline. Bilat bruits vs murmer. Chest: CTAB. Resp easy at rest. SOB with ambulation Heart: irreg irreg, Grade III Systolic Murmur Abdomen: Soft NTND. Extremities: Warm, well perfused. Distal pulses intact. 1+ LE edema bilaterally. Right groin site clean and dry. Palp 2x6cm ridge. No echymosis. Neuro: A&Ox3. OOB, ambulating with cane, gait unsteady. Pulses: Palp DP/PT/Fem bilat. Palp Radials Discharge physical exam: afebrile, vital signs stable Exam notable for - JVP non elevated - CHEST: CTABL no wheezes, no rales, no rhonchi - CV: S1 S2, 2/6 systolic murmur at RUSB, [**Month (only) **] in intensity. Pertinent Results: Admission labs: WBC 8.2 Hgb 14.8 Hct 43.5 Plts 146 INR 1.8 PT 19.6 PTT 40.1 NA 141 K 4.1 Cl 108 CO2 27 BUN 26 Cr 1.0 Gluc 198 ALT 40 AST 25 Alk phos 110 Tbili 0.8 CK 146 proBNP 250 HgbA1c 7.0 U/A: 2RBC 1WBC, no bact, no yeast, <1epi, tra protein, 150 glucose, neg leuk, neg nitrites Urine culture: no growth CXR ([**2121-8-25**]): No acute cardiopulmonary process. No change from prior. Post-operative EKG ([**2121-8-26**]): Notable for new LBBB. Normal sinus rhythm. Otherwise unchanged. Femoral vascular ultrasound, right([**2121-8-25**]): No evidence of arteriovenous fistula in right groin. Findings consistent with a 1.4 cm, thrombosed SFA branch pseudoaneurysm, decreased in size compared to prior outside hospital CTA. Transthoracic echocardiogram ([**2121-8-26**]): Pre valve deployment No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the results on [**2121-8-26**] at 845 am. Post valve deployment Corevalve seen in the aortic position. Appears well seated. There is 1- 2 + aortic insufficiency seen. The jet is eccentric. The mean gradient across the aortic valve is 10 mm Hg and the peak gradient is 17 mm Hg. The mitral regurgitation was moderate post implant and has settled to 1+ subsequently. Transthoracic echocardiogram ([**2121-8-27**]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No definite regional wall motion abnormality was identified is suboptimal views. Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric at least mild to moderate ([**1-5**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. At least moderate [2+] tricuspid regurgitation is seen around the pacemaker lead. The tricuspid regurgitation jet is eccentric and may be underestimated. There is no pericardial effusion. Transthoracic echocardiogram ([**2121-8-30**]): The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. There is no aortic valve stenosis. Mild (1+) paravalvular aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, laterally directed jet of at least mild to moderate ([**1-5**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. At least moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is borderline pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2121-8-27**], findings are similar. Discharge labs: WBC 7.7 Hgb 14.6 Hct 42.6 Plts 103 Na 141 K 3.6 Cl 105 HCO3 27 BUN 21 Cr 1.0 Glucose 130 proBNP 437 Brief Hospital Course: 68yo male with worsening symptomatic aortic stenosis including blurred vision and near syncope after 100feet. Past medical history significant for high dose mediastinal and chest radiation, prior CABG and CABG redo, CAD-s/p NSTEMI one month prior with PCI, pacemaker, lupus, diabetes - deemed prohibitively extreme risk for surgical AVR. He has met all the major inclusion and has none of the major exclusions for the CoreValve clinical trial. He has been screened and accepted for TAVI/Corevalve trial. # s/p Corevalve- Patient was extubated succesfully postoperatively. Post-operative echocardiogram showed appropriate placement of corevalve with 1+AR. EKG was notable for new LBBB. Patient was monitored overnight in the CCU post-operatively and was hemodynamically stable without arrhythmias on telemetry. His catheterization site was c/d/i after sheaths were pulled with no hematoma and no bruits appreciated on exam. Patient was transferred to the floor on HD2/POD1. He walked with physical therapy, and did not have further vision blurring or near syncope with walking. He was discharged on HD5/POD4 as he was feeling well, hemodynamically stable, without any events on telemetry and a stable echocardiogram. # CAD- Patient had no chest pain throughout admission. He was clopidogrel throughout admission. Aspirin was started post-operatively as coumadin was held initially. Patient was restarted on coumadin and will continue aspirin until therapeutic. Patient was continued on crestor throughout admission. ACE inhibitor was held day of procedure, but were restarted on POD1. Blood pressures were initially low and so captopril was started at low dose, but changed to lisinopril 10mg when pressures normalized. # Dye allergy- Patient has a known dye allergy. He was premedicated prior to catheterization with prednisone and an H2 blocker. These were discontinued immediately following the procedure. Patient had no reaction to contrast. # HTN- Patient's pressures were well controlled throughout admission. They were initially low and so lisinopril, diltiazem and imdur were held. Patient was discharged on lisinopril, but imdur and diltiazem continued to be held at the time of discharge. These should be restarted per the disgression of patient's outpatient cardiologist depending on blood pressures. # Lupus anti-coagulant- Patient is on warfarin for pro-coagulant state. This was held prior to procedure and restarted on HD3/POD2. Patient was continued on aspirin at the time of discharge until he reaches a therapeutic INR. # BPH- Patient was continued on home tamsulosin and dutasteride during admission. # COPD- Patient's lung exam was stable throughout admission. He tolerated intubation and was extubated without issue. He was continued on home albuterol and theophylline throughout admission. # Insulin dependent diabetes mellitus- Patient was on a diabetic diet throughout admission. His blood sugar was initially controlled with an insulin drip which was chagned to an insulin sliding scale on POD1. # Transitional issues: - Patient will follow-up with Dr. [**Last Name (STitle) **] on Friday [**9-19**]. He will have an echocardiogram during this appointment. - Imdur and diltiazem were held at the time of discharge - Patient will follow-up with PCP on [**Name9 (PRE) 766**] [**9-1**]. He will need an INR check. Once INR is >2.0, he can discontinue aspirin. - Patient should continue plavix for 3 months. - Patient was full code throughout admission. Medications on Admission: Warfarin 5mg, 5mg, 7.5mg rotation daily - last dose 8/19 diltiazem HCL ER beads 180mg [**Hospital1 **] crestor 10mg daily plavix 75mg daily isosorbide dinitrate 40mg 2 tabs four times a day albuterol sulfate (2.5mg/3ml) 0.083% as directed albuterol sulfate HFA 2 puffs q4h prn theophylline 300mg [**Hospital1 **] NPH 20-25units [**Hospital1 **] Humulin R 100 sliding scale levothyroxine sodium 175mg daily Proscar 5 mg daily flomax 0.4mg daily avodart 0.5mg daily alprazolam 0.5mg po TID perocet 5/325mg 1 tab prn q6h prn Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: take 7.5mg/7.5mg/5mg as before. 3. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation four times a day as needed for shortness of breath or wheezing. 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 6. theophylline 300 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO q12 (). 7. NPH insulin human recomb 100 unit/mL Suspension Sig: 20-25 units Subcutaneous twice a day. 8. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day. 9. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily (). 13. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 14. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Aortic stenosis s/p percutaneous CoreValve placement Coronary artery disease Hypertension Dyslipidemia Lupus anticoagulant Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had severe aortic valve disease and had the valve replaced using a CoreValve. This procedure went well and the echocardiogram shows that the valve is working well. You were restarted on your coumadin and should get your INR checked at Dr.[**Name (NI) 8716**] office on Monday [**9-1**]. Once your INR is more than 2.0, you can discontinue the aspirin but continue to take the plavix for the next few months. . We made the following changes to your medicines: 1. Stop taking Diltiazem amd Imdur 2. Continue to take plavix for at least 3 months. 3. Resume your previous coumadin regimen with goal INR 2.0-3.0. Stop taking aspirin when your INR is more than 2.0. 4. Start taking Lisinopril at 10mg to lower your blood pressure. Followup Instructions: Department: CARDIAC SERVICES When: [**9-9**] at 9:00am With: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 8725**] [**9-15**] appt is cancelled. Department: CARDIAC SERVICES When: FRIDAY [**2121-9-19**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2121-9-19**] at 10:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "88.47", "88.56", "35.22", "00.66", "36.06", "37.22", "00.45", "00.40", "35.96", "88.42" ]

icd9pcs

[ [ [] ] ]

13253, 13316

7687, 10744

335, 372

13512, 13512

3761, 3761

14417, 15219

2641, 2814

11772, 13230

13337, 13491

11226, 11749

13663, 14394

7562, 7664

2854, 3526

10765, 11200

246, 297

400, 1575

3777, 7546

13527, 13639

1597, 2550

2566, 2625

3551, 3742

20,325

132,952

49096

Discharge summary

report

Admission Date: [**2160-7-30**] Discharge Date: [**2160-8-7**] Date of Birth: [**2121-3-23**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old woman with a history of blurred vision, worsening over the last few months, in the left eye and also headache. PAST MEDICAL HISTORY: The patient has a past medical history of type 2 diabetes, hypertension, and depression. ALLERGIES: Tylenol with Codeine. PHYSICAL EXAMINATION: Temperature was 97.6, heart rate 65, blood pressure 148/88, respiratory rate 18, saturation 98%. In general, this is a woman in no acute distress. HEENT examination revealed question of left eye papilledema, no bruit over the left eye or temple, nonicteric. The neck was supple. The chest was clear to auscultation. Cardiovascular examination revealed regular rate and rhythm with no murmur, rub, or gallop. GI revealed a soft, nontender, and nondistended abdomen with positive bowel sounds. The extremities revealed no clubbing, cyanosis, or edema. The skin was within normal limits. Neurologically, the patient was awake, alert, and oriented times three. Speech was fluent. Deep tendon reflexes were 1+ bilaterally. Toes were down-going. The face was symmetric. There was no pronator drift. The patient was admitted to the Neurosurgery Service. She was seen by neuro-ophthalmology for visual field testing. The patient's MRI scan showed a 15 cm suprasellar enhancing mass that compressed laterally and displaced the left optic nerve just prior to the chiasm. This was causing decreased vision in the left eye. HOSPITAL COURSE: On [**2160-8-1**], the patient underwent right frontal craniotomy for resection of tubercular sellar meningioma. There were no intraoperative complications. Postoperatively the patient was monitored in the Surgical Intensive Care Unit. She was awake, alert, and oriented times three. Pupils were 5 down to 3 mm bilaterally. The face was symmetric. She had no drift. Her strength was [**3-22**] in all muscle groups. She continued to have a left superior field cut. Her dressing was clean, dry, and intact. She was transferred to the regular floor. Postoperatively she was very sleepy and difficult to arouse. It took several days for the patient's mental status to clear and she was finally awake, alert, and oriented times three and up out of bed on postoperative day #3 with full extraocular movements, no drifts, and face symmetric. She was seen by physical therapy and occupational therapy and found to be safe for discharge to home. MEDICATIONS AT THE TIME OF DISCHARGE: Decadron taper to off over one week, Zantac 150 mg p.o. b.i.d., Percocet 1-2 tablets p.o. q. 4 hours p.r.n., Ambien 15 mg p.o. q.h.s., Remeron 45 mg p.o. q.h.s., Atenolol 25 mg p.o. q. day, Premarin 0.625 mg p.o. q. day, Neurontin 100 mg p.o. q.h.s. CONDITION ON DISCHARGE: The patient was in stable condition at the time of discharge. She will return for staple removal 10 days postoperatively. She will be followed up in the Brain [**Hospital 341**] Clinic to see Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 724**] in three weeks time. Her dressing was clean, dry, and intact. Her vital signs were stable and she was afebrile at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2160-8-7**] 11:04 T: [**2160-8-11**] 18:56 JOB#: [**Job Number **]

[ "300.00", "401.9", "225.2", "250.00", "311" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

1614, 2855

467, 1596

155, 296

319, 444

2880, 3556

4,423

135,733

47695

Discharge summary

report

Admission Date: [**2137-2-11**] Discharge Date: [**2137-2-22**] Date of Birth: [**2084-3-23**] Sex: F Service: NEUROSURGERY Allergies: Vancomycin And Derivatives / Penicillins / Dilantin / Phenergan Attending:[**First Name3 (LF) 1835**] Chief Complaint: Left lower extremity weakness, ?seizures Major Surgical or Invasive Procedure: Bifrontal craniotomy for resection of tumor, Intraoperative MRI guidance. Reconstruction of skull base, dura, duraplasties and pericranial allograft flap, frontal sinus repair with exenteration, duraplasty, cranioplasties and autologous graft. History of Present Illness: The patient is a 53 year old female with a history of right sided CVA and seizures who has also cardiac compromise from mitral regurgitation who presents to [**Hospital1 827**] after MRI at an outside facility showed a large bifrontal lesion. The patient had complained about episodes of weakness for the last 6 months. She also had developed memory problems, difficulty [**Location (un) 1131**], fatigue, headaches, and change in personality. A workup including MRI was suggested by neurology and the patient was found to have a very large bifrontal meningioma arising from the falx. Past Medical History: 1. Preeclampsia ('[**22**]) 2. SBE ('[**22**]) 3. CVA ('[**22**]) - residual left sided weakness, difficulty with decision making, ataxia, anosmia (improving), left arm parasthesias 4. Seizures (started '[**22**], last one 8 yrs ago) 5. Depression 6. Mitral regurg 7. C-Sx ('[**22**]) 8. s/p tubal ligation ('[**24**]) Social History: Previously worked as nurse, at home x 15 yrs. Married one son, no [**Name2 (NI) **], drugs. Occ etoh. Family History: Mother w/[**Name (NI) **], father heart dx alive and, one sister. [**Name (NI) **] w/"brain tumor" Physical Exam: NAD AAOx3 S1 S2 holosystolic murmur, RRR CTAB soft NT/ND Neuro: Normal mini-mental status exam except for slight hesitation with serial 7's (after 3rd one) CNII-XII intact except for decreased sensation over region of mandibular branch of CN V, R pupil slightly more dilated than left (~3 vs 2.5 mm) Motor 5+ except for some weakness on left deltoid (complained of pain when tested) Coordination intact Deep tendon reflexes intact Sensorium on R>L - c/o decreased sensation on left side - upper and lower extremities No abnormal gait appreciated Pertinent Results: [**2137-2-11**] 02:45PM PT-11.8 PTT-21.9* INR(PT)-1.0 [**2137-2-11**] 02:45PM PLT COUNT-230 [**2137-2-11**] 02:45PM NEUTS-71.4* LYMPHS-22.0 MONOS-4.5 EOS-1.1 BASOS-0.9 [**2137-2-11**] 02:45PM WBC-5.3 RBC-4.10* HGB-12.6 HCT-34.6* MCV-85 MCH-30.8 MCHC-36.5* RDW-12.9 [**2137-2-11**] 02:45PM CARBAMZPN-6.8 [**2137-2-11**] 02:45PM VALPROATE-<3.0* [**2137-2-11**] 02:45PM DIGOXIN-0.7* [**2137-2-11**] 02:45PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.1 [**2137-2-11**] 02:45PM GLUCOSE-87 UREA N-19 CREAT-0.7 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 [**2137-2-11**] 09:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2137-2-11**] 09:51PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 . MRI head (no contrast): Large frontal mass (4.5 x 7 cm), spanning L and R ant [**Last Name (un) **] spaces - consistent with meningioma. Extensive vascularity. + Edema in both frontal lobes. Brief Hospital Course: 52 year-old female who has been followed by a neurologist initially presented with episodes of weakness for the last 6 months. She also had developed memory problems, difficulty [**Location (un) 1131**], fatigue, headaches, and change in personality. Out side MRI obtained by her neurologist showed bifrontal meningioma then referred to go to ED for neusurgical evaluation.The patient underwent a full work up including a CTA, MRV, and a 4 vessel angiogram which showed dense vascular supply to this lesion from both ethmoidal arteries, right sided anterior falcian artery arising from the ophthalmic artery, a supply from the R ECA and multiple sources of dural supply. The patient underwent preoperative angiographic embolization and was taken electively to the operating room for bifrontal meningioma resection, pericranial allograft flap and duraplasty under general anesthesia without intraoperaive complications. The estimated blood loss during the procedure was 1000 ml. The patient is transfused with blood products and was adequately loaded with anticonvulsants as well as received a second load of Decadron and antibiotics. Patient transferred to Neuro ICU for immediate postoperative period for hemodymamic and neurologic monitoring. She was seen by cardiology for endocarditis in the past who recommened keeping HCT greater than 25. Pt was transferred to step down unit on [**2136-2-20**] where she was awake, alert and orientated X3. Her affect appeared to exhibit symptoms of being "frontal" animated and impulsive. She was seen by PT/OT she was found to have some gait instability and impulsive behavior they recommended acute rehab. Her hematocrit was was 25 on [**2-16**] and [**2-20**] for which she received 2 units of blood on those dates. On discharge her crit was 39. Her tegratol level was 5.1 and goal is 8.5 she received extra Tegratol on [**2-19**] she should have it rechecked in a week. On discharge she was walking with assistance, tolerating a regular diet and voiding without difficulty, following commands and neurologically intact. Medications on Admission: Digoxin 0.25 qd lisinopril 5 qd tegretol 200 tid Neurontin 300 qAM and qNOON, 600 qPM ASA 325 QOD (d/c'd [**2-10**]) Celexa 40 qd Blue-green algae 500 qd (for left arm pain) Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever>101.0 F. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days: start on [**2-24**]. 14. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO three times a day for 2 days: start [**2-22**]. Tablet(s) 15. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days: start [**2-26**]. 16. Sodium Chloride 0.9 % Parenteral Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed. 17. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: probable meningioma Discharge Condition: Neurologically stable. Discharge Instructions: Follow Decadron taper per order. Please call for seizures, fever greater than 101.5, excessive nausea and vomiting, or any questions or acute change in neurologic status Followup Instructions: discharge to rehab facility. Return for suture removal in 3 days (Monday) in outpatient clinic at [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] between 9am and 12pm. Follow up with primary care physician upon discharge Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 608**] and cardiologist with Dr [**Last Name (STitle) 100733**] at [**Hospital1 18**] prn Completed by:[**2137-2-22**]

[ "438.89", "311", "780.39", "237.6", "427.9", "285.1", "781.1", "V12.59", "530.81", "424.0", "458.29", "998.11" ]

icd9cm

[ [ [] ] ]

[ "99.09", "99.07", "02.06", "99.05", "99.04", "01.51", "39.72", "88.72" ]

icd9pcs

[ [ [] ] ]

7245, 7315

3417, 5488

369, 616

7379, 7404

2394, 3394

7622, 8051

1711, 1812

5712, 7222

7336, 7358

5514, 5689

7428, 7599

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Discharge summary

report

Admission Date: [**2118-5-6**] Discharge Date: [**2118-5-26**] Date of Birth: [**2052-6-1**] Sex: F Service: MEDICINE Allergies: Morphine / Imdur / Haldol Attending:[**First Name3 (LF) 19836**] Chief Complaint: Dyspnea and confusion Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: 65 F c CAD/CHF, diabetes, hypertension, [**First Name3 (LF) 20440**] [**First Name3 (LF) 20441**], schizoaffective disorder, smoking history who was recently hospitalized for shortness of breath thought [**3-18**] to CHF ([**Date range (1) 20443**]). Diuresed with successful resolution of symptoms . On the day prior to admission, daughter called PCP [**Last Name (NamePattern4) **]: psychiatric concerns (non-sensical conversations, confusion re: meds). Saw psych this morning; felt that pt. thought process linear and cognition intact. Saw PCP on the afternoon of admission and complained of SOB. O2 sat was 89% RA and improved with supplemental O2 by NC. She also complained of chest pressure at that time and received SLNTG with good effect, she was then sent to ED. . In ED the pt was afebrile c BP 175/74. Negative set of cardiac enzymes. Etiology of dyspnea remained unclear and she was treated for CHF c 20 IV lasix, COPD flare c solumedrol, levofloxacin, nebulizers, and treated for possible CAD contributing to symptoms. She Recevied ASA, lopressor, and had one episode of CP in ED requiring SLNTG. Past Medical History: CAD NSTMI [**2-17**] s/p PCI w/ DES to proximal and distal LCX. CHF (diastolic dysfunction w/ EF >55%, 1+ AR and 2+MR) ho rheumatic heart disease w/ AR and MR [**First Name (Titles) 20440**] [**Last Name (Titles) 20441**] depression DM HTN schizoaffectie disorder hypercholesteronemia Social History: She lives alone, her daughter, [**Name (NI) **], who lives nearby and visits her frequently and helps her managing her medications, keeping appointments and daily living. Mobility limited due to joint pain. Currently uses walker for walking. Has home nurse aid visiting her regularly for daily acitivity as well; Smoker 1 pack qod for 30-40 years, quit 2 days ago; social drinker; no illicit drugs Family History: CAD in mother and brother Physical Exam: VS: 98.9, 174/80, 72, 20 GEN: pleasant, comfortable, NAD HEENT: EOMI, anicteric, MMM, op without lesions NECK: JVP not visualized [**3-18**] body habitus RESP: bibasilar crackles, no wheeze detected. no rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: diffusely tender to palpation, non distended, bs+ EXT: warm to touch, trace edema noted SKIN: no rashes/no jaundice NEURO: A*O*2; can number 4 quarters in a dollar but errs on nickels in quarter. Lists only meats when asked to make a grocery list. Difficulty naming presidents backwards (confused re: order). Often tangential. Pertinent Results: LABS ON ADMISSION: [**2118-5-6**] 01:40PM WBC-6.2 RBC-3.69* HGB-12.5 HCT-37.2 MCV-101* MCH-34.0* MCHC-33.7 RDW-14.2 [**2118-5-6**] 01:40PM CK-MB-3 cTropnT-<0.01 proBNP-2401* [**2118-5-6**] 01:40PM GLUCOSE-95 UREA N-14 CREAT-1.2* SODIUM-143 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14 [**2118-5-6**] 07:20PM CK-MB-3 cTropnT-<0.01 [**2118-5-6**] 07:20PM CK(CPK)-171* [**2118-5-6**] 01:57PM LACTATE-0.9 [**2118-5-6**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . CXR: 1. No acute cardiopulmonary process. 2. Stable left middle mediastinal contour irregularity, likely related to a trotous aorta and unchanged since [**2115**]. 3. Left lung base scarring. . HEAD CT: IMPRESSION: No evidence of intracranial hemorrhage. . CXR [**5-11**] IMPRESSION: Small bilateral pleural effusions. Partial obscuration of both hemidiaphragms may be related to effusions and body habitus, but early basilar pneumonia is not excluded. Followup radiographs may be helpful. . CTA CHEST: 1. No evidence of pulmonary embolus. 2. Asymmetric dilatation of descending thoracic aorta. Differential diagnosis includes a large penetrating ulcer, changes from prior focal aortic dissection or a post-traumatic pseudoaneurysm. There is no evidence of acute aortic dissection. 3. Bilateral lower lobe atelectasis. No pleural effusion. 4. Severe emphysema with superimposed areas of ground-glass opacity which could represent congestive heart failure. No pleural effusion. 5. Concentric left ventricular hypertrophy. 6. Abrupt cut-off of suprahepatic inferior vena cava, incompletely assessed. 7. Two right lung pulmonary nodules measuring up to 5 mm. Given underlying emphysema, three-month followup chest CT is recommended. . MR HEAD: IMPRESSION: No acute infarct or enhancing abnormalities. . [**Month/Year (2) **]: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (however images suboptimal; cannot exclude). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. No vegetation identified (cannot exclude). . . P-MIBI: IMPRESSION: Normal myocardial perfusion. Normal left ventricular cavity size. Calculated LVEF 57%. No anginal type symptoms or ischemic EKG changes . WRIST X_RAY: 1. Subtle early erosion of the distal radial-ulnar joint and ulnar styloid could be consistent with history of [**Month/Year (2) 20440**] [**Month/Year (2) 20441**]. 2. Osteoarthritic change at the first CMC joint. Diffuse demineralization.. . FOOT X_RAY: RIGHT FOOT: There is no fracture or dislocation. There is diffuse demineralization. There is no osseous erosion or joint space narrowing, but there is mild spurring at the tarsometatarsal joints dorsally. There are clawtoe deformities and lateral deviation at the tarsometatarsal joints. There is prominent ankle soft tissue swelling. No soft tissue calcification or radiopaque foreign bodies are seen. LEFT FOOT: There is no fracture or dislocation. There is no osseous erosion or joint space narrowing. Several clawtoe deformities are seen, and there is lateral tarsometatarsal deviation. There is diffuse demineralization. There is prominent ankle soft tissue swelling. . . LP: [**2118-5-12**] 05:13PM CEREBROSPINAL FLUID (CSF) TotProt-44 Glucose-99 [**2118-5-12**] 05:13PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-0 Lymphs-76 Monos-24 Negative HSV PCR Brief Hospital Course: The patient was admitted to the floor for further of hypoxia, fevers, and altered mental status. Her active hospital issues include: . . # Hypoxia: While on the floor she was hypoxic and had a new O2 requirement. She was treated for Pneumonia and for CHF. Antibiotics used were ceftriaxone and azithromycin. She was aggresivly diuresed to the point of a bump in creatinene wihtout resolution of her hypoxia. She also received steroids at the beginning of her admission for possible COPD, but these were quickly d/c'd after onyl 1 dose in ED [**3-18**] mental status. Ammonia, B12, folate,TSH all normal, RPR negative. No significant hypo- or hyperglycemia. Blood and urine cultures were negative. Additionally patient continued to have continued hypoxia and ABG on [**5-12**] was 7.41/42/58/28. . On [**5-12**] the pt was transferred to the MICU for intubation to treat her hypoxia and allow for deep sedation to obtain diagnostic tests. She was briefly intubated on [**5-13**] so that she could complete her diagnostic w/u and then extubated. LP was negative for infection, EEG was negative for seizure, MRI did not show stoke or mass, and CTA was negative for PE. It did show ground glass opacities on uncertain etiology. Pulmonary and infectious disease became involved after transfer back to the floor. Pulmonary recommended PFTs which were scheduled but the patient was unable to perform them [**3-18**] not following comands and not able to sit up right. Further work-up included an [**Month/Day (2) 113**] which was negative for pulmonary hypertension or shunt. Ultimately, it was felt by pulm and rheumatology consults that her hypoxia was not due to an acute pulmonary or rheumatologic issue. There is most likely a very large anxiety component on top of baseline restrictive lung disease + COPD. She will need outpatient PFT's after discharge. . # Chest Pain: With regard to her CP, she had 3 sets of negative CEs and no EKG changes suggestive of ischemia. P-MIBI revealed normal myocardial perfusion and EF 57%. She continued to have several episodes of chest pain and SOB per day during the remainder of her hospital course; however, during each episode, it was ultimately attributed to anxiety attacks. Thus, her chest pain episodes were felt to be secondary to her severe anxiety and were dramatically relieved with ativan. . # Anxiety: Patient was seen and evaluated by psychiatry for her hx of psychotic depression and extreme anxiety. She was restarted on Lexapro and ativan to good effect. On discharge, she was taking Lexapro 20 mg QD and Ativan 1-2 mg every 4 hours as needed for anxiety. . # Mental Status: CT of the head was negative for bleed or stroke and EEG did not show evidence of seizure. A medical cause for her fevers and hypoxia was investegated. It was thought that her hypoxia could be inducing her aggitation, but also it was possible that her aggitation was inducing her hypoxia and her oxygen need was lower when agitation was treated. She was treated empirically also for HSV but acyclovir was d/c'd after negative LP. She was seen by psychiatry who thought she had delirium. Initially treated with zyprexa but with variable reults. IV ativan seemed to acheive good effect. . # FEVERS: The patient had low-grade temperatures initially thought to be either PNA, UTI. Treatment for this did not resolve her fevers. Highest temp was 101.3 on [**5-12**]. With ID involvement, all antibiotics were d/c'd. Her low-grade fevers continued, but by [**2118-5-18**] seemed to have resolved. Rheumatology was consulted to investigate possible contriubtion of RA to her low grade fevers and lung disease seen on CT. RA was not felt to be involved. By discharge, she had been afebrile for >72 hours. She had one blood culture which grew coag neg staph felt to be contaminant. All subsequent cultures revealed no subsequent growth to date. C. diff was negative X 3. At the time of discharge, she was symptoms free and afebrilke Medications on Admission: Aspirin 325 mg qd Lexapro 20 mg qd Trazodone 150 mg q.h.s. Risperdal 1 mg q.h.s. Plaquenil 200 mg qd Naprosyn 500 mg q.12h. atorvastatin 20 mg a day lisinopril 40 mg b.i.d. fexofenadine 60 mg b.i.d. folic acid 1 mg once daily Hexavitamin 1 pill a day fluticasone nasal spray daily Protonix 40 mg a day nifedipine sustained release 30 mg q.h.s. sulfasalazine 500 mg b.i.d. Colace 100 mg b.i.d. metoprolol tartrate 75 mg b.i.d. furosemide 20 mg daily Combivent two puffs q.4-6h. p.r.n. Discharge Medications: 1. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet [**Month/Day/Year **]: One (1) Cap PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day/Year **]: One (1) Appl Topical TID (3 times a day) as needed. 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 3.5 Tablets PO BID (2 times a day). 8. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours). 10. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Nebulizer Inhalation Q6H (every 6 hours) as needed. 11. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) Units Injection TID (3 times a day): For use whil not amblatory. 13. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2 times a day) as needed. 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours). 18. Escitalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 19. Hydroxychloroquine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 20. Sulfasalazine 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 21. Insulin: Please continue insulin sliding scale 22. Ativan 1 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every four (4) hours as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Hypoxia of uncertain etiology - likely underlying lung disease exacerbated by aggitated delerium and psychiatric decompensation; now improved . Fever of unknown origin: now resolved . -CAD NSTMI [**2-17**] c Cath showing 90% LCx lesion treated with stent. 50% RCA stenosis. -CHF (diastolic dysfunction w/ EF >55%, 1+ AR and 2+MR), ho rheumatic heart disease w/ AR and MR. [**First Name (Titles) **] [**Last Name (Titles) **] c EF > 60% 11/06 c LVH. - Depression c psychotic features - DM - Hypercholesteronemia - History of pulmonary embolus in [**2080**], while taking oral contraceptives, s/p IVC "interruption procedure"), - Hypertension. - [**Year (4 digits) **] [**Year (4 digits) 20441**]. - History of thyroiditis. - Schizo-affective disorder. - Status post C5 to C7 anterior decompression fusion. - Status post cholecystectomy. - Status post repair of carpal tunnel syndrome. - History of seizure disorder from infancy to age of 17. Discharge Condition: stable, chest pain free Discharge Instructions: Please take all medications as prescribed. Please attend all follow up appointments. If you develop spiking fevers, an increased oxygen demand, or increased confusion and aggitaion please contact your health are providers. Followup Instructions: Once you are dicharged from rehab, please call to schedule an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**]. You can call [**Telephone/Fax (1) 250**]. . Please attend all additional appointments: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3520**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2118-6-2**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2118-6-27**] 11:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]

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Discharge summary

report

Admission Date: [**2154-5-17**] Discharge Date: [**2154-5-19**] Date of Birth: [**2098-8-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2736**] Chief Complaint: chest pain during elective coronary angiography Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 51 year old man with h/o CAD s/p PCI with DESX2 to RCA in [**2148**] admitted d/t chest pain episode during elective coronary cath likely [**2-6**] to jailing of septal perforator. . Patient has h/o of NSTEMI in [**2148**] s/p mid/distal RCA stenting at the time with 2 overlapping CYPHER stents, also found to have 40% LAD + 60% D1 lesions + 40% lesion in the origin of OM1. . Over past 2-3 months reports episodes 30-90 minutes long continous pain and discomfort in right proximal arm and posterior neck sometimes accompanied by anterior chest "ponding sensation". Had upto one episode per week always at rest and unrelated to exertion. He also describes a continous mild inter-scapular pain for the past 1-2 months. He denies SOB, nausea or other associated symptoms. He works as an electrical contractor, he says he climbs up upto 20 flights of stairs daily without becoming symptomatic. His STEMI in [**2148**] had presented at the time with anterior, lower jaw and left arm pain. Of note at home patient is on aspirin, statin and metoprolol, no nitrates. . The patient was recently seen by Dr. [**Last Name (STitle) 59323**] and had a stress test which demonstrated inferior, posterolateral and anterolateral ischemia with an EF of 71%. He has been enrolled in the CORE 320 CT trial and referred today for coronary catheterization. . Cath lab noted that patient vagaled during obtaining access, he was given atropine and fluid (for HR of 30s and SBP of 60s) with resolution. Case was continued, RCA 60% distal, mid Lcx 70%, mid LAD 80%. DES in LAD. Patient developed 8/10 chest pain, he was found to have a small jailed septal which was crossed with wire with partial restoration of flow. Patient was placed on nitro gtt for cp control and transferred to CCU for overnight monitoring. . On ICU admission he is on NG [**Last Name (un) **] and HD stable with SBPs in the low 100's high 90's. Reports pain [**1-14**] and significant malaise and nausea which improved with IV morphine + zophran + metoclopramide. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p 3.0 x 18mm and 3.5 x 33mm overlapping Cypher stents to RCA [**2148**] - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: NSTEMI Tonsillectomy Adenoidectomy Hyperlipidemia Carotid artery disease: 60% [**Country **] per ultrasound (pt to have further eval of this in near future) . . Social History: Electricity conntractor - Tobacco history: none - ETOH: 2 beers once weekly - Illicit drugs: none . Family History: FAMILY HISTORY: - Father: IHD with PCI and stenting in the 70's - Mother: HTN - Brother: HTN - Brother: HLD - Brother: Obesity . Physical Exam: PHYSICAL EXAMINATION on ICU admission: T: 96.6 ?????? HR: 66 bpm BP: 102/64(71)mmHg RR: 21 SpO2: 97% GENERAL: NAD. Oriented x3 but somnulent post IV morphine. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: minimal scattered expiratory wheezing. no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. groins w/o swelling hematoma or femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP doplerable PT doplerable Left: Carotid 2+ Femoral 2+ DP doplerable PT doplerable . Pertinent Results: admission labs: . . [**2154-5-17**] 07:15PM BLOOD WBC-13.6*# RBC-4.40* Hgb-13.8* Hct-38.9* MCV-88 MCH-31.4 MCHC-35.5* RDW-12.8 Plt Ct-278 [**2154-5-17**] 07:15PM BLOOD PT-14.8* PTT-147.0* INR(PT)-1.3* [**2154-5-17**] 07:15PM BLOOD Glucose-151* UreaN-17 Creat-0.9 Na-137 K-3.7 Cl-101 HCO3-26 AnGap-14 [**2154-5-18**] 06:21AM BLOOD ALT-30 AST-51* LD(LDH)-189 CK(CPK)-388* AlkPhos-56 TotBili-1.4 [**2154-5-17**] 07:15PM BLOOD Calcium-8.8 Phos-1.9*# Mg-2.0 [**2154-5-17**] 11:57PM BLOOD %HbA1c-5.6 eAG-114 [**2154-5-17**] 11:57PM BLOOD Triglyc-119 HDL-47 CHOL/HD-3.5 LDLcalc-92 [**2154-5-17**] 07:19PM BLOOD Type-[**Last Name (un) **] pO2-67* pCO2-45 pH-7.38 calTCO2-28 . cardiac enzymes: [**2154-5-17**] 07:15PM BLOOD CK-MB-3 cTropnT-<0.01 [**2154-5-17**] 11:57PM BLOOD CK-MB-13* MB Indx-7.0* cTropnT-0.06* [**2154-5-18**] 06:21AM BLOOD CK-MB-32* MB Indx-8.2* cTropnT-0.20* [**2154-5-18**] 02:09PM BLOOD CK-MB-43* MB Indx-7.5* cTropnT-0.83* [**2154-5-18**] 08:24PM BLOOD CK-MB-30* MB Indx-5.4 cTropnT-0.84* [**2154-5-19**] 06:22AM BLOOD CK-MB-14* MB Indx-3.9 cTropnT-0.64* . Discharge labs: [**2154-5-19**] 06:22AM BLOOD WBC-10.5 RBC-4.11* Hgb-13.0* Hct-36.7* MCV-89 MCH-31.6 MCHC-35.5* RDW-12.9 Plt Ct-207 [**2154-5-19**] 06:22AM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1 [**2154-5-19**] 06:22AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-142 K-3.7 Cl-108 HCO3-26 AnGap-12 [**2154-5-19**] 06:22AM BLOOD Calcium-7.9* Phos-2.3*# Mg-2.1 . - ECG on CCU admission: sinus 75, normal axis, small Q + NTW in III, biphasic T wave in AVF, good RWP across precordial leads, no significant change from tracing during cath. Compared to [**2148**] tracing no significant changes except that Q wave in III is now less pronounced, . . - ECHO [**2154-5-18**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: 51 year old man with h/o CAD s/p PCI with DESX2 to RCA in [**2148**] admitted [**5-17**] d/t chest pain episode during elective coronary cath [**2-6**] to jailing of septal perforator during the procedure. . # CAD: h/o CAD s/p PCI with DESX2 to RCA in [**2148**] admitted for elective cath d/t recent symptoms of right arm, posterior neck pain and interscapular pain at rest and a nuclear scan positive for inferior, posterolateral and anterolateral ischemia. In cath lab vagal episode during access which resolved with atropine and fluids. Diagnosis RCA 60% distal, mid Lcx 70%, mid LAD 80%. Intervention: DES to LAD. Patient developed 8/10 chest pain during procedure likely [**2-6**] small jailed septal which was crossed with wire with partial restoration of flow. Patient did not have significant ECG changes but on follow-up produced enzymes to Tn peak .84, MB peak 43 and CK peak 571. Patient was initially treated with nitro gtt and admitted to the CCU for further managment. He had recieved his daily aspirin 325mg the morning of the procedure and was plavix loaded 600mg prior to procedure. On admission to CCU pain was [**1-14**] and resolved completely with IV morphine. NG was weaned off overnight. He was sunsequently HD stable with no further complaints. Home metoprolol 25mg [**Hospital1 **] was continued as was his home Aspirin 325mg daily and crestor 40 mg pO daily; Clopidogrel 75mg daily was started and should be continued for 1 year Lisinopril 5mg PO was also started. . # Pump: No known Hx of CHF. No symptoms suggestive of CHF per history. TTE with Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. (LVEF >55%). . # RHYTHM: Sinus. No events on telemetry. . # Interscapular pain: this has been stable and ongoing over past months and is was unchanged during this admission. He did not have wide mediastinum on CXR or significant difference in BP between his arms. Patient's recent complaints of right arm, posterior neck and interscapular pain at rest are likely not anginotic and may be of musculoskeletal or spinal/nueral origin. These complaints may be further worked up in the outpatient setting. . # HLD: HDL 47, LDL 92. Continued on his home rosuvastatin 40mg daily. [**Month (only) 116**] require second [**Doctor Last Name 360**] as is maxed on crestor given goal of LDL <= 70. will coninue outpatient f/u . # DVT PROPHYLAXIS: recieved sq heparin during this admission. . # CODE STATUS: was full during this admission . . Out patient issues: - cardiology f/u with Dr [**Last Name (STitle) 59323**]. - work-up of interscapular, right arm and neck pain as above. - f/u of lipid profile and management as appropriate to LDL goal <= 70. Medications on Admission: CITALOPRAM - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily . Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (Prescribed by Other Provider) - Dosage uncertain ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain . Discharge Medications: 1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual Q5MIN () as needed for chest pain: [**Month (only) 116**] repeat every 5 minutes X 2. If no response, call 911. Disp:*30 tablets* Refills:*0* 2. citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. ergocalciferol (vitamin D2) Oral 11. B complex vitamins Oral Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease, sp NSEMI and RCA stent in [**2148**] Carotid Artery Disease Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname 60590**] it was a pleasure taking care of you. . You were admitted to the hospital for a cardiac catheterization to evaluate your righ arm discomfort. You were found to have a blockage in the left anterior descending artery and a stent was placed. Unfortunately during stent placement on of your accessory arteries was blocked. Post-procedure you were monitored closely and remained hemodynamically stable. You were started on medications to help remodel your heart after the event as well as medications, Aspirin (at an increased dose) and Plavix, that are integral to maintain stent patency. . You were started on a new medication, plavix. You will need to take this medication . . Stopping this medication early could result in a heart attack. . CHANGES TO YOUR MEDICATIONS: To maintain stent patency: 1. Plavix 75mg tablets. Take one tablet daily for at least the next 12 months 2. Aspirin 325mg tablets. Take one tablet daily. ** Again do not stop these medications unless instructed to do so by Dr. [**Last Name (STitle) 59323**]. To treat blood pressure as well as aid heart remodeling: 1. Start taking Lisinopril 5mg tablets. Take one daily. 2. Transition from metoprolol 25mg twice daily to metoprolol 50mg XL daily. . Again it was a pleasure taking care of you. Please feel free to contact with any questions or concerns. Followup Instructions: Dr [**Last Name (STitle) 60591**] office will call you to arrange an appointment Completed by:[**2154-5-20**]

[ "V70.7", "401.9", "V45.82", "272.4", "414.01", "411.1", "412" ]

icd9cm

[ [ [] ] ]

[ "99.20", "00.66", "00.40", "37.22", "88.56", "00.45", "36.07", "88.53" ]

icd9pcs

[ [ [] ] ]

11038, 11044

6444, 9184

351, 377

11188, 11188

3936, 3936

12725, 12837

3004, 3118

10031, 11015

11065, 11167

9211, 10008

11339, 12117

5039, 6421

3133, 3917

2510, 2660

12146, 12702

4621, 5023

264, 313

405, 2428

3952, 4604

11203, 11315

2691, 2853

2450, 2490

2869, 2972

29,096

156,803

44439

Discharge summary

report

Admission Date: [**2103-1-9**] Discharge Date: [**2103-1-15**] Date of Birth: [**2020-11-13**] Sex: M Service: MEDICINE Allergies: Zestril / Penicillins / Integrilin / Hydrochlorothiazide / Ciprofloxacin Attending:[**First Name3 (LF) 898**] Chief Complaint: fever and cough Major Surgical or Invasive Procedure: s/p intubation and extubation History of Present Illness: Mr. [**Known lastname 95253**] is an 82 y.o. M with CAD, AAA, CKD, recent GIB discharged from OSH 5 PTA who presented after he went to his PCP complaining of subjective fever and productive cough and was noted to be hypoxic to 90% on RA. He was referred in to the ED. He also reportedly had some angina on the night prior to admission which responded to 2 sublingual nitroglycerin. . In the ED: Tmax 101.5 HR 57 BP 108/40 RR24 O2 sat 100%4L/ EKG showed regular sinus rhythm @70bpm, diffuse ST twave abnormalities, no change from prior, and frequent pvcs. Labs showed a troponin of 0.22 (records show it to be chronically elevated. He was guaiac negative and was given ASA 325 mg x 1. CXR showed RLL infiltrate. Vancomycin/Levofloxacin were given. He then had an episode of hypotension with SBP 80s. RIJ and a-line were placed, he was started on levophed and he was given a total of 4L NS. Levophed was weaned off at 4:00am. He was transfused 2U PRBC for hematocrit 23, with post-transfusion hct 28. He was then transferred to the floor. Past Medical History: 1. CAD - s/p MIs, CABG x2, stents. MI resulting in CHF [**2-/2100**] and RCA cypher stents placed. Cath [**10-21**] with L subclavian stent proximal to takeoff of LIMA. Echocard [**10/2102**]: EF 20-25%. Low hdl syndrome. 2. HTN/bil RAS rx bare stents [**2099**]. 3. Gout 4. Prostate nodule with benign bx in past, asymptomatic 5. Chronic decreased vision left eye s/p retinal hemorrhage 6. [**Doctor Last Name 9376**] syndrome 7. Colon adenoma, next colonoscopy due [**2101**] 8. Sexual dysfunction, not a current concern 9. Stage 4 CKD, creat ~3.0 10. Chronic anemia due to renal insufficiency, rx pro-crit 11. AAA, rx endovascular graft repair [**2099**]. MRA [**8-/2100**] was reviewed by Dr. [**Last Name (STitle) **] and found to be satisfactory 12. PAD with claudication / bilateral iliac stenosis 13. Mitral regurgitation, SBE prophylaxis advised 14. DMII - diet controlled, dx [**2101**] 15. PNA 05 16. R-bicep tendon rupture. 18. Left knee surgery [**13**]. LBP/sciatica - past 20. Atrial flutter rx cardioversion, [**2101**] / anticoag 21. diverticulosis, ?GIB 22. chemical gastritis thought [**12-16**] ASA/plavix Social History: Social history is significant for (-)tobacco use, (+) one glass of wine every night. Patient is widowed, son lives with him. Previously worked for [**Company **] as a machinist. Family History: Father died of an MI at age 53. Son had an MI in his late 40's. Physical Exam: PHYSICAL EXAM: Vitals - T: 99.8 BP: 142/64 HR: 82 RR: 14 02 sat: 96% Vent settings: AC, Vt 500, RR 14, PEEP 5, FiO2 100% initially. GENERAL: Intubated, sedated (prior to intubation, was tachypneic, cyanotic, in obvious severe respiratory distress). HEENT: PERRL, MMM, ETT and OGT in place. CARDIAC: RRR, no m/r/g. LUNG: Coarse breath sounds b/l, with diffuse wheezes and bibasilar crackles. ABDOMEN: +BS, soft, NT/ND. EXT: 1+ edema b/l. 2+ DP pulses. SKIN: Dry, no rashes. Pertinent Results: Labs: see OMR . STUDIES: CXR (PA & LATERAL) [**2103-1-8**] (prelim) CHEST, TWO VIEWS: Moderate cardiomegaly is stable. The patient is status post sternotomy and CABG. Mediastinal contours are unchanged. There is chronic linear opacity at the left lung base and chronic blunting of the left costophrenic sulcus, presumably related to post-CABG scarring and pleural thickening. There is new airspace opacity of the right cardiophrenic angle on the frontal view, which obscures the right hemidiaphragm consistent with right lower lobe pneumonia. There is a small right pleural effusion. The bones are demineralized. There is no evidence of congestive failure. IMPRESSION: 1. Right lower lobe pneumonia. 2. Small right pleural effusion. 3. Stable moderate cardiomegaly. . CXR [**2103-1-9**]: IMPRESSION: Increasing parenchymal density in right lower lobe, new pneumonic infiltrate in right upper lobe. Probably mild increased congestion but right-sided infiltrates most likely infectious rather than atypical unilateral edema. . TEE [**2102-11-29**] No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrial appendage ejection velocity is depressed (<0.2m/s). A small secundum atrial septal defect is present with left to right flow at rest. LV systolic function appears depressed. There are complex (>4mm) non-mobile atheroma in the aortic arch (clip [**Clip Number (Radiology) **] frame 68). There are diffuse simple atheroma in the descending thoracic aorta to 45cm beyond the incisors with some areas of complex, nonmobile atheroma at 37cm (clips 82/83). The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-15**]+) mitral regurgitation is seen. IMPRESSION: No intra-atrial thrombus identified. Depressed LV function. Small secundum ASD with left-to-right flow. Simple aortic atheroma as described above. . CARDIAC CATHERIZATION [**2102-10-20**] COMMENTS: 1. Selective coronary angiography in this right dominant system was performed. The LMCA was not injected because it was known to be diffusely diseased. The LAD was totally occluded proximally. Distal to the touch down of the LIMA there was mild disease. A large OM was seen to fill via collaterals. The RCA had widely patent stents and a distal 40% stenosis. 2. Venous conduit angiography was not performed because all of the vein grafts were known to be occluded. 3. Arterial conduit angiography demonstrated a widely patent LIMA-LAD. There was a 70% proximal subclavian stenosis with a > 20 mmHg gradient. 4. Successful stenting of left subclavian with a 6x24 Genesis stent post-dilated to 8mm distally and 9mm proximally. Final angiography without complications. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 3. Left subclavian stenosis proximal to takeoff of the LIMA. 4. Successful stenting of left subclavian. . . Brief Hospital Course: When pt arrived on the floor oxygenation was initially stable on 3L nc. However, he soon developed worsening SOB, tachypneia, and rhonchi on exam. Due to concern for flash pulmonary edema he was given 100mg IV lasix, but did not put out much urine and hypoxia did not improve and he required a NRB, and he was transferred to the MICU. . In the MICU he was imediately intubated. Hypotension continued despite fluid boluses so was put on levophed. Vancomycin, Cefepime, and Ciprofloxacin were given to treat sepsis [**12-16**] PNA. Oxygenation and BP improved and [**2103-1-11**] he was weaned off levophed and extubated yesterday. He was ruled out for influenza. Renal has been following for Acute on Chronic renal failure, likely contrast induced. Because of recent admission to OSH for GIB Vascular surgery was consulted for concern about aortoenteric fistula, who felt it unlikely given his stable hct and guaiac negative. Further supporting this is that during admission to OSH 5 days PTA, pt had an EGD and colonoscopy which were normal. The vascular team initially recommended abd US to rule out endo leak since pt was unable to have a contrast study with his acute on chronic renal failure. Radiology advised that US would not be able to properly characterize an endoleak. When this was relayed to vascular surgery they felt that the index of suspicion for aortoenteric fistula was low enough that further imaging was not necessary. On [**2103-1-12**] he was called out the the medicine floor. Just before transfer his feet were noted to be purple and cold. Vascular re-evaluated, and noted that it was dependent and therefore likely due to vascular insuf. and ischemia was not a concern. . On the floor the pt had no complaints, and cough improved. He was discharged on a 10 day course of Levofloxacin. He was restarted on Imdur, but all other antihypertensives were held due to recent hypotension. During f/u with PCP BP will need to be checked and antihypertensives slowly added back. Coumadin was held due to recent GIB, and pt was told not to restart until instructed to do so by his PCP ([**Location (un) 1683**]). He was also given an appointment to follow up in the renal clinic, where he will need erythropoetin and for continued management of CRF. Medications on Admission: Calcitriol 0.25 mg qd Furosemide 40 mg qd Vitamins, iron not recorded Procrit 30,000 every 14 days Carvedilol 6.25 mg [**Hospital1 **] Nifedipine 30 mg qd Nifedipine SR 30 mg qd Lipitor 40 mg qd ALLOPURINOL 100 mg--1 tablet(s) by mouth every other day AMIODARONE 200 mg--1 tablet(s) by mouth once a day CENTRUM SILVER --1 tablet(s) by mouth once a day DIOVAN 160 mg--1 tablet(s) by mouth once a day DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth twice a day as needed for for constipation IMDUR 120 mg--1 tablet(s) by mouth daily Iron (Ferrous Sulfate) 325 mg (65 mg)--one tablet(s) by mouth twice a day LIDODERM 5 %(700 mg/patch)--apply 1 patch in the morning, remove 12 hours later, as needed for back pain NITROGLYCERIN 0.3 mg--1 tablet(s) sublingually every 5 minutes x maximum of 3 doses as needed for angina vitamin b complex 1 tab daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Epoetin Alfa 10,000 unit/mL Solution Sig: Three (3) Injection Q14 days. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Pneumonia . Secondary Diagnoses: Coronary Artery Disease Low HDL syndrome Hypertension Gout Prostate nodule with benign bx in past, asymptomatic Chronic decreased vision left eye s/p retinal hemorrhage [**Doctor Last Name 9376**] syndrome Colon adenoma Stage 4 CKD, baseline Cr ~3.0 Chronic anemia due to renal insufficiency, treated with pro-crit AAA, s/p endovascular graft repair [**2099**]. PAD with claudication / bilateral iliac stenosis Mitral regurgitation, SBE prophylaxis advised DMII - diet controlled, dx [**2101**] s/p R-bicep tendon rupture s/p Left knee surgery LBP/sciatica Atrial flutter s/p cardioversion [**2102**] and taken off coumadin [**11-21**] because of GI bleed Diverticulosis; recent GIB admitted to OSH [**11-21**] Discharge Condition: Vital Signs Stable(T 97, BP 108/52, HR 70, RR 16, sat 96%RA). Breathing without difficulty. Ambulating. Discharge Instructions: You were admitted with pneumonia. You were treated with antibiotics. Because of respiratory distress you were intubated and went to the ICU. Your breathing improved, and were successfully extubated. You also had low blood pressure that transiently reqired medications to raise the blood pressure. Your blood pressure also recovered, and those medications were stopped. Because of this period of low blood pressure your blood presure medications were held. We restarted imdur, but your other blood pressure medications have been held. . You should not restart Coumadin, Carvedilol, Nifedipine, or diovan until told to do so by your doctor. . Please take the Levofloxacin as perscribed. . Because Levofloxacin can have an effect on the heart (prolonged QT interval), especially when combined with amiodarone) your PCP should check an EKG. . Please keep all of your appointments as written below . Please take all of your medications as written below. . If you have any symptoms of worsening shortness of breath, fevers, chest pain, or any other concerning symptoms please go to the ER. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider [**Known firstname **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-1-16**] 11:30 Provider [**Name9 (PRE) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2103-1-17**] 2:30 Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-1-31**] 10:00

[ "585.4", "424.0", "403.90", "285.21", "440.21", "486", "E947.8", "440.1", "427.32", "277.4", "584.9", "274.9", "995.92", "250.00", "038.9", "518.81", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10782, 10839

6494, 8774

348, 380

11645, 11752

3384, 6304

12992, 13470

2810, 2876

9669, 10759

10860, 10860

8800, 9646

6321, 6471

11776, 12969

2906, 3365

10912, 11624

293, 310

408, 1448

10879, 10891

1470, 2598

2614, 2794

82,051

103,355

37391

Discharge summary

report

Admission Date: [**2132-1-19**] Discharge Date: [**2132-1-21**] Date of Birth: [**2062-5-7**] Sex: F Service: NEUROSURGERY Allergies: Phenytoin Sodium Attending:[**First Name3 (LF) 1835**] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: None History of Present Illness: 69 year old female with h/o metastatic melanoma originating on the right arm with mets to the lung was with her family for [**Holiday **] and she had a headache. She went to bed and woke up confused and her husband reported that she became unconscious. The family was able to catch her and help her to the ground so she did not hit her head. She was shaking on her right side, had loud respirations, and was intubated when EMS arrived. She went to the OSH where a CT scan revealed 2 brain lesions. She was given Ativan for presumed seizure and was loaded with 1 gram of phosphenytoin. She was also given 8 mg of decadron. She was then transferred to [**Hospital1 18**]. For transport she was on fentanyl and versed. Upon arrival to [**Hospital1 18**] she was started on propofol. Neurosurgery was consulted for the new brain lesions. The patient was seen this week by hem-onc for her melanoma and was waiting for tests to come back before possibly enrolling in a clinical trial. She had a brain MRI that was negative 2 months ago. Past Medical History: metastatic melanoma - originated on right arm, now has lung mets Hypertension Hyperlipidemia Discoid lupus diagnosed 25 years ago based on a malar rash and a back rash, finger stiffness. Doesn't know [**Doctor First Name **] or dsDNA status. MI in [**2112**] with cardiac arrest, treated with TPA with full resolution, no residual damage per the patient. PMR 2-3 years ago, resolved with steroid course Social History: Lives in [**State 108**] with husband. Was in [**Location (un) 86**] for [**Holiday **]. Family History: Noncontributory Physical Exam: T:97.7 BP:155/73 HR:104 RR:16 O2Sats:100% vented Gen: Intubated, off sedation for exam. HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic with brief eye opening. Does not follow commands. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. III, IV, VI: unable to test V-XII: unable to test Motor: Moves all 4 extremities to sternal rub. Localizes and is purposeful with both upper extremities. Briskly withdraws bilateral lower extremities. Sensation: unable to test Toes mute bilaterally Pertinent Results: [**2132-1-20**] 02:03AM BLOOD WBC-16.6* RBC-4.02* Hgb-11.6* Hct-34.4* MCV-85 MCH-28.9 MCHC-33.8 RDW-12.6 Plt Ct-248 [**2132-1-19**] 01:10AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3* Monos-1.6* Eos-0.1 Baso-0.2 [**2132-1-20**] 02:03AM BLOOD Glucose-162* UreaN-15 Creat-0.6 Na-139 K-4.4 Cl-108 HCO3-23 AnGap-12 [**2132-1-20**] 02:03AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 [**2132-1-19**] 03:41AM BLOOD Phenyto-11.1 [**2132-1-19**] 05:38PM BLOOD Type-ART pO2-151* pCO2-40 pH-7.37 calTCO2-24 Base XS--1 Intubat-INTUBATED [**2132-1-19**] 05:38PM BLOOD Na-145 K-3.4* Imaging: MRI Head [**1-19**]: Wet Read: NPw SAT [**2132-1-19**] 3:20 PM Multiple lesions in the rbain- largest in the right parietal lobe with moderate surroudning edema. While most lesions are in the cerebral parenchyma, i is noted in the right superior colliculus and another one in the right cerebellar hemisphere. Leptomeningeal spread cannot be excluded- consider further work up. A tiny lesion is noted on the surface of left cerebellar hemisphere. (series 16, im 6) Wet Read Audit # 1 NPw SAT [**2132-1-19**] 3:18 PM Multiple lesions in the rbain- largest in the right parietal lobe with moderate surroudning edema. While most lesions are in the cerebral parenchyma, i is noted in the right superior colliculus and another one in the right cerebellar hemisphere. Leptomeningeal spread cannot be excluded Brief Hospital Course: Ms [**Known lastname 3321**] was admitted to the ICU started on Dilantin and Decadron. She underwent a MRI of her brain which showed multiple lesions in the right [**Last Name (un) **]- largest in the right parietal lobe with moderate surroudning edema. On hospital day one she was extubated and found to have a normal neurological exam. On hospital day two she was transfered to the surgical floor. Her case was discussed in the brain tumor conference on [**1-21**] it was decided that whole brain radiation would be the best treatment. She was transferred to the [**Hospital Ward Name **] where the planning session took place. She was discharged to home, with instructions to return on [**1-22**] to have radiation. Medications on Admission: Simvastatin 20 mg each evening Lisinopril 10 mg daily Trimethoprim 100 mg - take [**1-26**] tablet QHS Paroxetine 20 mg daily Atenolol 50 mg daily Hydroxycholoquine 200 mg daily Discharge Medications: 1. Trimethoprim 100 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*21 Tablet(s)* Refills:*0* 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Brain masses presumed Metastatic Melanoma Discharge Condition: Neurologically Stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-28**], at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will be having whole brain radiation to treat your brain masses on [**1-22**]. Please follow the instructions that were provided to you during your planning session. Completed by:[**2132-1-21**]

[ "401.9", "725", "272.4", "348.5", "197.0", "345.3", "414.00", "V15.82", "412", "695.4", "198.3", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

6031, 6037

4049, 4770

302, 309

6123, 6147

2657, 4026

7388, 8005

1920, 1937

4998, 6008

6058, 6102

4796, 4975

6171, 7365

1952, 2205

241, 264

337, 1369

2298, 2638

2220, 2282

1391, 1797

1813, 1904

12,553

172,026

11637+56266

Discharge summary

report+addendum

Admission Date: [**2136-1-17**] Discharge Date: [**2136-1-23**] Date of Birth: [**2076-2-15**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36911**] is a 59-year-old male with a past medical history significant for hypertension, hyperlipidemia and gastroesophageal reflux disease, who presented to [**Hospital 1474**] Hospital at approximately 5 A.M. on [**2136-1-17**] with 9/10 substernal chest pain which awoke him from his sleep. His pain was unrelieved by sublingual nitroglycerin x 3. He called 911, and the EMS took him to the outside hospital. He underwent emergent catheterization after being transferred to [**Hospital1 346**] Emergency Department. The emergency catheterization showed a new totally occluded obtuse marginal I. It should be noted that the patient had a known history of coronary artery disease and was going to have a planned coronary artery bypass graft on [**2136-1-18**] at [**Hospital1 346**]. PAST MEDICAL HISTORY: Coronary artery disease, known three vessel disease. He had a catheterization on [**2136-1-6**] showing a left ventricular ejection fraction of 66%, a left anterior descending with diffuse disease with total occlusion at the distal artery. The diagonal had 90% proximal stenosis. Obtuse marginal I with 90% stenosis, obtuse marginal II with 70% stenosis. The left circumflex had serial 80% stenoses, and the right coronary artery had a mid-total occlusion. Other medical history was for hypercholesterolemia, borderline hypertension, no diabetes. ALLERGIES: None. MEDICATIONS ON ADMISSION: Metoprolol, Zocor, Prilosec, sublingual nitroglycerin and a baby aspirin. FAMILY HISTORY: No coronary artery disease, no hypertension, no diabetes. SOCIAL HISTORY: He is a previous 30+ pack year smoker, but quit several years ago. PHYSICAL EXAMINATION: Temperature 98.4, pulse 73 and sinus, blood pressure 104/64, respiratory rate 16, in no acute distress. He was in reverse Trendelenburg position with an intra-aortic balloon pump inserted. Mucous membranes are moist. The oropharynx is clear, no jugular venous distention. He had no bruits in his neck. His trachea was midline. His lungs were clear to auscultation bilaterally. The heart was regular rate and rhythm except for the intra-aortic balloon pump interference that was auscultation. The abdomen was soft, nontender, nondistended, with normal active bowel sounds. The extremities had no cyanosis, clubbing or edema. The right lower extremity was in a restraint. He had 2+ pulses bilaterally, dorsalis pedis and posterior tibial. He was alert and oriented x 3, and his neurologic examination was nonfocal. LABORATORY DATA: Hematocrit 38, platelet count 255,000, BUN and creatinine 22 and 1.3. Catheterization that was done emergently on [**2136-1-17**] for the patient's recurrence of anginal chest pain showed a totally occluded distal left anterior descending as previously noted, a 90% proximal D1, the left circumflex had an 80% disease, the obtuse marginal I, however, showed a new totally occluded disease. This is stented without success. The obtuse marginal II is 60% proximally occluded. The left posterior descending artery had serial 80 and 90% lesions. The right coronary artery had a known total occlusion at the mid-vessel and was subsequently not injected. Post-catheterization, his hematocrit was 30, down from 38 on admission. BUN and creatinine were 16 and .8. It should be noted that the patient was being hydrated. His INR was 1.5. CPK was 153, MB 18, with an index of 11.8, which was positive. Electrocardiogram on [**2136-1-11**] showed normal sinus rhythm at 60, with no ST/T wave changes. There was early R wave progression, and there were questionable Q waves in Leads II and III. HOSPITAL COURSE: On [**2136-1-17**], at [**Hospital1 190**] Emergency Room at 8 A.M., he had normal sinus rhythm at 80, with questionable 1 to 2 mm downsloping ST segments in V2 and V3, with a questionable .5 to 1 mm ST segment elevation in AVL, and there was a U wave noted in V6, as well as Q waves slightly increased in Lead II. Given the fact that he had known three vessel coronary artery disease and now a new total occlusion of obtuse marginal I, and intractable chest pain and ultimately requiring intra-aortic balloon pump resuscitation, he had an emergent consultation with the Cardiothoracic Surgery service with Dr. [**Last Name (STitle) 70**] to have coronary artery bypass graft. The patient was admitted to the Coronary Care Unit, where he was placed on an intra-aortic balloon pump and was placed on heparin and beta blockade and nitroglycerin. By hospital day number one, the patient was on the intra-aortic balloon pump at 1:1 with systolic pressures of 105 and diastolics augmented to 108. Heparin was running at 900 per hour, nitroglycerin at 3 mcg/minute. Vitals were stable, with heart rate in the 65 to 88 in sinus. His blood pressure was 93/66 with a mean arterial pressure of 72 to 93. His hematocrit was 29, his PTT was 71, BUN and creatinine were 13 and .9. His serial enzyme CKs were 153, 529, 543, with MB index of 11.8, 12.5 and 10.3. On [**2136-1-18**], Cardiac Surgery evaluated the patient with Dr. [**Last Name (STitle) 70**] and scheduled a coronary artery bypass graft that was ultimately done later in the day. Mr. [**Known lastname 36911**] was taken to the operating room and underwent a coronary artery bypass graft x 4, including left internal mammary artery conduit to the left anterior descending, a right saphenous vein graft with sequential bypasses to the obtuse marginal I and obtuse marginal II, as well as a saphenous vein graft bypass to the right coronary artery, posterior descending artery. The patient was left with his pericardium open. He had an arterial line in the right hand as well as a Swan-Ganz catheter. He had two ventricular wires, one atrial wire, and one ground. Tubes were right and left as well as two mediastinal. Mean arterial pressure upon leaving the operating room was 72, with a right atrial pressure of 12. He was on a propofol drip for sedation and intubated. He was brought to the Cardiac Surgical Recovery Unit, where he was maintained on a balloon pump. He was extubated on the night of surgery. Neurologically, he remained intact. His temperature was 101.5 on the night of surgery, down to 100.4 on the morning after surgery. He was 94 in sinus rhythm, with blood pressure of 116/53. His blood gas on 98% nasal cannula with respiratory rate of 23 was 7.48 pH, PACO2 48, PAO2 115. His hematocrit was 22, and he was subsequently transfused two units. Examination was neurologically intact. Cardiovascular was regular rate and rhythm. His intra-aortic balloon pump was weaned and discontinued. He had lasix and Lopressor held. His Neo-Synephrine drip was being utilized for pressure and outflows were consequently weaned off once he was transfused for a hematocrit of 22. Respiratory: He was already extubated on nasal cannula. This was weaned as tolerated. His chest tubes were also removed. Gastrointestinal: His diet was advanced to cardiac. He was given perioperative dosing of vancomycin and ultimately transferred to the floor. On postoperative day number two, the patient was comfortable. He did have a T-max of 102.0, down to 100.8. He was subsequently cultured with sputum cultures that grew out gram-negative rods, however, they were consistent with oropharyngeal flora. Additionally he had urine cultures that were negative and blood cultures sent that were also negative. He had a white count of 10,000, with a normal differential, hematocrit of 29. His BUN and creatinine were 15 and 1.0. His Lopressor was titrated accordingly for heart rates of 100 and blood pressures in the 120s. The patient tolerated this well. He was working aggressively with Physical Therapy and ambulating approximately three to four times per day. He was at a Level IV by postoperative day number four. He was feeling comfortable. He still was having persistent low-grade temperatures, however, his white count was 6,000. His Lopressor was titrated again for heart rate and blood pressure control. His electrolytes were repleted as needed. He was continued on a cardiac diet. Pain was well controlled with percocet. No culture data subsequently became positive. On postoperative day number five, the patient was afebrile, with a blood pressure of 123/70, and a heart rate of 87. Oxygen saturation was 96% on room air. The sternum was stable, with no evidence of drainage. There was no exudate, there was no erythema. His right saphenous vein graft harvest site was clean, dry and intact, well approximated, with no drainage noted. DISCHARGE MEDICATIONS: Lopressor 75 mg by mouth twice a day, lasix 20 mg by mouth every morning for seven days, K-Dur 20 mEq by mouth once daily for seven days, Colace 100 mg by mouth twice a day, percocet 5/325 one to two tablets by mouth every four to six hours as needed, Motrin 600 mg by mouth three times a day with meals as needed, Protonix 40 mg by mouth once daily, Zocor 20 mg by mouth once daily, and aspirin 325 mg by mouth once daily. CONDITION ON DISCHARGE: To home with VNA for blood pressure monitoring, home monitoring and mood checks. He will be on a cardiac diet. He has instructions for no heavy lifting greater than ten pounds for 30 days, including no driving for 30 days. He may shower in 24 hours from discharge. Follow up will be to see Dr. [**Last Name (STitle) 70**] in four weeks, see his primary care physician in three weeks. DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction with acute stenosis of obtuse marginal I status post coronary artery bypass graft x 4, left internal mammary artery to left anterior descending, right saphenous vein graft to right coronary artery and then a sequential graft to the obtuse marginal I and obtuse marginal II. The graft to the right coronary artery, it should be noted, goes to the posterior descending artery. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2136-1-22**] 21:53 T: [**2136-1-23**] 00:00 JOB#: [**Job Number 36912**] Name: [**Known lastname 6603**], [**Known firstname 3061**] Unit No: [**Numeric Identifier 6604**] Admission Date: [**2136-1-17**] Discharge Date: [**2136-1-23**] Date of Birth: [**2076-2-15**] Sex: M Service: DISCHARGE SUMMARY ADDENDUM: On the final day which was postoperative day five the patient had persistent low grade temperatures to 100.5 F. As a consequence he had a urinalysis that was sent that subsequently was negative. On microscopy no white cells were seen, no bacteria were noted. He had negative leukocyte esterase. Additionally he had a chest x-ray that was done that showed marked improvement of his bilateral pleural effusions. He had minimal platelike atelectasis at the base. There was also a small retrosternal air fluid collection that was discussed in the impression part of the dictation by the staff radiologist as a possible hydropneumothorax versus postoperative air fluid collection. Given these findings the patient was placed on Levaquin empirically 500 milligrams po q day times 10 days. The remainder of the body of dictation for the primary discharge is unchanged. DISCHARGE MEDICATIONS: 1. Levaquin 500 milligrams po q day times 10 days. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**] Dictated By:[**Last Name (NamePattern4) 935**] MEDQUIST36 D: [**2136-1-23**] 14:32 T: [**2136-1-30**] 09:43 JOB#: [**Job Number 6605**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2139-12-16**] Discharge Date: [**2139-12-22**] Service: MEDICINE Allergies: Penicillins / Aspirin Attending:[**First Name3 (LF) 898**] Chief Complaint: SOB, CP, Nausea Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old man with h/o COPD, recent NSTEMI who presents from [**Hospital3 **] facility c/o SOB and chest pain and nausea for most of Tuesday. He denies vomiting and abdominal pain. In the ED, he was found to have a temperature to 101.3, retrocardiac opacity on CXR, negative abdominal and pelvis CT. He was given levofloxacin, flagyl, and 1800 cc of NS with systolic pressures staying in the 90's. In the ED, he began ruling in for a non-ST elevation MI; cardiology initially recommended only antiplatelet therapy, but later recommended a heparin drip. While in the ED, after receiving IVF and approximately one unit packed red blood cells, the patient was noted to be in mild respiratory distress with oxygen saturations of 89% despite 4L NC. He was otherwise tachycardic to the 130s, but SBP stable in the 120s. A repeat CXR showed congestive heart failure. He was treated with lasix 40mg IV x 2 with good results. When patient came to the ICU, he denied CP and his breathing had improved. Past Medical History: coronary artery disease, s/p non-ST elevation myocardial infarction, no prior catheterization performed as his son did not feel he would want interventional measures; last echo ([**3-15**]) - EF 35% to 45% gastroesophageal reflux disease chronic obstructive pulmonary disease s/p cholecystectomy for gangrenous gallbladder in [**2139-7-13**] dementia iron deficiency anemia anxiety history of deep venous thrombosis Social History: Used to smoke 1 PPD for many years, quit several years ago. Occasional ETOH on special occasions. Lives in [**Hospital3 **], according to his son, he needs assistance for everything other than feeding. Per his son, he has dementia at baseline with poor short term memory but is able to remember people and is usually oriented. Family History: Noncontributory Physical Exam: Tm 101.3 Tc 99.2 BP 94/30 HR 98 RR 38 O2Sat 93% 2L NC Gen: Patient lying comfaortable in bed, able to communicate Heent: EOMI, sclera anicteric, MMM, poor dentition Lungs: Diffuse ins/exp wheezes Cardiac: RRR S1/S2 grade II/VI holosystolic murmur at apex Abdomen: distended, soft, +BS, NT no rebound or gaurding; giuac neg in ED Ext: no edema, DP 1+, trace PT Neuro: AAOx3 Pertinent Results: CXR: There appears to have been interval development of interstitial opacities bilaterally consistent with pulmonary edema. Again seen is a poorly defined retrocardiac opacity/consolidation consistent with left lower lobe pneumonia. CT Abdomen: No CT findings to explain the patient's abdominal pain/distention. No bowel abnormalities. Sigmoid diverticulosis without evidence of diverticulitis. Left base consolidation, suspicious for pneumonia. Multiple simple hepatic cysts. Stable tiny hypodensity in the left kidney, not well evaluated on this study. Status post cholecystectomy with stable mild prominence of the extrahepatic biliary system. Stable mild dilatation of the infrarenal aorta. Short left common iliac dissection, chronicity indeterminite. Brief Hospital Course: Assessment: [**Age over 90 **]yo man with COPD, recent NSTEMI admitted with dyspnea, chest pain, and nausea; found to have a LLL pneumonia by CXR and cardiac enzyme elevations suggestive of NSTEMI. . 1. Respiratory distress - His dyspnea and hypoxia were most likely secondary to the left lower lobe pneumonia in the setting of severe lung disease. In addition, he most likely had a component of congestive heart failure, especially given IVF and PRBC administration in the first few days of his admission. His pneumonia was treated with levofloxacin and vancomycin initially given his allergy to penicillin. There was no need to cover for anaerobes as he did not aspirate. Blood cultures were negative, and he tested negative for influenza and legionella. He was treated with supplemental oxygen, albuterol inhaler and nebulizer treatments, atrovent nebulizer treatments, fluticasone-salmeterol, and steroids. He remained afebrile, hemodynamically stable w/o any respiratory distress, and he will complete a 14 day total course of antibiotics. . 2. Chest pain - He was found to have cardiac enzyme elevations, with [**Known firstname **] CKs in the 300s. He was treated with a nitroglycerin drip in the [**Hospital Unit Name 153**] to become chest pain free, and a heparin drip for 48 hours. He was also treated with aspirin, plavix, and metoprolol. His imdur was restarted when the nitro drip was stopped. He had one additional episode of chest pain in the setting of exertion (transferring); this resolved within five minutes. His chest pain was frequently accompanied by nausea - this is likely to be an anginal equivalent for him. Pt had troponin rise from 0.36 to 0.64 over the weekend. Pt was asymptomatic - denied CP, nausea, vomiting. Considered other causes of enzyme leak such as PE, CHF, renal failure or demand ischemia. Given his baseline renal insufficiency and CHF, this troponin increase could be due in part to those causes. He was started on lovenox 70mg q12 and continued on this for 3 days. Also, given that his CKs were flat, he is not an ideal candidate for cardiac cath, and he is already on appropriate medical management, the team felt that there were no further interventions for this patient. Would continue to manage symptomatically and continue current cardiac regimen. . 3. CHF - On last ECHO, his LVEF was 35-45%. He went into pulmonary edema after receiving IV fluids and PRBCs. He was monitored clinically for signs of overload and treated as needed. . 4. HTN - He was continued on a beta-blocker, to keep his SBP<110. . 5. GERD - He was treated with a proton pump inhibitor. . 6. CRI - At baseline, his creatinine is 1.3-1.6; it was stable throughout his hospital stay. . 7. Anemia - The patient has chronic iron deficiency anemia and was transfused approximately one unit of packed red blood cells in the emergency room. His hematocrit remained stable throughout the hospitalization. . Communication - son [**Name (NI) 1399**] [**Name (NI) 7514**], [**Telephone/Fax (1) 49583**] (home), [**Telephone/Fax (1) 49584**] (office), [**Telephone/Fax (1) 49585**] (cell) Code status - DNR/DNI, no central lines w/o discussion w/ son, no invasive procedures including TEE. . Medications on Admission: 1. Docusate Sodium 100 mg PO BID 2. Aspirin 81 mg 3. Clopidogrel 75 mg DAILY 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] 5. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 6. Digoxin 125 mcg DAILY 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR DAILY. 8. Pantoprazole 40 mg PO Q12H. 9. Risperidone 0.5 mg PO HS 10. Toprol XL 25 mg Tablet Sustained Release once a day. 11. Senna 8.6 mg PO BID 12. Lactulose as needed. 13. Promethazine 12.5 mg tid prn 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual Q 5min as needed for chest pain. Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for back pain. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous ASDIR (AS DIRECTED): may d/c when steroid taper complete. 19. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every [**5-19**] hours as needed for nausea. 20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 3 doses. 21. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO qd () for 4 doses. 22. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 4 doses. 23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 4 doses. 24. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 4 doses. 25. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN (as needed) as needed for chest pain: take 1 every 5 minutes up to 3 times. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Primary: NSTEMI LLL pneumonia COPD dementia . Secondary: GERD iron deficiency anemia anxiety h/o DVT Discharge Condition: fair Discharge Instructions: Please return for further care if you have chest pain, shortness of breath, worsening nausea or vomiting, cough, fever, chills, change in mental status or any other symptoms that are concerning to you. . Please take all your medications as directed. You should continue your antibiotics for 8 more days. . Follow up with your physician at the appointment listed below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2140-1-11**] 3:30 Completed by:[**2139-12-22**]

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icd9cm

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13984

Discharge summary

report

Admission Date: [**2118-4-12**] Discharge Date: [**2118-4-16**] Date of Birth: [**2058-6-24**] Sex: F Service: [**Company 191**] CHIEF COMPLAINT: The patient was admitted originally for airway monitoring status post endoscopic retrograde cholangiopancreatography with adverse reaction to Fentanyl and tongue injury. HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old female status post endoscopic retrograde cholangiopancreatography on the day of admission, which had been done to evaluate for possible bile leak after cholecystectomy was performed four days ago. The patient was in her usual state of health until four days prior to admission when she had a cholecystectomy. Her postop course was uneventful until one day prior to admission when she developed abdominal pain. She went to an outside hospital Emergency Room and was reassured and sent home. On the day of admission she returned to the outside hospital Emergency Room where an abdominal CT was performed, which showed "thickened stomach and free air." She was sent to [**Hospital1 1444**] for an endoscopic retrograde cholangiopancreatography and possible stent placement. She had a successful endoscopic retrograde cholangiopancreatography, which showed a bile leak at the duct of Luschka. A stent was placed successfully. After her endoscopic retrograde cholangiopancreatography the patient developed "jaw clenching, biting tongue, rigidity and cold/chills." The patient received ampicillin, Gentamycin and Flagyl empirically as well as Narcan to reverse fentanyl. Because of the tongue injury and tachycardia as well as possible infection given her fevers or chills the GI Service transferred the patient to the MICU for close observation. PAST MEDICAL HISTORY: 1. Hiatal hernia. 2. Status post cholecystectomy four days prior to admission. 3. Urinary frequency secondary to interstitial cystitis. 4. Mitral valve prolapse. 5. Tubal ligation many years ago. MEDICATIONS ON ADMISSION: 1. Prempro. 2. Eye drops. ALLERGIES: No known drug allergies at the time of admission, however, it is assumed that her rigidity and jaw clenching was secondary to Fentanyl. SOCIAL HISTORY: The patient is married. She works as a teacher's aid in [**Location (un) 8072**]. She denies tobacco or alcohol use. PHYSICAL EXAMINATION ON ADMISSION TO THE MICU: Vital signs temperature 100.6. Heart rate 105. Blood pressure 162/76. Respiratory rate 18. Sating 98% on 3 liters. In general, the patient was groggy status post anesthesia, shivering, but awake. HEENT showed tongue with laceration on the right edge. Mucous membranes are moist. Pupils are equal, round and reactive to light. Extraocular movements intact. Lungs were clear to auscultation bilaterally. Heart regular rate and rhythm. No murmurs, rubs or gallops. Abdomen was soft, nontender, nondistended. There were normoactive bowel sounds. There was no rebound or guarding. There were post laparoscopic incisions without erythema with Steri-Strips in place. The extremities were without edema. Dorsalis pedis pulses were intact bilaterally. There were no rashes. LABORATORIES ON ADMISSION: White blood cell count 9.0, hematocrit 39.3, platelets 296, neutrophil count 82, lymphocytes 14, 4 monocytes, troponin was less then 0.3. Sodium 139, potassium 3.8, chloride 101, bicarb 26, BUN 9, creatinine 0.7, glucose 141, albumin 4.1, calcium 8.9, LDH 665, AST 44, ALT of 57, amylase 41, CK 32. Electrocardiogram showed normal sinus rhythm at 73 beats per minute. There was normal axis. Normal intervals. There were no ST or T wave changes. Abdominal CT showed inflammation in the right upper quadrant, small fluid in the circumferential thickening of the distal stomach. There was a question of a small ulcer. There was a tiny amount of free air. This was per report of [**Hospital3 3583**]. HOSPITAL COURSE: In summary the patient is a 59 year-old female who was admitted to [**Hospital1 188**] for an endoscopic retrograde cholangiopancreatography for possible stent placement for a bile leak secondary to cholecystectomy performed four days prior to admission. She then suffered rigidity with jaw clenching and tongue biting secondary to Fentanyl administration and was transferred to the MICU for close observation. She did well overnight in the MICU. She was started on Ampicillin, Gentamycin and Flagyl. Her liver function tests and amylase and lipase were followed closely. On the second hospital day the patient was doing much better and was stable from an airway perspective, so she was transferred to the General Medical Floor. 1. Gastrointestinal: As stated the patient was status post endoscopic retrograde cholangiopancreatography with stent placement for a bile leak from the duct of Luschka. The patient was continued on Ampicillin, Gentamycin and Flagyl, which had been started at the time of transfer to the MICU. She had waxing and [**Doctor Last Name 688**] fevers. However, her white blood cell count was never really elevated and she did not have a bandemia. On the day of transfer to the General Medical Floor the patient had received clear liquids. She did not tolerate this very well. Her amylase and lipase on the day following the endoscopic retrograde cholangiopancreatography were elevated. Amylase was 2304 with lipase being 7116. Therefore she was made NPO and given aggressive intravenous hydration. On the second hospital day on the General Medical Floor the patient had marked rebound to palpation of her abdomen. She was followed closely with serial abdominal examinations. Her amylase and lipase were trending down, however. An abdominal CT was obtained, which showed only mild pancreatitis. There were no intra-abdominal fluid collections, which required any drainage. On the third hospital day the patient's pain was improving and the rebound was decreasing. Her enzymes continued to trend down. She received clear liquids in the evening and tolerated these well. On the day of discharge the patient was tolerating a BRAT diet without significant abdominal pain. She had no further rebound. She had no temperature spikes in greater then 24 hours at the time of discharge. 2. Hematology: The patient's hematocrit was 34.8 at the time of admission. It decreased to 30 in the setting of aggressive hydration. It remained stable at the time of discharge and it was 29.5 on the day of discharge. 3. FEN: The patient was aggressively hydrated given that she was NPO. She required periodic repletion of her potassium. Her bicarb began to drop and she developed an anion gap acidosis. This was most likely secondary to ketoacidosis as she had no dextrose in her intravenous fluids. This was added on the evening prior to discharge and on the day of discharge her anion gap acidosis had resolved. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Levaquin 500 mg one po q day times seven days. 2. Protonix 40 mg po q day. 3. Percocet one to two tablets po q 4 to 6 hours prn. The patient was given a prescription for ten pills. 4. Prempro as the patient was formerly taking. 5. Trazodone at bedtime. DISCHARGE FOLLOW UP: The patient was to make an appointment with Dr. [**Last Name (STitle) **] within one to two months after discharge for removal of the stent. In addition, she would follow up with her primary care physician within one to two weeks following discharge. She was to continue on a BRAT diet over the weekend and two days after discharge she could advance to a low fat no dairy diet. She could slowly advance back to a normal diet over the next week. DISCHARGE DIAGNOSES: 1. Post endoscopic retrograde cholangiopancreatography pancreatitis. 2. Anemia. 3. Hypokalemia. 4. Anion gap acidosis. 5. Bile leak. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 6859**] MEDQUIST36 D: [**2118-4-16**] 13:49 T: [**2118-4-18**] 08:16 JOB#: [**Job Number 35463**]

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icd9cm

[ [ [] ] ]

[ "51.87" ]

icd9pcs

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164, 335

364, 1744

3177, 3883

1767, 1973

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6880, 6889

28,925

190,780

34162

Discharge summary

report

Admission Date: [**2136-6-9**] Discharge Date: [**2136-6-19**] Date of Birth: [**2069-10-27**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: right sided weakness, difficulty with speech Major Surgical or Invasive Procedure: Nasogastric tube placement History of Present Illness: Mr. [**Name13 (STitle) 17469**] is a 61 year old male with untreated hypertension found on the ground this morning with right sided weakness found to have a left globus pallidus hemorrhage. He was found by his brother this morning, noted the above deficits, and was taken to [**Hospital3 **]. Head CT at [**Hospital1 **] revealed left 2x4cm putaminal hemorrhage. He was given Mannitol 25g IV x 1, Nitroglycerin IV for elevated BP and transferred via [**Location (un) **] to [**Hospital1 18**]. Further history is difficult to obtain as the pt is unaccompanied and has a nonfluent aphasia. The patient denies any headache at present. He reports drinking vodka daily. Outside hospital records indicate the patient has not had any medical care for many years. Further ROS unavailable. Past Medical History: Prostate Cancer- s/p prostatectomy ? uncontrolled HTN Social History: lives with his brother, reports drinking vodka daily, unable to obtain h/o of any other illicit or IV drug use. Family History: NC Physical Exam: Vitals: T 100.2, BP 170/48, HR 69, R 17, 98% 2LNC Gen- slightly agitated moving about hospital bed with C-collar on, opens eyes to voice, attempts to cooperate with examiner, NAD HEENT- NCAT, MMM, OP clear, anicteric sclera. Neck- no carotid bruits bilaterally. CV- RRR, no MRG Pulm- CTA B Abd- soft, nt, nd, BS+ Extrem- no CCE Neurologic Exam: MS- He reports being at "[**Hospital1 **]" (prior hospital) I am unable to understand the pt's speech with regards to other ?'s of orientation. His speech is severely dysarthric and largely unintelligeble, however certain words seem appropriate and understandable as above. He follows all midline and appendicular commands with some impersistence. CN- PERRL 4-->2mm bilaterally, fundi flat discs without hemorrhages, EOM's are full with right conjugate gaze preference, blinks to threat bilaterally, right upper motor neuron facial droop, right facial weakness, hearing intact to finger rub. palate appears sluggish on the right. Motor- slight postural tremor on left arm, no left drift or asterixis. Right arm is plegic, extends and internally rotates to noxious stimuli. He can hold his right leg antigravity for 10 seconds. His left side appears to be full strength, but formal strength testing is difficult to perform. Sensation- intact to noxious throughout. Reflexes- 2+ symmetric in delt, [**Hospital1 **], tri, brachiorad, patellars, ankles bilaterally. Coordination- mildly ataxic on FNF on left, +impersistent. Plantar response is flexor on the left, extensor on the right. Gait- unable to assess. Pertinent Results: Labs: 142 105 6 AGap=15 ------------<175 4.0 26 0.8 Ca: 8.9 Mg: 1.8 P: 2.7 CK: 175 MB: 6 Trop-T: <0.01 ALT: 46 AP: 57 Tbili: 0.7 Alb: 4.1 AST: 39 Lip: 25 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Neg MCV 98 WBC 12.3, Hgb 12.8, Hct 36.6, Platelets 421 EKG- NSR 77, old IMI, IVCD, 1mm ST elevation in V5, V6 IMAGING: CT HEAD [**6-9**]: There is a 4.8 x 1.9 cm region of hyperdensity with surrounding hypodensity in the region of the left lentiform nucleus and external capsule is consistent with acute intraparenchymal hemorrhage with a mild amount of surrounding vasogenic edema. This causes mild compression of the left lateral ventricle and 3 mm rightward shift of normally midline structures. Otherwise, there are no other foci of hemorrhage, edema, mass, or large vascular territory infarction. The basal cisterns are preserved. Prominence of the extra-axial CSF spaces may be due to age-related involutional change. No fractures are seen. There is mild mucosal thickening in the left maxillary sinus. IMPRESSION: Hemorrhage involving the left lentiform nucleus and external capsule with mild surrounding vasogenic edema unchanged from images from outside hospital. Mild shift of normally midline structures towards the right. <br> CXR [**6-9**]: One supine portable view of the lower chest and upper abdomen. Comparison with the previous studies of [**2136-6-9**]. A Dobbhoff feeding tube has been inserted and terminates in the right upper quadrant of the abdomen in the region of the gastric antrum or duodenal bulb. There is persistent streaky density at the right lung base consistent with subsegmental atelectasis. IMPRESSION: Tube placement as described. <br> CXR [**6-13**]: Atelectasis at the right lung base persists. Lungs are otherwise clear. Normal cardiomediastinal and hilar silhouettes. Small bilateral pleural effusion is unchanged. Nasogastric tube is looped in the distal stomach and ends in the proximal. Brief Hospital Course: BRIEF ICU COURSE: Admitted initially to the Neuro ICU for close monitoring and blood pressure control. Neurologic exam was significant for non-fluent aphasia, right facial droop, right arm and leg hemiplegia with extensor posturing of arm and triple flexion of leg to noxious stimulation. The repeat head CT obtained here revealed stable appearance of the hemorrhage relative to that obtained at the OSH. The likely etiology of the hemorrhage given the location is hypertension. However, MRI/MRA as an outpatient in 1 month (once heme components are resorbed) should be considered to rule out an underlying mass lesion. His blood pressure was controlled initially with a nicardipine drip. After a few days, his pressure dropped into the 80s to 120s systolic; he was given fluid boluses to maintain a SBP > 100. He was covered with an insulin sliding scale and Tylenol for fevers. His mental status and language gradually improved over four days and he was transferred to the Stepdown Unit. He did show signs of alcohol withdrawal and was treated with prn Ativan. His Ativan requirement peaked at day 2 and declined after that. His autonomic instability was treated with clonidine. He was given daily IV Thiamine, Folate, and MVI. He was ruled out for MI via serial cardiac enzymes. Nutrition was initially provided via a nasogastric tube, as he was unable to handle his own secretions. This improved as well over the next several days, and once he required less suctioning of his secretions he was transferred to the Stepdown Unit and re-evaluated by the Speech and Swallow Consult. He was febrile early in his admission, and grew staph aureus from his sputum. He was treated with 4 days of vancomycin, but switched to cefazolin once sensitivities were resulted. He also was found to have a UTI by urinalysis and was treated with 3 days of ciprofloxacin. PT and OT were provided. BRIEF FLOOR COURSE: No further complications arose on the floor. He pulled out his NG tube on Sunday [**7-18**], but it didn;t need to be replaced since the next AM he past his speech and swallow evaluation. His bloodpressure medications were further titrated upwards, but they may need further adjustment. Towards the end of his hospital stay, the evening prior to discharge, he was a given Ativan x 1 for restlessness and climbing out of bed putting him at risk for falls. The next AM ([**2136-6-19**]) he was his usual self and there were no overt signs of delerium. He was discharged to rehab in stable condition. Medications on Admission: Allergies: NKDA Medications: none Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation, withdrawal for 7 days. 9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Left basal ganglia hemorrhage (stroke). Discharge Condition: Stable. Discharge Instructions: You have been admitted with a left sided hemorrhage in the brain - in the "basal ganglia" which are structures that control motor systems of the R side of your body. Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with speech, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2136-8-21**] 4:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2136-6-19**]

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

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361, 389

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26228

Discharge summary

report

Admission Date: [**2187-7-24**] Discharge Date: [**2187-8-2**] Date of Birth: [**2133-10-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: EGD on [**2187-7-24**] 1. Hemigastrectomy with Billroth II reconstruction. 2. Feeding jejunostomy History of Present Illness: 53M with a PMHx of HTN, DMII, COPD, developed dizzyness with nausea, stomach pain, and vomitting 3-4 days prior to admission. Emesis was dark black. Melanotic stools began on saturday and continued for three days until admission. This morning dizzyness and weakness progressed, he called 911 and was brought to ED by EMS. In the ambulance, was noted to have inferior ST elevations (got ASA 325 by EMS). These resolved on the ED 12-lead and were attributed to machine calibration; he does not have a cardiac hx and had no chest pain. Trop on arrival 0.05, CK=28 (Cr at 1.6, baseline unknown). . In the ED, initial vs were: T=96.8 P=99 BP=90/29 R=20 O2 sat 95%. Patient was pale and diaphoretic at presentation c/o weakness. His initial Hct was 23.7 (unknown baseline) with WBC of 20, normal plts, normal coags. His pants were stained with melanotic stool. NG drainage was drak red and did not clear with lavage. He was given 4L NS (1 prior to Hct, 3 post) and erythromycin for motility prior to EGD. Pressure transiently as low as 81/28 in the ED, at time of transfer (POST 4L), HR=86, BP=105/60, R=20, 96%ra. One unit of blood given in transit and second unit given over one hour in MICU. . EGD in MICU showed clot in fundus with no active bleeding. Currently feels weak but significatly better than earlier today. Denies ever having had chest pain. Denies GIB hx, ulcer hx, etoh abuse, denies excess NSAID use. Never had stomach pain before 4 days PTA. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. PCP informed of admission; has not seen him in one year. Past Medical History: Chronic pain on home opiates s/p MVA with femur fx 20+ years ago R knee OA HTN COPD/asthma Hypercholesterolemia Hospitalization for PTX s/p bleb rupture several years ago. Social History: The patient is married, has two children. Denies alcohol or drug use. He currently smokes 2 packs of cigarettes per day. He works and owns a pizza shop in [**Location (un) 745**]. Wife is travelling in [**Country 5881**] and has been updated. Family History: non-contributory, no CAD hX, NO ONCOLOGIC HX Physical Exam: Vitals: T:97.4 BP:109/58 P:95 R:22 O2:98ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, distant BS, no wheezes, rales, ronchi CV: Regular rate and rhythm, DISTANT S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Brief Hospital Course: # Upper GI Bleed - In the emergency department, the patient received two peripheral 16 gauge IV's. Overall, he received 5 liters of normal saline and 3 units of blood. After receiving these fluids, his tachycardia resolved and his blood pressure returned to the low-normal range. After the patient was transferred to the emergency department, an EGD was performed. When he received sedation for his EGD, he did have an episode of hypotension that required a saline bolus. The EGD showing significant clot in stomach with no active bleeding. The patient had no additional melena or emesis. Hematocrits were followed throughout the night and remained stable around 25 (up from his initial hematocrit of 23.7). He was also maintained on an IV PPI. Overnight, he remained normotensive. The day after his admission, he was transferred out of the MICU to the floor with plans for a repeat EGD after 48 hours. Pt had repeat EGD on [**2187-7-26**] which showed a fungating, ulcerated and infiltrative 5-7cm mass with stigmata of recent bleeding of malignant appearance at the stomach body, with a ventral vessel. Surgery was consulted and the decision was made to go to the OR on [**2187-7-27**] with Dr. [**Last Name (STitle) 519**]. A hemigastrectomy with Billroth II reconstruction was performed along with a feeding jejunostomy. Metastatic gastric adenocarcinoma was diagnosed on biopsy. The patient recovered from his surgery in the unit before being transferred to the floor. He was discharged on post-operative day 5 and hospital day 9. Medications on Admission: HCTZ 25',lisinopril 20', atenolol 50', simvastatin 10', oxycontin 20", advair diskus 250/50, spiriva, fenofibrate cap 200mg (1 cap PO daily with meals), metformin 500" Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with pain meds. Disp:*60 Capsule(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Maximum of 4gm of APAP daily. . Disp:*45 Tablet(s)* Refills:*0* 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation once a day. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Upper gastrointestinal hemorrhage with gastric mass. Adenocarcinoma of the stomach Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow up appointment. -Steri-strips will be applied and will fall off on their own. Please remove any remaining strips 7-10 days after application. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . J-TUBE: Please continue to flush J-TUBE with 30-60 cc of water daily. Please continue to change dressing daily and as needed. Please continue to assess site for s/s of infection. Followup Instructions: 1. Please call Dr.[**Name (NI) 1745**] office, [**Telephone/Fax (1) 6554**], to make a follow up appointment in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

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icd9cm

[ [ [] ] ]

[ "45.16", "46.39", "43.7", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

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323, 423

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8008, 8259

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275, 285

451, 1906

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32,122

121,433

45515

Discharge summary

report

Admission Date: [**2104-7-18**] Discharge Date: [**2104-8-2**] Date of Birth: [**2032-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: weakness Major Surgical or Invasive Procedure: colonoscopy endoscopy endoscopic ultrasound and pancreas biopsy History of Present Illness: Please see nightfloat H&P for full HPI, PMH, meds, SH, FH. Briefly, pt is a 72 y/o African-American M with CRI, h/o nephrolithiasis, who presented with weakness. His weakness has been progressive over the week prior to admission, is present in his upper and lower extremities, makes it difficult for him to stand, and is accompanied by pain. He reports inability to grasp objects with his hands and he feels that his fingers are stiff. He has never experienced this before. He also had a recent episode of 2 days of abdominal pain, starting at his umbilicus and then moving to his RLQ. This was accompanied by N/V x 1. It has been resolved for 2-3 days and was not accompanied by a change in bowels. He has chronically loose bowels which have worsened over the past 2 months. He has loose stools after each meal, up to 10x per day. He denies BRBPR, melena. Past Medical History: Nephrolithiasis- s/p surgery [**2071**] Perforated ulcer- s/p surgery [**2066**] "ileitis" in [**2061**] s/p surgery s/p thumb surgery Social History: No tobacco, rare ETOH. Lives alone. Supportive family. Family History: NC Physical Exam: VS: T: 96.9F BP 126/84 HR: 107 RR: 22 SaO2: 100% RA GEN: Middle-aged man in NAD, awake, alert HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT, ND, no HSM EXT: 1+ BLE edema SKIN: diffusely erythematous/scaly skin over face Pertinent Results: Admission labs: Na 144, K 1.9, Cl 122, bicarb 01, BUN 32, Cr 4.6, glucose 109 WBC 11.6, Hct 34.8, plt 256 Discharge labs: Na 141 K 5.5 Cl 116 Bicarb 19, BUN 12, Cr 2.3, glucose 73 WBC 11.6, Hct 34.8, PLt 197 calcium 7.5, Mag 1.2 (repleted), phos 3.4 AST 39 ALT 69 bili 0.6 albumin 2.8 PTH 667 gastrin 222 ([**Year (4 digits) **] 90) VIP pending 5-HIAA normal niacin pending copper: slightly over [**First Name9 (NamePattern2) **] [**Doctor First Name **] neg IGF-1 normal hepatitis a,b,c serologies negative Reports: LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2104-7-18**] 6:55 PM FINDINGS: Grayscale evaluation of the liver demonstrates diffusely increased echogenicity without focal hepatic lesions or masses. There is no intra- or extra-hepatic biliary dilation. The CBD measures 7 mm appropriate for patient's age. There is no choledocholithiasis. There is a 1.3 cm gallbladder stone without pericholecystic fluid or gallbladder wall edema to indicate acute cholecystitis. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was absent. The extrahepatic portal vein is patent with wall-to-wall hepatopetal flow and normal waveform. However, there is prominent perihepatic collateral vessels extending into the porta hepatis, which may replace the main portal vein suggesting possible cavernous transformation of the portal venous system. The limited visualization of the renal parenchyma demonstrates normal echogenicity. IMPRESSION: 1. Diffusely echogenic liver may represent fatty infiltration; however, more advanced liver disease including cirrhosis and advanced fibrosis cannot be excluded on this study. 2. Prominent perihepatic collateral apparently immediately distal to the extrahepatic and possibly replacing the main portal vein raise the possibility of cavernous transformation of the portal vein, related to underlying chronic portal hypertension. 3. Cholelithiasis without acute cholecystitis. 4. Normal echogenicity of right renal parenchyma argues against chronic medical renal disease (could the patient's acute renal failure reflect hepatorenal syndrome?) . CHEST (PA & LAT) [**2104-7-18**] 7:07 PM PA AND LATERAL VIEW, CHEST: The lungs are clear. There are no focal consolidations. There is no pleural effusion or pneumothorax. Minimal atelectasis is noted at the left lower lobe. Cardiomediastinal silhouette and pulmonary vasculature is normal. The aorta is markedly elognated and unfolded. The pulmonary vasculature is unremarkable without evidence of pulmonary edema. There is diffuse osteopenia with loss of height of mid thoracic vertebra ad resultant kyphosis. IMPRESSION: No acute cardiopulmonary process. . ECG Study Date of [**2104-7-18**] 5:33:52 PM Sinus rhythm. Possible old inferior myocardial infarction. Left anterior fascicular block. Intraventricular conduction delay. No previous tracing available for comparison. TRACING #1 . ECG Study Date of [**2104-7-19**] 3:07:12 AM Sinus rhythm. Occasional premature atrial contractions. Compared to the previous tracing atrial ectopy is new. TRACING #2 . RENAL U.S. [**2104-7-20**] 8:37 AM RENAL ULTRASOUND: Bilateral sub-1.6 cm kidney cysts are noted. The right kidney measures 8.9 cm without evidence of hydronephrosis, stone or mass. the left kidney measures 9.8 cm, evidence of hydronephrosis, stone or mass. An enlarged prostate measuring 5.1 x 5.4 x 6.6 cm and encroaches into the bladder. The spleen measures 12.9 cm and is otherwise unremarkable. There is cholelithiasis without evidence of cholecystitis. IMPRESSION: 1. No hydronephrosis. 2. A large prostate protrudes into the bladder. . CHEST (PORTABLE AP) [**2104-7-21**] 9:14 AM The recently placed left PICC distal tip probably projects at the expected location of the mid SVC. No pneumothorax, pleural effusion or focal consolidation is noted. The cardiac silhouette and hilar contours are normal. The aorta is tortuous. IMPRESSION: Satisfactory position of left PICC with no complication. -------------------- V/Q Scan: IMPRESSION: The above findings are consistent with a moderate to high likelihood of pulmonary embolism. Colonoscopy: normal. Stricture at ileocolonic anastamosis, unable to pass scope through. Pathology: A. Anastomotic area: 1. Fragment of enteric mucosa with fibrosis, atrophic changes and active inflammation involving the surface epithelium. 2. Fragment of unremarkable colonic mucosa. B. Random: Fragments of unremarkable colonic mucosa. Upper endoscopy: Erythema and congestion of the mucosa were noted in the stomach. These findings are compatible with gastritis. Cold forceps biopsies were performed for histology at the stomach antrum. 3 cords of grade 1 varicees. Pathology revealed chronic active gastritis with H pylori present. . Endoscopic ultrasound: EUS was performed using a linear echoendoscope at 7.5 MHz frequency: The head of the pancreas were imaged from the duodenal bulb and the second duodenum. The body and tail were imaged from the gastric body and fundus. The uncinate process of the pancreas could not be imaged. Pancreas parenchyma: The parenchyma in the uncinate pancreas was homogenous, with a normal ??????salt and pepper?????? appearance. No discrete mass lesions or changes suggestive of chronic pancreatitis were noted. Pancreas duct: The pancreas duct measured 3 mm in maximum diameter in the head of the pancreas and 1.7 mm in maximum diameter in the body of the pancreas. The duct was normal in echotexture and contour. No intra-ductal stones were noted. No dilated side-branches were noted. Multiple, dilated, tortuous abnormal vessels were noted in the portal hepatis. These may represent varices or cavernous transformation of the portal vein. Duodenum mucosal biopsy: No diagnostic abnormalities recognized, but nearly all the surface epithelium has been stripped off and is not present for evaluation of villous architecture. Multiple levels have been examined. Brief Hospital Course: A/P: 72 yo male with CRI, s/p colectomy for Crohn's disease, nephrolithiasis who presents with acute renal failure and hepatitis. #Diarrhea: Acute on chronic by history. Patient reported frequent loose stools for many years at home (since his bowel resection) and could not recall any substantial change that precipitated his presentation to the hospital. Further history was obtained from his long time friend who reported that he had had a substantial increase in gas, bloating, diarrhea in the past week that was associated with his other presenting complaints. Patient's diarrhea persisted in the hospital reaching as much as 5L per day in the ICU and persisted even when he was NPO. His stool osms in the ICU initially showed a gap of 68 (suggesting secretory diarrhea) This history prompted an extensive work-up for secretory diarrhea illnesses. Causes considered included neuroendocrine tumors [gastrin 221 ([**Month/Day/Year **] 90), VIPp, IVF1 normal, 5-HIAA normal, niacin (for pellagra) pending], bacterial toxins, Crohn's, microscopic(lymphocytic) colitis, hyperthyroidism (normal TSH). Stool cultures were negative. Small bowel barium follow-through revealed hypermotility as well as chronic malabsorption as suggested by the increased number of folds in the ileum. EGD/colonoscopy w biopsies only showed mild gastritis and H pylori. Colon biopsy was normal. After aggressive elecrolyte repletion his diarrhea slowed down to 5-10 small BM's per day. His stool gap increased to 114, closer to a secretory type diarrhea. Given his history of bowel resection and oxalate stones (indicating probabale disruption in enterohepatic bile acid circulation) we started the patient on cholestyramine (presuming osmotic diarrhea from non-absorbed bile acids) and immodium for symptomatic relief. # Acute renal failure on Chronic kidney disease: As per OSH records patient's Cr is baseline 3.5. Renal team consulted who felt that chronic kidney disease may be due to chronic hypokalemia from chronic diarrhea. Spoke with patient's PCP who confirmed this history. Patient's Cr steadily returned to baseline 2.4 and at time of discharge. # Electrolytes: Patient with severe hypokalemia, and non-anion gap metabolic acidosis with bicarbonate level in the single digits. This was felt to be from his severe diarrhea as well as a renal concentrating defect from his hypokalemia (according to the nephrology team). He was in the ICU for many days where he received aggressive elecrolyte repletion and eventually had some stabilization in his electrolyte panel. His potassium was slightly high (5.5) on discharge after daily 60mEq per day of potassium repletion. He may need further potassium repletion at a later date (would recommend either aldactone or 20mEq of potassium per day). # Proximal Muscle Weakness: Thought secondary to electrolyte disturbances arising from acute on chronic diarrhea and chronic kidney disease. Improved with resolution of his electrolytes. Ultimately, serologic tests such as RF, [**Doctor First Name **] for evidence of dermatomyositis, polymyositis were negative. Given symptomatic improvement and that CK's trended to baseline a muscle biopsy was deferred. # transaminitis/pancreatitis: Patient with no known liver disease. Imaging demonstrated inflammation of the pancreatic head c/w pancreatitis or possibly an underlying mass lesion. Also noted cholelithiasis. Patient was never with clinical cholecystitis or pancreatitis in the hospital but did report abdominal pain prior to admission. It was felt that he had likely passed an obstructed stone at home leading to the elevated enzymes, CT findings without overt evidence of acute pancreatitis. Endoscopic ultrasound was performed to exclude an underlying pancreatic mass and showed no evidence of any abnormalities. Viral hepatitis panels, auto-immune liver serologies, iron studies were all negative. Serum copper was mildly elevated. Patient declined HIV testing. Endoscopy did reveal grade 1 varices consistent with chronic liver disease. He was started on nadalol 20mg po daily. He will follow-up in the liver center. #PE: Post-ICU stay patient was with resting sinus tachycardia of 100-110 bpm that was unexplained. During periods of exertion his HR would rise to 130-140bpm. Patient underwent V/Q scan which showed moderate-high probability for PE and so patient was started on heparin gtt. He was transitioned to coumadin (2.5mg po daily) and after 3 days of this he was supratherapeutic with INR of 4.9. He is instructed to hold coumadin until he sees his PCP on monday. I would suspect that a regimen of coumadin 1mg po daily may be adequate for him given the evidence of liver dysfunction and likely malabsorption from his chronic diarrhea. # Hyperparathyroidism: patient had relatively normal calcium and phosphorus, but was found to have a very very high PTH level (667). He was started on calcitriol. This level should be followed by his nephrologist. Medications on Admission: none Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). Disp:*180 Tablet, Chewable(s)* Refills:*2* 2. Niacin 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qWeek () for 8 weeks. Disp:*30 Capsule(s)* Refills:*0* 5. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day): do not take within 1 hour of your other medications. (this medicine can prevent absorption of other drugs). Disp:*90 Packet(s)* Refills:*2* 6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Loperamide 2 mg Capsule Sig: [**2-6**] Capsules PO every six (6) hours as needed for for diarrhea. Disp:*100 Capsule(s)* Refills:*2* 8. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig: Ninety (90) ML PO QID (4 times a day). Disp:*[**Numeric Identifier 16501**] ML(s)* Refills:*2* 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: please do not take until you see Dr. [**Last Name (STitle) **]. He will check your INR. Disp:*30 Tablet(s)* Refills:*2* 10. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: for treatment of H pylori. Disp:*28 Tablet(s)* Refills:*0* 11. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 14 days: for treatment of H pylori. Disp:*56 Tablet(s)* Refills:*0* 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 14 days: for treatment of H pylori. Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: do NOT start until you have seen your doctor . Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: diarrhea pulmonary embolus acute renal failure hyperparathyroidism pancreatitis chronic liver disease NOS with portal hypertension Discharge Condition: good Discharge Instructions: You were admitted to the hospital with severe weakness, electrolyte abnormalities, and diarrhea. An extensive evaluation did not show a conclusive cause of your problems. We think that many of your symptoms may have been due to your electrolyte problems from long standing diarrhea. You will need to see many doctors in follow-up for these problems. In addition we have started many new medications to help the diarrhea and your electrolyte problems. Additionally, we found that you have a blood clot in your lungs. You will need to be on coumadin to thin your blood. Your primary care doctor will follow your INR (coumadin level). Because your blood is thin, do not take any coumadin until Dr. [**Last Name (STitle) **] checks your blood on Monday. Lastly, we found that you have gastritis (inflammation of the stomach) due to infection with H pylori. You should finish a course of antibiotics for this. Please seek medical attention if you have any further weakness, worsening diarrhea, fevers, chills, abdominal pain, or other worrisome symptoms. Followup Instructions: Please see Dr. [**Last Name (STitle) **] on [**8-4**] at 11AM. [**Telephone/Fax (1) 80088**]. You will need to see the following specialists Nephrology: Provider: [**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **],MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 435**] Date/Time:[**2104-8-15**] 10:00 Hepatology (liver): [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2104-11-13**] 8:30 Gastroenterology: [**Name6 (MD) 8758**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2104-8-26**] 4:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2104-8-3**]

[ "787.91", "572.3", "577.0", "276.2", "571.9", "584.9", "585.3", "415.19", "252.00", "276.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.16", "45.25" ]

icd9pcs

[ [ [] ] ]

14953, 15010

7905, 12882

322, 388

15185, 15192

1989, 1989

16300, 17051

1523, 1527

12937, 14930

15031, 15164

12908, 12914

15216, 16277

2112, 7882

1542, 1970

274, 284

416, 1274

2005, 2096

1296, 1433

1449, 1507

10,117

105,150

1246+55268

Discharge summary

report+addendum

Admission Date: [**2138-11-9**] Discharge Date: [**2138-11-18**] Date of Birth: [**2072-5-5**] Sex: F Service: CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female with a history of multiple myeloma recently admitted to [**Hospital1 69**] with methicillin-resistant Staphylococcus aureus line infection. She returns with fever since the night prior to admission to 103, positive cough, sore throat, no shortness of breath or chest pain, makes very little urine, no nausea, vomiting or diarrhea, positive fevers and chills. She also reports a skin lesion on her left lower extremity x 3 days. Prior to admission she was otherwise in her usual state of health until the day prior to admission. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed in [**2135**]; status post VAD x 4; status post autologous bone marrow transplant. 2. Recurrent streptococcus infections on penicillin prophylaxis. 3. Total abdominal hysterectomy and bilateral salpingo-oophorectomy. 4. Status post appendectomy. 5. Status post tonsillectomy. 6. Perforated tympanic membrane. 7. Carpal tunnel syndrome. 8. Recently discharged from [**Hospital1 69**] after admission for a bleeding dialysis catheter which was placed by interventional radiology and subsequently developed a methicillin-resistant Staphylococcus aureus line infection and has been on vancomycin since then. 9. End-stage renal disease on dialysis. MEDICATIONS ON ADMISSION: Vancomycin dosed at dialysis; Protonix 40 mg p.o. q.d.; Tums 500 mg p.o. b.i.d.; Renagel; Ambien 5 mg p.o. q.h.s.; penicillin V 500 mg p.o. b.i.d. ALLERGIES: Sulfa. SOCIAL HISTORY: The patient lives alone; no alcohol or tobacco use. She is a retired math teacher. FAMILY HISTORY: Prostate cancer in her father. Hypertension and breast cancer in her mother. REVIEW OF SYSTEMS: As per history of present illness. PHYSICAL EXAMINATION: On admission her blood pressure was 102/50, pulse 115, respiratory rate 16, O2 saturation 97% on two liters, temperature 101. Head, eyes, ears, nose and throat examination showed no jugular venous distension, dry mucous membranes with oral petechiae. Cardiovascular examination showed a regular rate and rhythm, slightly tachycardic, normal S1 and S2, positive S4. Lungs had bibasilar crackles with left chest field positive for crackles and dullness to percussion. The abdomen was soft, nontender and nondistended with normal active bowel sounds. Extremities were warm with no edema, positive multiple bruises and a 3 x 2 cm erythematous nonpruritic plaque with central clearing on the left lower extremity. LABORATORY DATA: On admission the white blood cell count was 1.9, hematocrit 24.1, platelet count 19, granulocytes 1,100, partial thromboplastin time 33.6, INR 1.3. Sodium was 127, potassium 4.3, chloride 94, bicarbonate 22, BUN 33, creatinine [**5-24**]. Chest x-ray showed left lower lobe superior portion with evidence of consolidation. IMPRESSION: The patient is a 66-year-old female with multiple myeloma, end-stage renal disease, methicillin-resistant Staphylococcus aureus line infection admitted for treatment of pneumonia. HOSPITAL COURSE: 1. Infectious disease: The patient is chronically receiving doses of IVIG as an outpatient due to poor immune response secondary to the multiple myeloma. She was admitted with no evidence of neutropenia, however was given antibiotic coverage in the Emergency Department with ceftriaxone and gentamicin which was changed to levofloxacin for renal dosing with 250 mg q.o.d. The day following the patient's admission she began to spike a fever once again, however she was feeling significantly better and her breathing was substantially better. The following day she started to develop some mild respiratory distress. Chest x-ray was consistent with worsening pneumonia now with bilateral infiltrates as well as some overlying pulmonary edema. IVIG was administered to increase her immune globulin and her immune response to the pneumonia. 2. Renal: The patient has chronic renal failure on hemodialysis and was dialyzed the Monday following the first day of her admission. Following the administration of IVIG the patient began to have increasing respiratory distress likely due in part to the worsening pneumonia, however also likely due to worsening pulmonary edema due to fluid overload. The patient was emergently dialyzed on the night of [**2138-11-10**] and transferred to the medical intensive care unit for further management of her volume status as well as respiratory status. The medical intensive care unit course will be dictated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**] Dictated By:[**Name8 (MD) 4630**] MEDQUIST36 D: [**2138-11-19**] 14:06 T: [**2138-11-21**] 08:35 JOB#: [**Job Number 7785**] Name: [**Known lastname 991**], [**Known firstname 992**] Unit No: [**Numeric Identifier 993**] Admission Date: [**2138-11-9**] Discharge Date: [**2138-11-18**] Date of Birth: [**2072-5-5**] Sex: F Service: BMT This is a discharge summary addendum covering hospital course [**2138-11-15**] to [**2138-11-18**]. Patient was transferred to the BMT [**Hospital1 **] after being made comfort measures only while in the Intensive Care Unit. On [**2138-11-16**], all antibiotics were discontinued as well as vital signs. Comfort measure medications including pain control, anxiolytics, and gastrointestinal medications were continued. Patient appeared comfortable during this period of her hospitalization and was semiresponsive. Her family visited frequently and the evening of [**2138-11-18**], the patient expired. Family members were notified and no postmortem examination was requested. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 994**], M.D. [**MD Number(1) 1001**] Dictated By:[**Last Name (NamePattern1) 1008**] MEDQUIST36 D: [**2138-11-19**] 19:48 T: [**2138-11-20**] 04:38 JOB#: [**Job Number 1009**]

[ "203.00", "276.6", "790.7", "112.0", "585", "V42.81", "996.62", "486", "518.81" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

1769, 1848

1482, 1650

3197, 6200

1927, 3179

1868, 1904

145, 153

182, 749

772, 1455

1667, 1752

58,685

111,057

46924+58965

Discharge summary

report+addendum

Admission Date: [**2131-9-17**] Discharge Date: [**2131-10-25**] Date of Birth: [**2074-3-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Hip Pain Major Surgical or Invasive Procedure: - Endotracheal Intubation - Central Venous Line - Arterial Line - Peripherally Inserted Central Catheter History of Present Illness: 57M w hx of IVDU, endocarditis, recent diagnosis of cutaneous lupus treated only with cream, presenting w/ severe left hip pain. Approx 5 days ago, had 3 days of nausea, vomiting, diahrrea which he claims was secondary to eating bad steak tips, these symptoms have resoved. resolved. Nausea was consistency of coffee grounds per patient. No gross blood, No blood in his stool. He also reported general malaise which persisted. Approx 2 days ago, developed severe left hip pain, worse with walking and movement, and worsened despite taking ibuprofen and tylenol. Hip ROM severely limited with flexion and extension [**1-29**] pain, ABduction and ADduction more or less preserved. No obvious erythema or deformity. Denied fevers, night sweats, chills. he is unsure when he last used IV heroin, reporting it may have been 1 week or several months ago. . In the ED, initial vs were: T97.6 P101 BP 107/65 R 17 O2 sat 98% RA. The patient had a CXR which showed right lung opacity concerning for pneumonia. Multiple lab abnormalities were also present, including hyponatremia, hypokalemia, elevated creatinine to 2.2, thrombocytopenia with plts of 21, bandemia of 24, elevated LFTs. Also, INR 1.5 and PTT 100. Patient was given vancomycin, levaquin, ceftriaxone, and 3.5 liters of fluid. Orhopedics saw patient and recommended pelvis CT, which was unrevealing, though limited because it was without contrast. RUQUS was also done which was negative for cholecystitis, negative son[**Name (NI) 493**] [**Name2 (NI) **]. However, multiple hyperechoic splenic lesions were identified. After 3.5l of fluid the patient's heart rate increased to 130's, RR increased to 40's. A right EJ and left IJ were placed. Also received 40mEq Potassium, ativan 1mg IV x1, morphine 4mg IV X2. . Past Medical History: -Cutaneous lupus, diagnosed last year at [**Hospital1 2177**] and treated topically -MRSA TV endocarditis, treated at [**Hospital1 112**] ([**4-5**]) with daptomycin complicated by multiple septic pulmonary emboli and splenic abscess -Hepatitis B -Hepatitis C, negative viral load Social History: no tobacco, no alcohol, IV heroin use 2-3 months ago or potentially sooner. Family History: Mother alive at 88 with hypertension. Physical Exam: At Admission Vitals: T:99.4 axillary BP:129/64 P:149 R:35 O2: 97% 5LNC General: tachypneic, cachectic, dyspneic HEENT: Sclera anicteric, dry mucous membranes Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, no m/g/r Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: no clubbing, cyanosis or edema MSK: tenderness to palpation over lateral hip and anterior hip. tenderness with passive extension, passive internal and external rotation. patient does not actively move his hip joint. Skin: multiple scars and excoriations on arms. Pertinent Results: LABS ON ADMISSION: [**2131-9-16**] 09:45PM BLOOD WBC-8.6 RBC-6.08 Hgb-14.6 Hct-44.5 MCV-73* MCH-24.1* MCHC-32.9 RDW-16.0* Plt Ct-21* [**2131-9-16**] 09:45PM BLOOD Neuts-64 Bands-24* Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2131-9-16**] 09:45PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-3+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-2+ Burr-3+ Acantho-OCCASIONAL [**2131-9-16**] 09:45PM BLOOD Plt Smr-VERY LOW Plt Ct-21* [**2131-9-17**] 06:44AM BLOOD Fibrino-159 Thrombn-12.3 [**2131-9-16**] 09:45PM BLOOD Glucose-130* UreaN-76* Creat-2.2* Na-125* K-2.8* Cl-88* HCO3-16* AnGap-24* [**2131-9-16**] 09:45PM BLOOD ALT-68* AST-92* CK(CPK)-52 AlkPhos-136* TotBili-2.9* DirBili-2.2* IndBili-0.7 [**2131-9-16**] 09:45PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2131-9-17**] 04:30AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.6 [**2131-9-17**] 06:44AM BLOOD calTIBC-230* Hapto-168 Ferritn-443* TRF-177* [**2131-9-16**] 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-25.9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2131-9-17**] 02:00AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [**2131-9-17**] 02:00AM URINE RBC-0-2 WBC-[**6-6**]* Bacteri-MOD Yeast-NONE Epi-0-2 TransE-[**3-1**] [**2131-9-17**] 02:00AM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-TR -------------------- RUQ US [**10-22**]: No intra- or extra-hepatic biliary dilatation. Small gallbladder polyp. Otherwise unremarkable study. WBC SCAN [**10-17**]: Focal areas of increased radiotracer uptake projecting over site of known cavitary lesions on recent chest CT involving the posterior aspect of the right lower lobe most compatible with lung abscesses. CT-TORSO [**10-16**]: 1. New right pneumothorax. In a patient with risk of lung necrosis from complicating infection, differential diagnosis includes possibility of bronchopleural fistula, although less likely. Correlate with history of recent instrumentation. 2. Innumerable cavitary lesions within the lungs for which the differential diagnosis includes septic emboli, cavitary pneumonia such as staphylococcus, or less likely metastasis or acute presentation of Wegner's granulomatosis. There is interval improvement of air opacification in the lungs. Interval improvement of appearance of the pleural effusion, with remaining small right pleural effusion. 3. Splenic hypodense lesions some could be hemangiomas; however in keeping with lung findings cannot exclude septic emboli. 4. Lytic small iliac lesions bilaterally, incompletely characterized on this study. 5. Multiple bilateral cystic lesions in the kidneys, likely simple cysts. MR HEAD [**10-10**]: 1. Multiple small lesions scattered throughout the bilateral frontal and parietal lobes with varying degrees of restricted diffusion representing infarcts of varying ages, very likely embolic and related to known bacterial endocarditis. There is no hemorrhage. 2. Series of lesions within the paramedian right frontal and temporo-occipital regions, which appear more acute and may represent watershed infarcts, in the appropriate clinical setting (ie. acute [relative] hypotensive event]; there is no evidence of vascular territorial infarction. 3. Scattered punctate lesions in the posterior frontal lobes, bilaterally, corresponding to some of the older foci of resolving restricted diffusion, above, and likely representing septic emboli. There is no evidence of microabscess or pathologic leptomeningeal enhancement. 4. There is no evidence of cerebral venous thrombosis. MR [**Name13 (STitle) **] [**10-10**]: 1. C6-7: Findings involving the contiguous endplates, intervening disc and annuloligamentous complexes, characteristic of vertebral osteomyelitis/discitis, in this clinical setting. Though there is no epidural phlegmon or discrete abscess, there is a likely focal phlegmon in the left anterolateral prevertebral space, subjacent to that longus [**Last Name (un) **] muscle, at the C6 level. 2. C5-6: Contiguous findings, though less marked, are suspicious for a second level of involvement with discitis/vertebral osteomyelitis; again, no discrete epidural phlegmon or abscess is seen. 3. No non-contiguous vertebral involvement, elsewhere in the imaged spine. 4. Normal cervical spinal cord caliber and intrinsic signal intensity, with no pathologic leptomeningeal or intramedullary enhancement. CT HEAD [**9-22**]: Since the CT head of four days prior, there is increased conspicuity of subcortical white matter hypodensities which are bilateral but slightly more prominent on the right. Etiology is indeterminate. MRI with diffusion-weighted imaging and post-contrast imaging is recommended for further assessment. TEE [**9-18**]: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is likely partial flail of the anterior tricuspid valve leaflet with possible leaflet perforation without evidence of a tricuspid valve abscess. There is a large vegetation measuring 2.8 cm by 1.7 cm in largest dimension on the atrial side of the anterior leaflet of the tricuspid valve. Severe [4+] tricuspid regurgitation is seen. There is a small pericardial effusion. IMPRESSION: Large tricuspid valve vegetation with partial flail and likely perforation of the anterior tricuspid valve leaflet in the setting of severe tricuspid regurgitation. Small pericardial effusion. MRI HIPS [**9-17**]: IMPRESSION: 1. Fluid tracking along the gluteal muscles bilaterally, left more than right extending to the greater trochanter likely represents bursitis. 2. Mild intramuscular edema may be inflammatory or reactive in nature. 3. Diffuse signal abnormality of the visualized osseous structures signifying anemia or chronic disease. CT TORSO [**9-17**]: IMPRESSION: 1. Innumerable cavitatory lesions within the lungs, for which the differential includes septic emboli (favored given the lesions in the spleen), cavitatory pneumonia (such as Staph aureus) or less likely metastases or acute presentation of Wegener's granulomatosis. 2. Splenic lesions likely represent septic emboli less likely in this clinical context of neoplasm/metastases. 3. Bilateral pleural effusions and associated relaxation atelectasis. 4. Lytic lesions in the iliacs bilaterally are incompletely characterized onthis study. In the absence of prior imaging stability/acutity cannot be assessed. Recommend bone scan and/or MR are for further characterization. 5. Multiple bilateral renal hypodensities, simple in attenuation and structure, likely simple cysts. MICROBIOLOGY: [**2131-9-17**] 06:44AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE [**2131-9-17**] 11:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE * [**2131-9-17**] 03:05PM BLOOD HIV Ab-NEGATIVE [**2131-9-17**] 06:44AM BLOOD HCV Ab-POSITIVE*, HCV VIRAL LOAD NEGATIVE [**2131-9-17**] Urine culture: STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S NITROFURANTOIN-------- 32 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2131-9-19**]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] AT 10:50PM ON [**2131-9-19**]. GRAM STAIN (Final [**2131-9-18**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2131-9-20**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Brief Hospital Course: This is a 57 year old man with pmh IV drug use, cutaneous SLE, endocarditis, presenting with three days of gastrointestinal symptoms, followed by intense left hip pain, along with multiple lab abnormalities including bandemia, thrombocytopenia, elevated transaminases, and coagulopathy found to have a large MRSA vegetation on tricuspid valve. # Sepsis / Endocarditis: patient intially presented with sepsis was intubated and started on pressors. Initial TTE showed a TV vegetation and mild TR with moderate pulmonary HTN and systolic HTN. A follow up TEE showed large TCV vegetation with partial flail and possible perforation of anterior tricuspid valve leaflet with severe TR, small pericardial and complex pleural effusions. Blood cultures were also possitive for MRSA. ID was consulted and patient was started on IV Vancomycin. Additional imaging was performed which showed multifocal lung lesions and splenic lesions consistent with septic emboli. Imaging was also performed for his initial complaint of hip pain which was only significant for bursitis. Cardiac surgery was consulted and felt the patient was an extremely poor surgical candidate given the severity of his condition. Patient remained persistently tachycardic throughout his stay. Cardiology was consulted and felt his persistent sinus tachycardia was a physiologic response to TR in an effort to maintain adequate cardiac output. They initially advised diuresis as appropriate as the only potential medical therapy to help reduce RV strain. A repeat TTE was performed on [**9-21**] which showed worsening TR and RV strain. On [**9-22**] a CT head was performed to evaluate altered mental status (patient remained unresponsive despite no sedation) and concerns for ICH given setting of multiple septic emboli which showed foci of subcortical white matter hypodensities in bifrontal lobes extending from the superior convexity to the inferior frontal lobes. Gentle diuresis with lasix gtt was continued and then stopped for increased pressor requirements. On [**9-24**] a repeat TTE was performed which showed mild interval improvement. Clinical exam began to change with improving mental status and decreased ventilation requirements. On [**9-27**] a power PICC line was placed in hopes of decreasing the line burden. On [**9-28**] the patient was successfully extubated. He remained alert, interactive, able to follow commands but appeared very weak overall. At the time of transfer to the floor, he continued to have daily fever spikes and tachycardia, to be expected with his underlying endocarditis. On the floor he had an episode of hypoxia and tachycardia and was transferred back to the ICU. With each progressing day he gained strength in his upper and lower extremties as well as his voice. His fevers were less frequent and his white count decreased. An abdominal u/s was done due to rising AP which was negative for obstruction. He was transferred to the medical floor for further management. The patient remained in sinus tachycardia throughout his stay, near the 130's, likely a hyperdynamic response to severe TR and underlying infection. He required around the clock alternating Acetaminophen and Motrin for fever control. His fever curve was periodically checked off the anti-inflammatories but persistently returned, associated with rigors. ID felt this will be his prolonged clinical picture in the setting of multiple pulmonary abscesses [**1-29**] the endocarditis. Additional fever workup was also performed including an opthomology consult which ruled out endopthalmitis, a WBC scan which targetted the lungs, and a MRI which showed a C5-6 and C6-7 discitis and possible osteomyelitis. Cardiac surgery followed patient as well and felt that no surgical intervention was appropriate at this time. This may be revisted after the course of antibiotic therapy is complete. Also of note, the patient began to have large urine outputs while on the floor in the setting of known septic emboli to his brain. The pituitary looked unaffected on MRI but there is some suspicion that he may be suffering from central DI. A water deprivation test was performed which was inconclusive. Patient was able to keep up with his urine output as long as he has access to adequate PO fluids. Also of note, liver was consulted regarding an isolated alkaline phosphatase elevation that progressed throughout his hospitalization. [**Doctor First Name **], AMA, [**Last Name (un) 15412**] and IgG were all sent and pending at the time of discharge. Initial differential for possible etiologies included infiltrative process vs. drug induced process. The patient will require an outpatient ultrasound guided percutaneous liver biopsy to rule out infiltrative process. He should also follow up with Liver at [**Hospital1 18**] for further evaluation. They are aware and expecting patient. Infectious Disease followed throughout the hospitalization and recommended continued INTRAVENOUS VANCOMYCIN (no substitutions) with goal trough of 20 through [**11-18**]. They will be following his labs and appointments have been made for follow up. They will evaluate if patient will require additional antibiotcs after complete of this 2 month course. Patient was advised never to use drugs again. # Respiratory status/sedation: Patient was intubated for respiratory distress (intially presented with RR to 50's). Imaging showed a multifocal PNA c/w septic emboli from his TCV endocarditis. He was initially started on an ardsnet protocol but was later switched to PSV. His ventilator requirements gradually improved throughout his MICU stay and he was successfully extubated on [**9-28**]. He now is saturating well on RA. Throughout his stay on the medical floor, his respiratory exam substantially improved. Repeat CT-chest imaging showed marked interval improvements in lung infection; however, it did reveal a small, stable retrocardiac pneumothorax. IP felt no interventions were required. The patient continued to have fevers throughout his stay and interventional pulmonology were consulted to evaluate for possible drainage; after additional imaging was obtained, they recommended persistent medical management. # Tachycardia: Pt was found to have worsening tachycardia several days into his MICU stay. Repeat TTE showed worsening TR. Cardiology was consulted and felt that this was a physiologic response to poor forward flow. They also noted that B-blockade would be dentrimental. They also recommended gentle lasix gtt to help offload the RV which was attempted and limited by pressor requirements. The episodes of worsening tachycardia were also noted to correlate with fever spikes. The patients tachycardia persists at discharge and likely represents a hyperdynamic response to poor forward flow [**1-29**] TR. This is exacerbated by fevers which is responsive to Tylenol, Motrin and gentle fluid boluses # Weakness: Pt initially slow to recover s/p extubation. Initial differential included myopathy of chronic disease vs. central process. MR of the head and C-spine showed areas of likely septic embolization. Neuro exam and strength gradually increased throughout hospital stay and patient was near baseline and non-focal at time of discharge. # Microcytic anemia: Fe studies showed low Fe with elevated Ferritin (likely [**Month (only) **]). Hemolysis labs were unremarkable. The anemia is likely multifactorial with possible component of Fe deficiency and anemia of chronic disease. HCT were reoutinely monitored throughout his stay and remained stable. # Liver abnormalities: transaminases were noted to be slightly elevated throughout his admission. AP also noted to gradually rise in the setting of a normal BR. A GGT level was tested which verified the AP was a biliary source. Hepatitis serologies were performed which showed no active disease. There were no findings on abdominal u/s to suggest liver abnormalties or obstruction. Liver was consulted regarding the isolated alkaline phosphatase elevation (it progressed throughout hospitalization). [**Doctor First Name **], AMA, [**Last Name (un) 15412**] and IgG were all sent and pending at the time of discharge. Initial differential for possible etiologies included infiltrative process vs. drug induced process. Unsuccessful attempts were made to obtain an in-patient liver biopsy. The patient will require an outpatient ultrasound guided percutaneous liver biopsy to rule out infiltrative process. He should also follow up with Liver at [**Hospital1 18**] for further evaluation. They are aware and expecting patient. Medications on Admission: None Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. Tablet(s) 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for fever. Tablet(s) 4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 5. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 1 months: This Medication Should Be continued until [**11-18**]. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary Dx - Tricuspid Valve Endocarditis Secondary Dx - severe Triscuspid Regurgitation with persistent sinus tachycardia - septic emboli to lung, spleen, brain - C [**5-2**] and C [**6-3**] discitis with extra-epidural phlegmon - trochanteric bursitis - anemia of chronic disease - retrocardiac pneumothorax - stable - isolated alkaline phosphatase elevation Discharge Condition: Improved - sinus tachycardia to 130's at baseline - persistent fevers (likely from pulmonary abscesses) suppressed by around the clock Tylenol and Advil Discharge Instructions: Mr. [**Known lastname 66673**], You were admitted to the hospital for a serious infection involving your heart. This infection is caused by bacteria. This bacteria was introduced into your body most likely from your intravenous drug use. Parts of this heart infection broke off and spread throughout your body, also infecting your lungs, spine and potentially your brain and spleen. This was a very serious infection which almost took your life. You will require an extensive course of IV antibiotics (NOT ORAL) for this infection and close follow up with the Infection sepcialists at [**Hospital1 18**]. Please stay at the rehab facility and complete your entire course of IV antibiotics. This infection is very serious, and any pause in your treatment may cause you to become very very sick. Once you leave the rehab facility, please call your primary care doctor listed below or return to the emergency department for any of the following: - increased fevers, shaking chills - chest pain, shortness of breath - increasing weakness, confusion - nausea, vomiting, abdominal pain - any other symptoms which concern you Please note the follow-up appointments we have made for you Infectious Diseases - [**Hospital1 18**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-11-13**] 9:00 Liver Center - [**Hospital1 18**] [**Hospital Unit Name **] Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10 Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-11-13**] 9:00 Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-11-15**] 3:15 Patient should also be re-evaluated by cardiology or cardiac surgery after completion of his medical management to evaluate for any surgical interventio Name: [**Known lastname 15116**],[**Known firstname **] Unit No: [**Numeric Identifier 15962**] Admission Date: [**2131-9-17**] Discharge Date: [**2131-10-25**] Date of Birth: [**2074-3-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1775**] Addendum: Please note that liver believe isolated AP elevation may also be cause by cholestatsis of sepsis. Discharge Disposition: Extended Care Facility: [**Hospital6 4356**] - [**Location (un) 164**] [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**] Completed by:[**2131-10-25**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "38.93", "34.91", "88.72", "96.72" ]

icd9pcs

[ [ [] ] ]

26197, 26432

13581, 22162

323, 430

23264, 23419

3391, 3396

25080, 26174

2642, 2681

22217, 22762

22879, 23243

22188, 22194

23443, 25057

2696, 3372

11886, 13558

275, 285

458, 2228

3410, 11842

2250, 2533

2549, 2626

5,910

143,682

6267

Discharge summary

report

Admission Date: [**2194-2-15**] Discharge Date: [**2194-2-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: hypoxiema at rehab Major Surgical or Invasive Procedure: intubation History of Present Illness: 80 yo male with history of COPD on home oxygen, lung Cancer with recent admission to [**Hospital1 **] [**2-6**] - [**2-13**] for recurrent LLL PNA with effusion, treated for H. Flu PNA at the VA in [**12-19**] and had been at [**Hospital **] [**Hospital 21079**] Rehab for 2 days and today developed shortness of breath, decreased oxygen saturation to 80% and RLQ pain, taken to [**Location (un) 24356**] ED and then transferred to [**Hospital1 **]. In the ED, the patient was in moderate respiratory distress, 80% room air oxygen saturation and was put on NRB with sats of 100%, ABG on NRB was 7.24/87/139 and had RLQ fullness. The patient's repeat gas was 7.29/74/50 and he was placed on 100% O2. He was initally felt to have pulmonary edema and given 60mg Lasix IV prior to arrival and placed on a nitro drip for 1 hour which was stopped after his pressure decreased. The patient was placed on Bipap 3 hours after arrival however still had a PaO2 of 50. He was then intubated for continued hypoxima. CT abd showed large rectus sheath hematoma but not dissection or retroperitoneal bleeding. He was given Levofloxacin and Flagyl for concern for PNA and morphine for pain. He was also gien 2 mg Ativan, 100mcg of Fentanyl, and Solumedrol 80mg. Past Medical History: 1. Recent hospitalization at the VA for pneumonia with intubation for H. flu pneumonia (grew in sputum culture) treated with Ceftazidime, Flagyl and Vancomycin 2. AAA repaired [**12/2187**] 3. COPD- on home O2 1L 4. Hx Lung Ca - [**2187**]; details of tx unavailable 5. Depression 6. Recurrent hip fx- last [**6-18**] 7. HTN 8. Hypercholesterolemia 9. Anemia - Hct at bl 31-35 Social History: Patient is retired, normally lives with his wife but has been in rehab for the last 2 days. >100 pack year hx of smoking. He has two daughters, both involved in his care. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**] and wife are health care proxy. Family History: Non-contributory Physical Exam: Vitals: T= 97.2, HR = 112 afib, BP = 105/56, AC, 600 TV, 12 RR, PEEP 5 , SaO2 = 100% General: Shivering elderly male, NAD. HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. Chest: chest rose and fell with equal size, shape and symmetry, lungs had clear BS ant. CV: [**Last Name (un) 3526**], [**Last Name (un) 3526**], very distant heart sounds Abd: Normoactive BS, NT. RUQ fullness with multiple ecchymosis Back: No spinal or CVA tenderness. Ext: Cool mottled extremities, no clubbing; [**3-20**] + pitting edema over both legs L > R Integument: no rash Neuro: PERRLA. Pertinent Results: CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: sbo, colitis, hernia Field of view: 39 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 80 year old man with abdominal pain, distended abdomen REASON FOR THIS EXAMINATION: sbo, colitis, hernia CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 80-year-old with abdominal pain and a distended abdomen with an abdominal wall mass, question incarcerated hernia. TECHNIQUE: CT of the abdomen and pelvis with IV contrast. No oral contrast was used. 150 cc of Optiray was used for this examination due to patient history of debility. Coronal and sagittal reformatted images were obtained. No prior studies for comparison. CT ABDOMEN W/IV CONTRAST There are moderate-sized bilateral pleural effusions, left greater than right. Atelectatic changes are seen at both lung bases. Bullous changes are also seen at the right lung base. The liver, spleen, pancreas, adrenals, and kidneys are unremarkable in appearance. The left kidney demonstrates mild cortical thinning. The gallbladder is not distended, but its wall appears enhanced slightly. No free air, free fluid, or pathologic lymphadenopathy is seen within the abdomen. The intra-abdominal small bowel is normal in appearance. Numerous diverticula are seen scattered throughout the colon without evidence of diverticulitis. The abdominal aorta is aneurysmal. Just inferior to the diaphragmatic hiatus it measures 3.9 x 3.5 cm. It is largest in diameter just inferior to the right renal vein at the level of the left renal vein where it measures 4.2 x 4.3 cm. Mural thrombus and plaque are seen throughout the aneurysm. There is a graft in place which begins just inferior to the left renal artery and continues through the iliac bifurcation into the common iliac arteries. The graft appears to be a venous bypass type graft. Calcification is seen throughout the intra-abdominal aorta. Dense calcification is seen at the ostia of both the celiac and superior mesenteric arteries, though contrast is seen within both of these arteries. CT PELVIS W/IV CONTRAST The rectum is distended with stool. Numerous sigmoid diverticula are seen without evidence of diverticulitis. A Foley catheter is seen within a partially collapsed bladder. There is a small amount of air in the bladder secondary to the Foley catheter. As stated above, there is a bypass graft in the abdominal aorta, extending into the iliac arteries. The common iliac artery is aneurysmal measuring 2.2 x 2.7 cm in maximal diameter. Mural thrombus is seen within the common iliac artery. The right iliac artery also is aneurysmal and is thrombosed measuring 2.2 x 2.4 cm in greatest diameter. The soft tissues demonstrate an extensive hematoma within the right rectus abdominis muscle and rectus sheath. This measures roughly 3.2 x 7.9 cm in the axial dimension, and 12.4 cm in the craniocaudad dimension. The osseous structures demonstrate degenerative changes throughout the lower thoracic and lumbar spine. There is a mild concavity of the superior endplate of the L1 vertebral body. Coronal and sagittal reformatted images significantly aided in the evaluation of the above findings and confirmed the above findings. IMPRESSION 1. Extensive hematoma within the right rectus abdominis muscle and rectus sheath as described above. 2. Bilateral pleural effusions with associated atelectatic changes. 3. Extensive abdominal aortic aneurysm with mural thrombus. A bypass graft is in place. Aneurysmal dilatation is also seen of both right and left common iliac arteries. The right common iliac artery aneurysm is thrombosed. 4. Diverticulosis without diverticulitis. These findings were communicated to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at the completion of the study. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) 24357**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24358**] Approved: SAT [**2194-2-15**] 11:36 AM CHEST (PORTABLE AP) Reason: r/o PNA [**Hospital 93**] MEDICAL CONDITION: 79 year old man with fever, recent pna with respiratory distress. REASON FOR THIS EXAMINATION: r/o PNA HISTORY: Fever, respiratory distress. REFERENCE EXAM: [**2-8**]. FINDINGS: The extreme right CP angle is off the film. There continues to be obscuration of the left hemidiaphragm consistent with left lower lobe volume loss with or without infiltrate and effusion. Incidental note is again made of an azygous lobe. Compared to the film from [**2-8**], there has been no significant interval change. DR. [**First Name (STitle) **] [**Doctor Last Name **] CT HEAD W/O CONTRAST Reason: eval for infact, limited study for bleed given that he alrea [**Hospital 93**] MEDICAL CONDITION: 80 year old man with resp failure, known aortic thrombi and mental status changes REASON FOR THIS EXAMINATION: eval for infact, limited study for bleed given that he already received IV contrast for CTA of chest. CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: Respiratory failure with known aortic thrombi and mental status change, evaluate for infarct or intracranial hemorrhage. COMPARISON: None. TECHNIQUE: Noncontrast head CT. Please note that the patient received IV contrast prior to the examination for performance of additional CT. FINDINGS: CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: The examination is somewhat limited by the patient motion. Allowing for this, there is no evidence of acute intracranial hemorrhage. There is diffuse prominence of the ventricles and sulci consistent with age-related involutional change. Note is made of cavum septum pellucidum et vergae. There is no mass effect or shift of normally midline structures. Bone windows demonstrate no evidence of fracture. The mastoid air cells and visualized portions of the paranasal sinuses are normally pneumatized. IMPRESSION: Limited examination due to the patient motion and previous administration of IV contrast. Allowing for this, no acute intracranial hemorrhages or mass effect is identified. DR. [**First Name (STitle) 8913**] R.M. SUN CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: r/o PE and f/u ulcerated aortic arch thrombosis Contrast: VISAPAQUE [**Hospital 93**] MEDICAL CONDITION: 79 year old man with h/o lung cancer now with resp distress and A-a gradient. Please r/o PE REASON FOR THIS EXAMINATION: r/o PE and f/u ulcerated aortic arch thrombosis CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of lung cancer, now with respiratory distress and AA gradient. Please evaluate for pulmonary embolus and follow up ulcerated aortic arch thrombosis. COMPARISON: [**2194-1-30**] TECHNIQUE: Axial MDCT images were obtained through the lungs prior to and following the administration of intravenous Visipaque. Multiplanar reformatted images are provided. CONTRAST: Intravenous nonionic, low osmolar contrast was administered due to the patient's debility as well as due to the previous contrast load from CT of the abdomen and pelvis with contrast performed on the same date. FINDINGS: CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: An endotracheal tube and nasogastric tube are in place. Again seen are prominent calcifications of the thoracic aorta. There are coronary arterial calcifications. There are numerous sub cm mediastinal lymph nodes located in the left paratracheal, subcarinal, and right and left hilar distributions. These do not individually meet criteria for pathologic enlargement and appear unchanged from the previous examination. The airways are patent to the level of the segmental bronchi bilaterally. No filling defects are identified within the pulmonary arteries to suggest pulmonary embolus. The lumen of the thoracic aorta is poorly evaluated on this examination due to maximization of bolus timing for opacification of the pulmonary arteries. There is faint but incomplete visualization of the previously described mural thrombus extending from the aortic arch inferiorly, with irregular margins. The thoracic aorta is grossly unchanged in caliber and contour. In comparison with the previous examination, there is interval increase in left- sided pleural effusion, which tracks along the major fissure. An area of rounded fluid density seen within the major fissure superiorly (series 3 image 43) is consistent with loculated fluid within the fissure. The pleural effusion measures approximately 14 to 24 Hounsfield units in density. There are bilateral calcified pleural plaques and emphysematous changes bilaterally. Note is again made of an azygous lobe. Stable appearance of atelectasis within the left lower lobe. There are scattered peripheral nonspecific nodular opacities within the right lower lobe (series 3, image 48 and image 44), unchanged from previous examination. Limited images of the upper abdomen including limited images of the liver, spleen, and stomach appear unremarkable. There are multiple old, healing, rib fractures on the right. Multiplanar reformats: Multiplanar reformatted images demonstrate no evidence of filling defect within the pulmonary defect within the pulmonary arteries to suggest pulmonary embolus. The mural thrombus within the aortic arch extending to the descending aorta is faintly but incompletely visualized. IMPRESSION: 1. No pulmonary embolus. 2. Interval increase in large left-sided pleural effusion layering within the fissures. 3. Stable atelectasis within the left lower lobe. 4. Limited visualization of mural thrombus within the aortic arch and descending aorta due to bolus timing to pulmonary arterial phase. 5. Multiple old right-sided rib fractures. DR. [**First Name (STitle) 8913**] R.M. SUN DR. [**First Name11 (Name Pattern1) 24357**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24358**] Brief Hospital Course: 79 yo male with past medical history significant for lung cancer, COPD, recent H. Flu pneumonia, and recent new-onset atrial fibrillation now admitted with mental status changes, respiratory failure, and rapid atrial fibrillation. Atrial fibrillation was first documented in this patient during his last admission. He was rate contolled at that time. Rates here have been in the 130s - 170s with inverese BP's. Patient spontaneously converted to normal sinus rhythm on [**2194-2-16**] . Cardiology was consulted and felt that atrial fibrillation was likely from heightened sympathetic discharge in face of acute illness. Amiodarone was not recommended due to beta blockade effect given significant COPD history. Patient was continued on aspirin. Cardiac catheterization was not indicated. Cardioversion was also not indicated since thromboembolic risk was too high. Patient was extubated on [**2194-2-21**] and post extubation developed atrial fibrillation again. He was rate controlled with metoprolol. Patient initially required fluid blouses and levophed for blood pressure support. Peri-extubation, levophed was weaned off and prednisone was tapered. He was edematous from all the fluid resusciation. However, he also has low UOP and rising Cr, likely from poor forward flow from AF. The treatment goal was to rate control and then diurese(massive edema with albumin of 3) From the respiratory failure standpoint, he had thoracentesiss in [**Month (only) **], cytology:atypical and reactive cells, no CA. PE was also ruled out by CTA . He was continued on levofloxacin for presumed pneumonia. He was extubated on [**2193-2-18**] and was doing well up until [**2194-2-21**]. He began developing increasing secretion and was agressively suctioned by respiratory therapy. On the night of [**2194-2-22**], he became increasingly tachypneic and agressive suctioning by respiratory therapy did not bring up significant mucus plug. Patient was put on BiPAP but was showing increasing respiratory effort. Family member was called regarding re-intubation and they agreed. Anesthesia was called and patient was intubated without difficulty. However, right after that, his daughter(HCP) called back and wanted DNR/DNI status. Patient subsequent became hypotensive and bradycardic. No code was called and patient passed away peacefully after that. The cause of death was presumed to be aspiration. Autopsy was requested but family members denied. Discharge Disposition: Expired Discharge Diagnosis: aspiration pneumonia atrial fibrillation rectus sheath hematoma COPD Discharge Condition: passed away Completed by:[**2194-4-16**]

[ "491.21", "518.81", "428.0", "441.4", "E934.2", "459.0", "285.9", "486", "427.31", "401.9", "584.9", "728.89", "511.9", "272.0", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

15423, 15432

12952, 15400

280, 292

15544, 15586

3018, 3129

2279, 2297

9382, 9474

15453, 15523

2312, 2999

222, 242

9503, 12929

320, 1566

1588, 1966

1982, 2263

78,855

130,996

11754

Discharge summary

report

Admission Date: [**2131-2-23**] Discharge Date: [**2131-2-28**] Date of Birth: [**2048-11-11**] Sex: F Service: SURGERY Allergies: Neosporin / Penicillins Attending:[**First Name3 (LF) 4691**] Chief Complaint: Trauma: MVC non-displaced R 1-5th ant rib fx R sup/inf pubic rami fx R lat tib plateau fx with hematoma L knee hematoma Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 82 year old female who complains of TRAUMA TRANSFER. time seen is 1052 P.m. The patient was a restrained driver of a head-on car accident at 2 PM. sHe is transferred from [**Hospital3 **]. There is no loss of consciousness. In the emergency department she had blood pressure in the 80/s. By CT scanning she had a nasal fracture, right fourth rib fractures, right pelvic fracture without any pelvic hematoma. The patient received 2 units of blood. She also has a left tibial plateau fracture. Her mental status is at baseline. Head CT was negative chest CT was otherwise negative. Abdominal CT was otherwise negative. Past Medical History: Past Medical History: Hypertension, COPD, H. fibrillation, rheumatoid arthritis. Social History: SH: h/o tobacco, denies etoh/ivdu Family History: NC Physical Exam: PHYSICAL EXAMINATION upon admission: [**2131-2-22**]: BP:126/ O(2)Sat:100 Normal Constitutional: There is no color. HEENT: Left eye periorbital ecchymosis with no significant facial bone deformity or tenderness., Pupils equal, round and reactive to light, Extraocular muscles intact. Left lower lip contusion. She has a nasal septal bruise She has left neck ecchymosis. Chest: Clear to auscultation, anterior chest bruising Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Extr/Back: Back is nontender, pelvis is stable though she has a large left knee bruise and deformity Neuro: Speech fluent, she is awake alert oriented, normal motor normal sensory, nonfocal Physical examination upon discharge: [**2131-2-28**]: vital signs: bp=94/60-146/79, hr 82, resp rate 20, t=96, oxygen saturation 97% on 3 liters o2 General: sitting in chair, NAD CV: normal s1, s2, -s3, -s4 LUNGS: Diminished ( related to patient effort), paradoxical upper chest wall movement ABDOMEN: soft, non-tender EXT: + dp bil, feet warm, brace right knee, left knee DSD, ecchymotic areas left lower leg NEURO: Ecchymnotic areas face, alert and oriented x 3, speech clear Pertinent Results: [**2131-2-26**] 03:36AM BLOOD WBC-5.0 RBC-2.93* Hgb-9.1* Hct-26.9* MCV-92 MCH-31.0 MCHC-33.7 RDW-14.7 Plt Ct-125* [**2131-2-25**] 01:33AM BLOOD WBC-7.6 RBC-3.04* Hgb-9.5* Hct-27.4* MCV-90 MCH-31.2 MCHC-34.5 RDW-14.9 Plt Ct-111* [**2131-2-24**] 01:31AM BLOOD WBC-7.9 RBC-3.12* Hgb-9.9* Hct-28.1* MCV-90 MCH-31.6 MCHC-35.0 RDW-14.8 Plt Ct-105* [**2131-2-23**] 07:55PM BLOOD Hct-28.4* [**2131-2-23**] 02:40AM BLOOD Neuts-85.3* Lymphs-10.2* Monos-3.7 Eos-0.5 Baso-0.3 [**2131-2-26**] 03:36AM BLOOD Plt Ct-125* [**2131-2-25**] 01:33AM BLOOD Plt Ct-111* [**2131-2-22**] 11:17PM BLOOD Fibrino-269 [**2131-2-26**] 03:36AM BLOOD Glucose-101* UreaN-51* Creat-1.4* Na-137 K-4.6 Cl-105 HCO3-24 AnGap-13 [**2131-2-25**] 01:33AM BLOOD Glucose-119* UreaN-40* Creat-1.3* Na-140 K-4.4 Cl-108 HCO3-26 AnGap-10 [**2131-2-24**] 01:31AM BLOOD Glucose-123* UreaN-34* Creat-1.2* Na-139 K-4.3 Cl-110* HCO3-23 AnGap-10 [**2131-2-23**] 02:40AM BLOOD Glucose-133* UreaN-33* Creat-1.2* Na-138 K-5.1 Cl-109* HCO3-21* AnGap-13 [**2131-2-22**] 11:17PM BLOOD UreaN-31* Creat-1.2* [**2131-2-24**] 02:53AM BLOOD CK(CPK)-143 [**2131-2-24**] 02:53AM BLOOD CK-MB-4 cTropnT-0.07* [**2131-2-26**] 03:36AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2 [**2131-2-22**]: chest x-ray: IMPRESSION: Mild pulmonary edema. No pneumothorax. Multilevel right rib fractures, better visualized in the concurrent outside hospital trauma torso CT [**2131-2-22**]: ct of the c-spine: IMPRESSION: 1. No acute cervical fracture or malalignment. 2. Non-displaced right anterior first rib fracture. [**2131-2-22**]: cat scan of the head: IMPRESSION: No acute intracranial traumatic injury. Age-related global atrophy [**2131-2-22**]: cat scan of the abdomen: Multilevel non-displaced right rib fractures at 1st, 2nd, 4th, and possibly 3rd and 5th. 2. No PTX or lung contusion. No intrathoracic vascular injury 3. Right anterior chest wall soft tissue contusion. 4. Posterior linear splenic lucency (image 3:56), without perisplenic hematoma, making it less likely to represent a splenic laceration. Otherwise no solid organ injury. 5. Right superior and inferior pubic rami fractures, minimally displaced. Small adjacent hematoma. 6. L2 and L4 compression deformities, of uncertain chronicity, but probably old [**2131-2-22**]: cat scan of the lower extremities: Schatzker type 3 fracture with depression of the lateral tibial plateau of the right lower extremity with lipohemarthrosis and small anterior soft tissue hematoma. 2. Large left lower extremity hematoma with intramuscular involvement of the vastus medialis oblique muscle without evidence for definite fracture. 3. Diffuse osteopenia limits assessment of subtle fractures and given the extent of soft tissue hematomas, MRI of the bilateral knees can be performed for further evaluation. [**2131-2-23**]: x-ray of the right knee: IMPRESSION: Nondisplaced lateral tibial plateau fracture with associated moderate lipohemarthrosis. [**2131-2-23**]: chest x-ray: 1. Mild-to-moderate volume overload. Bibasilar opacities, likely atelectasis, although superimposed infection cannot be excluded. 2. No pneumothorax [**2131-2-23**]: cat scan of sinus and mandible: Mild deformity of the right-sided nasal bone likely a subtle fracture of undetermined age. [**2131-2-24**]: Echo: IMPRESSION: Right ventricular cavity enlargement with mild free wall hypokinesis. Pulmonary artery systolic hypertension. Mild-moderate tricuspid regurgitation. Preserved regional and global left ventricular systolic function. This constellation of findings is suggestive of a primary pulmonary process (e.g., pulmonary embolism, bronchospasm, or a chronic condition such as sleep apnea, COPD, etc.) [**2131-2-24**]: chest x-ray: IMPRESSION: Worsening pulmonary edema [**2131-2-24**]: chest x-ray: FRONTAL CHEST RADIOGRAPH: No pneumothorax is appreciated. The cardiomediastinal silhouette is slightly decreased in size. Diffuse ground-glass opacity and vascular congestion has also mildly decreased consistent with mild improvement of a moderate degree of pulmonary edema. There are small bilateral pleural effusions with associated atelectasis. There is a small hiatal hernia [**2131-2-25**]: chest x-ray: FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is stable. Ground-glass opacity and vascular congestion continues to mildly decrease, consistent with improving pulmonary edema. There are small bilateral pleural effusions as well as streaky left retrocardiac opacity, which likely represent atelectasis. A moderate sized hiatal hernia is also noted. [**2131-2-26**]: chest x-ray: FINDINGS: As compared to the previous radiograph, the pre-existing and pre-described pleural effusions have slightly increased in extent. Also increased is a small retrocardiac atelectasis. Minimal overhydration and borderline size of the cardiac silhouette. No newly appeared focal parenchymal opacities. No pneumothorax. Brief Hospital Course: 82 year old restrained driver admitted to the Acute care service after being involved in a motor vehicle [**Last Name (un) 8886**]. Prior to her admission, she was hypotensive and required intravenous fluids and packed red blood cells. Upon admission, she was made NPO, had intravenous fluids started, and imaging studies of her neck, chest, and abdomen. She was reported to have a subtle non-displaced nasal fracture, right tibial plateau fracture, and a pelvic fracture. She also sustained right rib fractures. Orthopedics was consulted because of the extent of her injuries and recommended a left knee immobilizer. The pelvic fracture was reported to be stable and managed with a closed reduction. The acute pain service was consulted and placed a right intercostal nerve block to help alleviate the pain from her rib fractures. On HOD #3, she developed atrial fibrillation associated with hypotension. After unsuccessful control with oral agents, she was successfully cardioverted and her home beta-blockers were resumed. A TEE was done which showed RV changes with a normal ejection fraction. She reverted back to atrial fibrillation on HOD #4, and again oral anti-arrhythmics were administered with the addition of digoxin to her regimen. She successfully converted into a regular rhythm. Her chest x-ray did show mild pulmonary edema and she was started on a gentle diuresis with lasix. She was evaluated by cardiology who recommended maintaining her electrolytes within normal limits and discontinuing her digoxin. They also recommended starting coumadin. This was addressed with the patient who refused. Upon transfer to the floor, her vital signs have been stable. She is tolerating a regular diet and has been out of bed. She is voiding without difficulty. She is preparing for discharge to a rehabiltation facility with instructions to follow-up with her primary care provider regarding coumadin and prednisone taper. She will also need to follow up with Orthopedics. Of note: pt reports that she resumes taper of prednisone on [**3-4**] to 2 mg. She has not resumed her daily aspirin. Medications on Admission: MEDS AT HOME: ASA 81, prednisone 3', tapering, lisinopril 40', HCTZ 25', atenolol 25', vitamin D 1000', spiriva Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for rib pain. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for diarrhea. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 9. prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours: as needed for pain. 12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for systolic blood pressure <110. 15. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Trauma: MVC non-displaced R 1-5th ant rib fx R sup/inf pubic rami fx R lat tib plateau fx with hematoma L knee hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after you were a driver involved in a head-on [**Last Name (un) 8886**]. You sustained facial fractures, rib fractures, and a fracture to your right leg. You were taken to the operating room to have your right knee repaired. You are now preparing for discharge to a rehabiliation facility with the following instructions: You did sustain rib fractures because of your injury. Please follow these instructions: Your injury caused right anterior rib fractures [**11-29**] which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ) Please follow these general discharge instructions: You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you Please follow these orthopedic instructions: brace on R knee per ortho, TDWB RLE, WBAT LLE *report any numbness/pain in lower extremities Followup Instructions: Please follow-up with Plastic [**Hospital 37176**] clinic, as an outpatient, regarding elective repair of your right sided nasal fracture on CT maxillofacial imaging. Office number: [**Telephone/Fax (1) 4652**] Please follow up two weeks from [**2131-2-26**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Orthopedics [**Telephone/Fax (1) 1228**]. Please follow up with your Primary care provider [**Last Name (NamePattern4) **] 1 week regarding the tapering of your prednisone. Completed by:[**2131-2-28**]

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icd9cm

[ [ [] ] ]

[ "99.61", "04.81" ]

icd9pcs

[ [ [] ] ]

11520, 11617

7510, 9633

407, 414

11782, 11782

2553, 7485

14973, 15510

1305, 1309

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11638, 11761

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39483

Discharge summary

report

Admission Date: [**2101-7-3**] Discharge Date: [**2101-7-14**] Date of Birth: [**2029-3-17**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Knee Pain Major Surgical or Invasive Procedure: CVVH Surgical washout of knee and wrist Central Line Placement (HD line) History of Present Illness: 72 year old male with h/o CAD s/p MI and CABG, CHF s/p ICD (3 years ago per wife), atrial fibrillation on coumadin, DM2, gout who transfered from [**Location (un) **] with septic arthritis, UTI and congestive heart failure. . On arrival patient was confused, history was obtained from wife [**Name (NI) **] over telephone and from outside records. Per wife, patient has had progressive right knee pain over the last week. He usually ambulates with a walker, but it has been getting harder to ambulate. Last week he saw his rheumatologist, who may have performed a joint tap. His pain has gotten worse over the last few days to the point he could not ambulate and had new right wrist pain. + chills, no recorded fevers. Otherwise denies CP/SOB, nausea/vomiting, dysuria. . At [**Location (un) **], he has x-rays of his right wrist and knee which showed no fracture. RLE extremity U/S was negative for DVT. He was given a dose of levaquin. R knee arthrocentesis was performed, and showed [**Numeric Identifier **] WBC with 91% PMN and Gram stain was positive for GPCs. Patient was started on vanc/gent and given one dose of ceftriazone and was transferred to [**Hospital1 18**] for further management. On transfer his vital signs were T 99.4, P 70, RR 22, 92% 2L O2 . On floor, patient was confused and unable to provide a history. He was diaphoretic, had a baseline tremor and in distress. Past Medical History: - Coronary Artery Disease s/p CABG - Atrial Fibrillation on coumadin - s/p ICD/PPM - DM2 - AAA - Stage 3 CKD - Gout - recurrent LE cellulitis Social History: Lives at home with his wife, usually uses a walker for ambulation. Retired, used to work in a lumbar yard. Former smoker, quit in [**2070**], prior 50-60 pack year smoking history. No current alcohol use, but used to drink one drink a day per wife. Family History: Father by bypass surgery, and AAA. Mother with history of CHF. Physical Exam: ADMISSION PHYSICAL EXAM VS - Temp 100.1 F, BP 144/66 , HR 70, R 18, O2-sat 98 % 2L GENERAL - ill appearing caucasian male, tremor, diaphoretic, moderate distress HEENT - Mucous membranes dry, OP clear NECK - JVD not assessed LUNGS - Clear anteriorly HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, midline sternal scar ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 2+ edema to the hip, RLE swelling > LLE swelling, signs of chronic venous stasis, dark thickened skin on shins, with evidence of multiple healing ulcers. long scar from vein harvest. R knee effusion, erythematous, exquisitely tender to palpation. R wrist erythematous, exqusitely tender to palpation. NEURO - AAO to self, "hospital", EOMI intact, face symmetric, speech fluent, moving all extremities Pertinent Results: ADMISSION LABS [**2101-7-3**] 05:15AM BLOOD WBC-15.5* RBC-3.34* Hgb-10.3* Hct-31.7* MCV-95 MCH-30.9 MCHC-32.6 RDW-17.0* Plt Ct-285 [**2101-7-3**] 05:15AM BLOOD PT-64.1* PTT-52.0* INR(PT)-7.3* [**2101-7-3**] 05:15AM BLOOD Plt Ct-285 [**2101-7-3**] 05:15AM BLOOD Glucose-181* UreaN-84* Creat-2.6* Na-131* K-4.9 Cl-95* HCO3-20* AnGap-21* [**2101-7-3**] 05:15AM BLOOD ALT-43* AST-56* LD(LDH)-249 CK(CPK)-26* AlkPhos-140* TotBili-1.6* DirBili-0.9* IndBili-0.7 [**2101-7-3**] 05:15AM BLOOD CK-MB-2 cTropnT-0.07* [**2101-7-3**] 05:15AM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.7 Mg-2.8* [**2101-7-3**] 04:45PM BLOOD CRP-217.0* ECHO FROM [**2101-7-11**] No thrombus/mass or spontaneous echo contrast is seen in the body of the left atrium or right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened without regurgitation. No vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. An eccentric jet of mild-moderate ([**12-4**]+) mitral regurgitation is seen. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened with (1+) tricuspid regurgitation. No vegetation/mass is seen on the pulmonic valve and no pulmonic valve regurgitation. There is no pericardial effusion. IMPRESSION: Mild mitral leaflet thickening without discrete vegetation. Mild-moderate mitral regurgitation. No discrete masses or vegetations identified on any of valves or visualized RA/RV wires. RUQ US [**2101-7-9**] Two limited views of the abdomen. There is motion artifact. The bowel gas pattern is unremarkable. No free air is identified. There is no evidence of pneumobilia, although this would be difficult to assess on this limited study. Soft tissue shadows are indistinct. There are degenerative changes in the spine. There are multiple calcifications in the right upper quadrant that likely represent gallstones. IMPRESSION: Right upper quadrant calcifications likely representing gallstones. Limited study. ABDOMINAL US [**2101-7-8**] IMPRESSION: 1. Nodular hepatic architecture, splenomegaly, and mild ascites suggestive of cirrhosis. No focal liver lesion identified. 2. Distended gallbladder with a stone in the neck and sludge. The patient could not be turned to assess mobility of the stone. Consequently an impacted stone and/or cholecystitis cannot be excluded. A HIDA scan could be performed if clinically indicated. HIDA SCAN [**2101-7-9**] INTERPRETATION: Serial images over the abdomen show poor uptake of tracer into the hepatic parenchyma with persistent blood pool throughout the course of the study. At 90 minutes, the gallbladder was not visualized so continued delayed imaging was performed with anterior and [**Doctor Last Name **] projections of the abdomen obtained at 3 and 1/2 hours demonstrating activity within the gallbladder. Tracer activity noted in the small bowel at 17 minutes. The above findings are consistent with no evidence of cholecystitis though with severe hepatic dysfunction out of proportion to the current level of elevated bilirubin. IMPRESSION: 1. No evidence of cholecystitis with visualization of the gallbladder. 2. Worsening severe hepatic dysfunction out of proportion to to the current level of increased bilirubin. RENAL US [**2101-7-7**] FINDINGS: The right kidney measures 10.1 cm and the left kidney measures 10.8 cm. There is no hydronephrosis in either kidney. No cysts or stone or solid mass seen bilaterally. No perinephric fluid collection is identified. IMPRESSION: No hydronephrosis and no indication of a renal abscess. CT HEAD [**2101-7-5**] FINDINGS: No prior studies are available for comparison. There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. Prominence of the ventricles and sulci represents generalized atrophy, age related. Periventricular and subcortical white matter hypodensity likely represents sequelae of chronic small vessel ischemic disease. There are calcifications of the bilateral carotid siphons. No concerning osseous lesion is seen. The visualized paranasal sinuses are unremarkable. IMPRESSION: No evidence of acute intracranial process. BLE DOPPLERS [**2101-7-3**] FINDINGS: Color Doppler and grayscale ultrasonography of the bilateral lower extremities demonstrates normal flow, compressibility, and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins. The posterior tibial and peroneal veins are visualized bilaterally and compress normally. IMPRESSION: No DVT. Brief Hospital Course: # Septic Shock: The patient developed a hypotensive picture from an infectious source. At first, this was thought to be [**1-4**] the septic joints. However, over time and after surgical washout of the joints, the source was less certain. We were concerned for a possible biliary source, so a HIDA scan was done which was neg for gallbladder disease. SBP a concern given cirrhosis and known ascites. Disseminated septic arthritis raises concern for infection of ICD lines or pocket. For the hypotension, the patient was maintained on vasopressin and levophed gtts with a goal SBP of 80. Cardiac enzymes were checked to r/o a cardiac source. the enzymes were normal and an ECHO done had a normal EF. The patient had a lactic acidemia which normalized over time and with fluids. His c-diff was negative, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was also negative essentially ruling out adrenal insufficiency thought possibly [**1-4**] home prednisone on gout. While he was on CVVH, daily blood cultures were obtained. Finally, there was a concern that the leads from his ICD may be infected, however the risks of the removal were thought to be too great for the relative benefit. . # Septic Arthritis/bacteremia: S/P joint washout done by ortho [**2101-7-5**]. Growing MSSA from joints. His joints were washed out daily by the orthopedics team. Nafcillin was used to cover for MSSA. We appreciated ID and ortho recs. . #. Respiratory status: Pt was intubated for mental status changes and multiple procedures. There was no concern for an acute lung process. sedation was weaned as much possible, but was kept to keep him comfortable. . #. ARF: On top of stage III Chronic Kidney Disease. Showing Uremic with altered mental status. Consider hepatorenal. Renal c/s and rec HD placement for CVVHD. He was maintained on CVVH with a goal of 1-2L negative daily. . #. Coagulopathy: Unclear etiology. Initially thought to be from coumadin in the setting of infection/antibiotics. Also concerning for DIC given systemic infection, elevated PT and PTT, elevated D bili, and renal failure. However, no increase in FDP or decrease in fibrinogen or platelets. LENIs previously were negative for DVT. We administered vitamin k in an effort to reverse the high INR, and FFP was given prior to any invasive procedures, such as his HD line placement. We continued to trend his coags. . # Cirrhosis: Seen on RUQ U/S. Has history of mild etoh. However unknown cause as EtOH unlikely to give this clinical picture. Over time, his LFTs vacillated, but on his last hospital day, his D-bili increased to 15 from 5. Liver c/s was following the pt, and we appreciated their recs. This could have also been complicating the hypotension picture. . #. Fever/Leukocytosis: Resolving with stable WBC and no fevers over the past few days. Likely was due to MSSA septic arthritis/bacteremia, +/- UTI. No positive blood or urine cultures at [**Hospital1 18**], but joint fluid grossly positive. Since his admission, he was continued on nafcillin and trended his WBC and fevers. . #. CAD/Congestive Heart Failure: Patient has significant signs of fluid overload. EF 40-45%. Cardiologist is Dr. [**Last Name (STitle) **] at St. Vincents. Otherwise he had his CABG and stents at [**Hospital1 **] [**Hospital1 1559**]. We supported him with supplemental O2 and held spironolactone, bumex, and ranexa given ARF. We also held statin given coagulopathy We continued carvedilol with holding parameters. We also continued CVVHD for volume removal as above. . #. Diabetes Type II: Unclear per wife is patient is on long acting insulin at home, but was started on detemir at [**Location (un) **]. Will hold orals, and cover with sliding scale for now. . # Gout: continue allopurinol at renally dosed levels . #. Atrial Fibrillation: Will need to reverse anticoagulation as above. On carvedilol for rate control, regular rate one exam. We held anticoagulation, and given low risk of imminent CVA while in house. Also, with the coagulopathy, we felt extra anticoagulation is not warranted. . Medications on Admission: --Zyloprim 300 mg qday --Bumex 1 mg qday --Coreg 6.25 mg [**Hospital1 **] --Arnaryl 2 mg [**Hospital1 **] --Levemir 20 unit qday --Metolazone 2.5 mg prn --Nitrostat 0.4 mg prn --Klor-Con 20 mEq qday --Pravachol 40 mg [**Hospital1 **] --Prednisone 10 mg prn --Januvia 100 mg qday --Aldactone 25 mg [**Hospital1 **] --Coumadin 1 mg qday Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2101-7-14**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "81.91", "38.91", "80.76", "39.95", "88.72", "38.93", "80.83" ]

icd9pcs

[ [ [] ] ]

12303, 12312

7778, 11888

291, 365

12364, 12374

3136, 7755

12426, 12596

2233, 2297

12274, 12280

12333, 12343

11914, 12251

12398, 12403

2312, 3117

242, 253

393, 1784

1806, 1950

1966, 2217

31,073

104,918

29336

Discharge summary

report

Admission Date: [**2123-4-7**] Discharge Date: [**2123-5-11**] Date of Birth: [**2044-2-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Loose stools and fevers Major Surgical or Invasive Procedure: [**2123-4-8**] right chest tube (pleurex tube) [**2123-4-13**] ERCP [**2123-4-15**] removal of pleurex tube and insertion of pigtail catheter [**2123-4-30**] Right-sided pigtail catheter drainage [**2123-5-4**] Talc pleurodesis right lung [**2123-5-7**] ERCP History of Present Illness: 79F s/p segment VII resection of metastatic colon CA to liver ([**3-1**]). Was here to have pleurex catheter placed but was having abdominal pain, fevers, and nausea and was sent to the ED. She reports passing flatus and stool. Past Medical History: Past Medical History: Bipolar HTN Past Surgical History; TAH Appendectomy Social History: Married, lives with husband and son, drinks one glass of wine per day, former smoker Family History: Non-contributory Physical Exam: In ED 97.4, 94, 86/54 to 149/71 96% 3L NC NAD RRR decreased Breath sounds in bases R>L Abdomen soft, obese, nondistended, no tympany, Midline incision inferior to umbilicus well healed with 2 small incisional hernias. Bowel easily reducible. EXT: warm and dry Pertinent Results: JP drain fluid GRAM STAIN (Final [**2123-4-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. [**2123-4-7**] 12:05PM BLOOD WBC-19.7*# RBC-4.20 Hgb-11.5* Hct-35.2* MCV-84 MCH-27.4 MCHC-32.7 RDW-14.1 Plt Ct-316# [**2123-4-7**] 12:05PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.4* Monos-2.0 Eos-0.1 Baso-0.1 [**2123-4-8**] 08:40AM BLOOD PT-16.1* PTT-28.2 INR(PT)-1.4* [**2123-4-8**] 05:30AM BLOOD Glucose-106* UreaN-14 Creat-1.1 Na-135 K-3.9 Cl-101 HCO3-27 AnGap-11 [**2123-4-7**] 12:05PM BLOOD ALT-15 AST-24 AlkPhos-156* TotBili-0.4 [**2123-4-8**] 05:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8 [**2123-4-7**] 12:17PM BLOOD Lactate-2.9* [**4-7**] CT chest/abd/pelvis IMPRESSION: 1. Dilated loops of small bowel up to 3.5 cm, with air-fluid levels, and transition point in small ventral hernia in the midline lower abdomen, after which bowel loops are decompressed, and contain no oral contrast. This appearance is concerning for small-bowel obstruction, although the presence of gas within the colon and rectum suggests that it may be an early obstruction, or a partial obstruction. 2. Heterogeneous 6.3 x 2.5 cm fluid collection posterior to the right hepatectomy resection margin could represent post-surgical change and material such as Surgicel, although it is difficult to exclude abscess formation. 3. Increased size of multiple hypodense lesions within the liver concerning for progression of metastatic disease. 4. Unchanged appearance of ill-defined hypodense lesion within the spleen. This lesion was characterized by MRI from [**2123-1-10**] as having features suggestive of a lymphangioma. 5. Large right pleural effusion and right lower lobe atelectasis Small left pleural effusion. 6. Small-volume ascites. . Labs at discharge: [**2123-5-8**] WBC-8.4 RBC-4.27 Hgb-11.6* Hct-36.5 MCV-85 MCH-27.1 MCHC-31.8 RDW-14.4 Plt Ct-298 Glucose-99 UreaN-10 Creat-0.7 Na-144 K-3.7 Cl-104 HCO3-33* AnGap-11 ALT-14 AST-20 AlkPhos-111 Amylase-35 TotBili-0.4 Albumin-2.5* Brief Hospital Course: Patient was seen in ED and admitted to General Surgery service. IV cipro and flagyl was started, an NGT and Foley were placed, and she was kept NPO with IVF. An abdominal CT was done showing dilated loops of small bowel up to 3.5 cm, with air-fluid levels. Point of obstruction appeared to be a ventral hernia in the lower abdominal wall. A heterogeneous 6.3 x 2.5 cm fluid collection posterior to the right hepatectomy resection was noted. There was increased size of multiple hypodense lesions within the liver concerning for progression of metastatic disease and small-volume ascites. A large right pleural effusion and right lower lobe atelectasis with a small left pleural effusion was noted. . Interventional pulmonology was contact[**Name (NI) **] and on [**Name (NI) 58274**] a right pleurex catheter was placed and attached to a pleuravac and suction. This initially drained ~ one liter of straw colored fluid. She remained on O2 nasal cannula with diminished breath sounds in the lower lobes. On [**4-13**], 700cc of serous fluid was removed from the pleurx tube. The pleurx catheter was removed on [**4-14**] due to persistent leaking at the connection site to the pleuravac. A right pleural 14 french pigtail catheter was placed at the 5th ICS. The pigtail was connected to a pleuravac. On [**2123-5-4**] a talc pleuradesis was performed on her right lung with follow-up CXRs with no PTX and stable pleural effusion. She remains on O2 via nasal cannula. O2 sats drop into high 80's when ambulating, she remains asymptomatic. Most recent Chest xray on [**5-7**] shows: the bilateral moderate pleural effusions are unchanged with associated right lower lobe atelectasis. . On [**4-9**], the NG tube was removed. Diet was advanced slowly and tolerated. LFTs remained stable as well as chemistries. . The JP continued to drain bilious fluid. This fluid was cultured and grew two species of E.coli resistent to ampicillin and cipro, but sensitive to Bactrim. Therefore, Bactrim DS [**Hospital1 **] was started on [**4-11**]. The JP drainage averaged approximately 70cc/day. On [**4-13**], ERCP was performed noting bile leak. Sphincterotomy was done with stent placement. Post ERCP, the JP drainage decreased to ~ 30cc/day. WBC was 17 on admission with downward trend to 11. She had a second ERCP on [**5-7**] and she had a stent exchanged. She will remain on Bactrim on discharge. The JP drain remians in place. . She had a UTI with a resistant strain of E coli. She received 10 days of Meropenem IV. There was also concern for urinary retention. She should be encouraged for frequent toileting and bladder training. Urine culture from [**5-4**] was no growth. A surveillance culture was sent on [**5-11**] prior to discharge and should be followed up as an outpatient. . Dr.[**Name (NI) 3377**] team was consulted regarding possibility of repairing ventral hernia. Given bile leak, infection and effusion repair was deferred at this time. . PT/OT evaluated her. She was safe to transfer and ambulate with nursing, but continued to require PT. The plan was for her to go to rehab facility for further rehab, as she is requiring assistive devices and has increased O2 requirements with activity. Medications on Admission: atenolol 50', lasix 20', keppra 500", risperidol 1.5', mvi', folic acid' Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: abdominal pain right pleural effusion UTI Bile leak Discharge Condition: Stable Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever >101, chills, nausea, vomiting, abdominal distension or increased abdominal pain, jaundice, shortness of breath, Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 673**] [**2123-5-19**] 2:00 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**] 11:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**] 11:30 ERCP 2 (ST-4) GI ROOMS Date/Time:[**2123-7-20**] 4:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2123-5-11**]

[ "997.4", "V10.05", "552.21", "276.51", "197.7", "518.0", "401.9", "789.59", "518.4", "511.9", "296.80", "599.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "99.04", "34.91", "51.87", "99.29", "34.92", "51.85" ]

icd9pcs

[ [ [] ] ]

7476, 7547

3403, 6610

336, 597

7643, 7651

1385, 3133

7892, 8489

1070, 1088

6733, 7453

7568, 7622

6636, 6710

7675, 7869

1103, 1366

273, 298

3152, 3380

625, 854

898, 951

967, 1054

9,253

187,222

406

Discharge summary

report

Admission Date: [**2142-7-13**] Discharge Date: [**2142-7-19**] Service: MEDICINE Allergies: Valium Attending:[**First Name3 (LF) 3561**] Chief Complaint: -Unresponsive -Mental status changes Major Surgical or Invasive Procedure: -Tracheostomy -Femoral Line -[**First Name3 (LF) 282**] tube change History of Present Illness: Mr. [**Known lastname **] is a [**Age over 90 **]-year-old gentleman with history of [**Last Name (un) 3562**] Disease, several aspiration events, multiple admissions for respiratory distress who was sent from [**Hospital 100**] rehab for evaluation after being found unresponsive at 3 PM. Per report, patient was found to open eyes but otherwise not responding to verbal commands. ABG done at rehab showed marked hypercarbia (pCO2 100) and patient was referred urgently to the ED. . In the Emergency Department, patient was intubated for presumed hypercarbic respiratory failure. ABG was not done on admission. CXR did not show any acute changes from ED visit 3 days prior (he had presented to ED on [**2142-7-10**] with dyspnea, respiratory status had returned to baseline, CXR was unchanged, and labs did not reveal leukocytosis). He was given Vanc/Levo/Flagyl for possible sepsis, albuterol/atrovent for bronchodilation, and methylprednisolone for ? assumed COPD exacerbation given hypercarbia. . In discussing history and events with wife, she noted that patient appeared more lethargic than normal today, with some confusion. At baseline, patient is AO x 2, occasionally disoriented to place and sundowns at night, but otherwise is able to carry on normal daily conversations with her. During prior hypercarbic episodes, wife reported that patient's speech becomes softer and non-sensical, which she reported was occurring throughout the day today. At 3 PM, she reports that patient became very somnolent, and she sought immediate Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [**Date Range 282**] placement on [**10-9**] 3. Parkinson's 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [**2126**] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [**46**]. Glaucoma 13. Hypertension Social History: Lives at [**Hospital 100**] Rehab. The patient has a sixty-pack-year history of tobacco. He is a retired history professor. He reports no alcohol intake. Family History: Non-contributory Physical Exam: VS: T 97.8; HR 62; BP 96/58; RR 17l 100% AC TV 550 FIO2 0.4 RR 20 GEN: intubated, sedated, comfortable HEENT: ET tube in place. Surgical pupil on L, reactive on R. MMM. CV: S1S2 RRR LUNGS: occasional expiratory wheeze. otherwise clear. ABD: G-tube in place, tube worn/old. Dressing C/D/I. Soft + BS. NT/ND. EXT: cool, diminished DPs, symmetric. trace LE edema. NEURO: Intubated, sedated. Surgical pupil on L, pupil reactive on R. Toes downgoing B/L. Tremor at baseline. Pertinent Results: IMAGING: Head CT [**7-13**]: FINDINGS: There is no acute intracranial hemorrhage, mass effect, shift of the normally midline structures or hydrocephalus. No major vascular territorial infarct is identified. There is prominence of the ventricles and sulci consistent with age-related involutional change. Mild periventricular and subcortical white matter hypodensity is consistent with microvascular ischemia. No fractures are identified. The visualized paranasal sinuses are unremarkable. IMPRESSION: No intracranial hemorrhage or mass effect. . Admission chest x-ray: AP SUPINE CHEST: Tip of an endotracheal tube terminates 5 cm above the carina. The tube could be advanced 2 cm for optimal placement. A nasogastric tube courses to the stomach, tip off the inferior margin of the radiograph. The cardiomediastinal silhouette is stable. Calcified lymphadenopathy within the mediastinum is also unchanged. There is persistent bibasilar atelectasis, left greater than right. No pneumothorax or pleural effusion is seen. The pulmonary vasculature is not congested. IMPRESSION: ETT just below the thoracic inlet. The tube could be advanced 2 cm for optimal placemtent. Persistent bibasilar atelectasis. CXR: [**7-15**]: IMPRESSION: AP chest compared to [**5-29**] through [**7-14**]: Atelectasis at the base of the left lung has improved. Small left pleural effusion persists. Right lung is clear. Heart size top normal. ET tube is in standard placement, although the cuff is highlighted by retained secretions pooling in the trachea, while a nasogastric tube passes into the stomach and out of view. No pneumothorax. . [**7-16**] EGD: Findings: Stomach: -Other: The old [**Month/Year (2) 282**] was removed and a 24 Fr new [**Month/Year (2) 282**] placed endoscopically. Pt tolerated procedure without any complications. Impression: The old [**Month/Year (2) 282**] was removed and a 24 Fr new [**Month/Year (2) 282**] placed endoscopically. Pt tolerated procedure without any complications. Otherwise normal EGD to second part of the duodenum Recommendations: 1. OK to use [**Month/Year (2) 282**] for meds/ feedings right now. . LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2142-7-19**] 04:49AM 5.2 2.88* 9.4* 28.0* 97 32.7* 33.6 14.8 232 [**2142-7-18**] 03:09AM 5.6 3.02* 9.3* 28.4* 94 30.9 32.8 14.9 232 [**2142-7-17**] 04:11AM 5.4 3.19* 10.3* 30.6* 96 32.3* 33.8 14.8 247 [**2142-7-16**] 04:19AM 5.1 3.01* 9.5* 28.6* 95 31.5 33.1 14.9 238 [**2142-7-15**] 03:29AM 5.5 2.69* 8.7* 25.7* 96 32.3* 33.8 15.0 233 . Glucose UreaN Creat Na K Cl HCO3 AnGap [**2142-7-19**] 04:49AM 117* 13 0.6 138 4.6 102 29 12 [**2142-7-18**] 03:09AM 97 13 0.7 137 3.6 100 29 12 [**2142-7-17**] 04:11AM 101 14 0.7 140 4.2 103 33 8 [**2142-7-16**] 04:19AM 95 17 0.6 136 3.7 101 30 9 [**2142-7-15**] 03:29AM 76 22 0.7 131 3.9 95 30 10 . ABG: Type Temp pO2 pCO2 pH calTCO2 Base XS Intubat [**2142-7-14**] 06:30PM ART 123* 51 7.39 32* 5 [**2142-7-14**] 03:43AM ART 36.2 88 44 7.48 34* 8 INTUBATED . MICRO: . [**Date range (1) 3563**] BLOOD CULTURES X8-NGTD . [**2142-7-13**] 7:53 pm URINE Site: CATHETER TRAUMA. **FINAL REPORT [**2142-7-16**]** URINE CULTURE (Final [**2142-7-16**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S . [**2142-7-13**] 7:37 pm BLOOD CULTURE FEMORAL LINE. **FINAL REPORT [**2142-7-17**]** AEROBIC BOTTLE (Final [**2142-7-17**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2142-7-14**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. ANAEROBIC BOTTLE (Final [**2142-7-17**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Brief Hospital Course: [**Age over 90 **]M hx aspiration PNA, Parkinsons disease, who p/w unresponsive episode, intubated for hypercarbic respiratory failure . # HYPERCARBIC RESPIRATORY FAILURE: Patient with several recent admissions for hypercarbic respiratory failure secondary to recurrent aspiration events in setting of neuromuscular disease/Parkisons, which is presumed to contribute to chronic CO2 retention. Initial ABG at [**Hospital 100**] rehab 7.2/100/60, pronounced hypercarbia. In reviewing prior ABGs at [**Hospital1 18**], PCO2s have been in 60s, with HCO3 in the high 30s, confirming chronic CO2 retention. Furthermore patient has restrictive lung disease. Pt was intubated for several days with notable secretions. Respiratory failure in this event was due to multifactorial issues-mucous plugging with excessive secretions, myositis/muscular weakness from Parkinson's disease and mental status changes/lethargy from hypercarbia. Given that he has multiple admission for respiratory failure, a tracheostomy was discussed with the patient, his wife and Dr. [**Last Name (STitle) **] his longtime family physician, [**Name10 (NameIs) 1023**] agreed to proceed with a tracheostomy. On [**7-17**] the IP service placed a tracheostomy, #8 portex trach w/disposable inner cannula. On [**7-18**] the pt was placed on trach collar and tolerated it well. He was placed on ventilatory support for rising PaCO2 in the 70s and placed on AC overnight with good ventilation and oxygynation. He had a cuff leak, which was discussed with IP service, if his oxygenation and ventilation are good, then will tolerate the leak. Plan to downsize the trach in 2 weeks. Per his insurance he was accepted back to [**Hospital 100**] Rehab MACU for ventilatory care and support. If the MACU can not change the trach, please call [**Telephone/Fax (1) 3020**], IP service to change trach. OK to continue with aucapella/chest PT vest. . # UNRESPONSIVE EVENT: Per wife pt gets very obtunded when his CO2 levels increase, his lethargy and unresponsiveness corresponded with significant hypercarbia. His mental status improved markedly as his hypercarbia improved with ventilatory support. His Head CT was negative for bleed, neuro exam was not remarkable for gross neurologic insult . #. ID: Line Infection--Pt was noted to have coag neg staph on 2 blood cultures from [**7-13**] 2 bottled from femoral line that was placed in the ED. On subsequent blood cultures he had NGTD. He was treated with a 4 out of 5 day course with Vanco. . Klebsiella UTI--UTI noted to be ESBL which was sensitive to bactrim. He was continued on Bactrim with a 7 day course, he was due to complete his 7 day course on [**7-22**]. #. Bradycardia: Patient with multiple types of AV delay, but per EP does not have Mobitz type II and does not meet criteria for pacemaker placement. Therefore, will continue to hold nodal blocking agents and follow hr. Of note, patient does not have hypotenision with bradycardia. # PARKISONS DISEASE: He was continued on his outpatient medication regimen of Mirapex, Sinemet, Entacapone . # GLAUCOMA: He was continued on his outpatient drops . # HTN: His anti-hypertensives were held and BP well-controlled, some BP decrease while under sedation which resolved when sedation was removed. His BP meds were not continued during this hospitalization. . #. Nutrition: Pt was resumed on Tube Feeds once his G tube was changed per GI on [**7-16**]. [**Month/Year (2) 282**] tube was used immediately form meds, and TF without any problems. . # CODE: FULL, wife is having ongoing discussion with Pt's longtime family physician and the patient regarding DNR. . Medications on Admission: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) injection Injection TID (3 times a day). 2. Hexavitamin Tablet [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO 7X/D (). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 5. Latanoprost 0.005 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic HS (at bedtime). 6. Polyvinyl Alcohol 1.4 % Drops [**Month/Year (2) **]: 1-2 Drops Ophthalmic TID (3 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: [**12-5**] PO BID (2 times a day). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: Two (2) nebs Inhalation Q4H (every 4 hours) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 12. Entacapone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO 7x/day (). 13. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: Two (2) nebs Inhalation Q6H (every 6 hours). 14. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 16. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Month/Day (2) **]: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 17. Pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO six times per day (). 18. Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 19. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day). 20. Fexofenadine 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 21. Pramipexole 0.125 mg Tablet [**Hospital1 **]: 1.5 Tablets PO qday (). 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q3H FROM 5 AM - 11PM (). 2. Pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO q3h from 5 Am - 11PM (). 3. Entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO q3h from 5 AM - 11 PM (). 4. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation Q4H (every 4 hours). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation QID (4 times a day). 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-5**] Drops Ophthalmic PRN (as needed). 7. Dorzolamide-Timolol 2-0.5 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO BID (2 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic DAILY (Daily). 13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 14. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). 15. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 3 days: last day [**7-22**]. 17. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray [**Month/Year (2) **]: One (1) Nasal DAILY (Daily). 18. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: One (1) PO Q6H (every 6 hours) as needed. 19. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Month/Year (2) **]: One (1) Injection Q6H (every 6 hours) as needed: while on ventilator as needed. 20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary -Hypercarbic Respiratory Failure -ESBL Klebsiella UTI -Mental Status Changes Secondary -Parkinson's disease -Muscle weakness -chronic back pain -Recurrent Aspiration events Discharge Condition: Stable, breathing well on trach collar with ventilatory support as needed, mental status improved, speaking and mentating well. Discharge Instructions: Please continue your medications as directed. . Return to the emergency room if you have fevers, have difficulty breathing, have bleeding around your tracheostomy. Followup Instructions: Provider: [**Name10 (NameIs) 3557**] [**Name8 (MD) 3558**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2142-8-3**] 4:30 . Please have Tracheostomy down sized in 2 weeks, if you have any problems, please call IP at [**Telephone/Fax (1) 3020**] for assistance with trach change. Completed by:[**2142-7-19**]

[ "491.21", "041.3", "427.89", "934.9", "041.19", "V55.1", "V10.46", "401.9", "996.62", "733.00", "518.81", "365.9", "790.7", "332.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "31.1", "45.13", "97.02", "96.72" ]

icd9pcs

[ [ [] ] ]

16137, 16203

8029, 11664

251, 320

16428, 16558

3121, 8006

16770, 17084

2597, 2615

13907, 16114

16224, 16407

11690, 13884

16582, 16747

2630, 3102

175, 213

348, 1887

1909, 2410

2426, 2581

6,923

189,836

19984+19985

Discharge summary

report+report

Admission Date: [**2172-4-19**] Discharge Date: [**2172-4-24**] Date of Birth: [**2096-2-28**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 76 year old male with a past medical history of a right-sided cerebrovascular accident, coronary artery disease, status post coronary artery bypass graft, hypertension, lower gastrointestinal bleed on Coumadin who was sent to [**Hospital6 649**] from [**Hospital1 **] for right upper quadrant pain, nausea, vomiting and change in mental status. The patient denies any fevers, chills, chest pain, or shortness of breath. He was recently discharged from [**Hospital6 1760**]. He was here from [**4-9**] to [**4-14**], for a right hemisphere watershed stroke. He had diarrhea that was nonbloody during that admission while he was on Coumadin. Previously the patient has had projectile vomiting and bloody diarrhea at the rehabilitation facility while on Coumadin, so the Coumadin was discontinued at [**Hospital6 1760**]. The patient in the Emergency Room had systolic blood pressures in the 200s and elevated liver function tests and lipase. A gallbladder ultrasound showed acute cholecystitis. His troponin was also elevated at 0.[**Street Address(2) 53869**] elevation son his electrocardiogram. Surgery was consulted. The patient was made NPO and given Levofloxacin and Flagyl intravenously, intravenous fluids and admitted to Medicine for further care. PAST MEDICAL HISTORY: 1. Cerebrovascular accident. He had a right hemisphere watershed infarct on [**2172-4-9**]. He had a right carotid artery total occlusion, and he had a 79% left internal carotid artery stenosis. 2. Lower gastrointestinal bleed on Coumadin. 3. Hypertension. 4. Patent foramen ovale by echocardiogram in [**2171-11-18**]. There was an ejection fraction of 40 to 45%. He had apical akinesis, 1+ aortic regurgitation, 1+ tricuspid regurgitation. 5. Coronary artery disease, status post coronary artery bypass graft 26 years ago. 6. Chronic obstructive pulmonary disease. 7. He had had a left groin hematoma. MEDICATIONS ON ADMISSION: 1. Ativan 2 mg p.o. q.i.d. 2. Aspirin 325 q.d. 3. Aggrenox 1 tablet b.i.d. 4. Coumadin had been discontinued on [**2172-4-9**]. 5. Lisinopril 30 q.d. 6. Lipitor 40 q.d. 7. Protonix 40 q.d. 8. Iron tablets. 9. Neurontin 300 b.i.d. 10. Tylenol prn. ALLERGIES: Penicillin causes a rash. SOCIAL HISTORY: He lives with his wife in clinic. He has a 100 pack year tobacco history. He quit in [**2171-11-18**]. He is a retired homicide detective. FAMILY HISTORY: He has a sister with [**Name (NI) 2481**] disease. PHYSICAL EXAMINATION ON ADMISSION: His temperature was 98.8, blood pressure was 193/95 which improved to 177/79, heart rate was 96, respiratory rate was 16. He was 98% on room air. In general he was awake and alert. He had dysarthria. Head, eyes, ears, nose and throat: He has a left facial droop, otherwise he was anicteric. Mucous membranes were dry. Neck was supple. He had bilateral bruits. His jugulovenous distension was at 8 cm. Cardiovascular, he had regular rate and rhythm, normal S1 and S2. He had a I/VI holosystolic murmur heard best at the right upper sternal border. Lungs were clear to auscultation bilaterally. Abdomen was soft. He had right upper quadrant tenderness with palpation. There was no rebound, no guarding. Extremities: There was no cyanosis, clubbing or edema. He had 2+ pulses bilaterally. Neurologic, he had dysarthria, he had good comprehension. He had a left-sided facial droop. His left upper extremity strength was [**3-23**]. The lower extremity strength was 4+/5. Otherwise strength was throughout intact. He did have a pronator drift on the left. His toes were downgoing bilaterally. LABORATORY DATA ON ADMISSION: Complete blood count, white count 14.5, hematocrit 40.9, platelets were 297. His coags were within normal limits. His chem-7 was remarkable only for a creatinine of 1.5 which was slightly elevated from his baseline of 1.2 to 1.4. His first set of cardiac enzymes, his creatinine kinase was 73, MB was 2. His troponin was 0.88. His liver function tests were significant for an ALT of 57, AST of 93, alkaline phosphatase 50 to 55, Total bilirubin 1.6, amylase was 920 and lipase was 2,025. Liver ultrasound showed distended thickened gallbladder with no pericholecystic fluid, was consistent with stones and sludge, there was no ductal dilatation, there was son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. This was overall consistent with acute cholecystitis. Chest x-ray was clear. Electrocardiogram was 94 beats/minute, normal interval and axis. He has evidence of prior enteric septal infarct, low voltage throughout. There were no ischemic ST or T wave changes compared to an old electrocardiogram. PLAN: The patient was admitted to Medicine. HOSPITAL COURSE: (By systems) GASTROINTESTINAL: 1. Acute cholecystitis - The patient was seen by the Surgery Service. It was felt that he was too high risk of an operative candidate, so he was made NPO and continued on intravenous fluids and intravenous Levaquin and Flagyl. Once the patient was able to tolerate oral intake, he was changed over to oral antibiotics and he will complete a 14 day course of antibiotics. 2. Gallstone pancreatitis - The patient [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2172-4-24**] 08:31 T: [**2172-4-24**] 08:34 JOB#: [**Job Number 53870**] Admission Date: [**2172-4-19**] Discharge Date: [**2172-5-7**] Date of Birth: [**2096-2-28**] Sex: M Service: [**Last Name (un) **] NOTE: For admission history and physical, please previous discharge summary dictated by the Medical Service. HISTORY OF PRESENT ILLNESS: This is a 76-year-old male who was discharged on [**4-14**] from [**Hospital6 2018**] after an admission for right hemispheric stroke, emesis, and bloody diarrhea. The emesis and diarrhea resolved, and he was sent to rehabilitation. The patient did well for the last two days however developed daily nonbloody bowel movements but tolerating p.o.'s until the morning when he started vomiting, and he occasionally complained of abdominal pain without fever noted. PAST MEDICAL HISTORY: Right hemispheric stroke, hypertension, coronary artery disease, coronary artery bypass graft 26 years ago, right carotid artery occlusion, chronic obstructive pulmonary disease, 100 pack-year history of smoking, history of gastrointestinal bleed on Coumadin, left internal carotid artery stenosis of 79 percent, PFO by echocardiogram with an ejection fraction of 45-50 percent and apical akinesis. MEDICATIONS: Ativan 2 mg q.h.s., Aspirin 325 q.d., Atenolol 25 q.d., Lisinopril 30 q.d., Lipitor 10 q.d., Protonix 40 q.d., Iron supplements, Neurontin 300 b.i.d., Aggrenox 1 tab b.i.d. ALLERGIES: PENICILLIN CAUSES RASH. LABORATORY DATA: The patient's white count on admission was 14.5, hematocrit 40.9, platelet count 297; the patient's other laboratory values of significance was a BUN of 22, creatinine 1.5; ALT 57, AST 93, alkaline phosphatase 255, total bilirubin 1.6, amylase 920, lipase 20-25; the patient's troponin was 0.88. SOCIAL HISTORY: The patient has a 100 pack-year of smoking. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, blood pressure 193/95, respirations 16, oxygen saturation 99 percent on room air. General: The patient had slurred speech with a left facial droop. He was difficult to understand. HEENT: There was no scleral icterus. No jaundice. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: The patient had mild right upper quadrant tenderness. No tympany. No guarding. There was no rebound. Rectal: No masses. Heme negative. Extremities: The patient had no peripheral edema. IMAGES: Ultrasound on [**4-18**] showed distended thickened gallbladder with stones and sludge, no pericholecystic fluid, no ductal dilatation, no obvious son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. The patient was admitted to the Medical Service. HOSPITAL COURSE: This is a 76-year-old male with electrocardiogram changes with apparent gallstone pancreatitis with cholecystitis. Given the patient's multiple medical problems, it was felt best to conservatively treat the patient with intravenous antibiotics and follow the patient. A cholecystostomy tube was considered. This plan was discussed with Dr. [**Last Name (STitle) **], and the patient was admitted to the Medical Service. For medical admission history and physical, please see medical dictation. On hospital day2, the patient continued to be afebrile, however was hypotensive with blood pressures in the 190s/80s. The patient did have a decrease in his white count from 14 to 12 and a decrease of his BUN from 1.5 to 1.3. The patient's examination showed no pain to deep palpation. Follow-up of his amylase and lipase showed improvement of his pancreatitis. On hospital day 2, the patient was confused and tachycardiac over night. The patient was afebrile with a T-max of 99.8, blood pressure 161/83. The patient had some questionable voluntary guarding on examination; however, it was felt that there was some tenderness in the epigastrium. The patient was continued NPO with intravenous fluids. A discussion was held with the attending for a possible cholecystostomy tube. The patient's white count increased from 12 to 20.1; however, the patient's amylase and lipase were resolving to normal levels. The patient continued to be followed by the Surgical Service while on the Medical Service. The patient was seen by Neurology for evaluation of his stroke. Neurology recommendations were to restart the patient's Aggrenox and Aspirin for stroke prevention, continue statins for stroke prevention, keep hematocrit greater than 30 percent, and to keep the patient's blood pressure in the 150-170s. Neurology was following the patient through the hospital course. On hospital day 4, the patient had some loose stools and continued to remain afebrile with stable vital signs. The patient was on a clear-liquid diet. White count was 12.9. The patient seemed to be improving. MRCP request was made by the Surgical Service, and a AC-difficile was checked. The patient continued to have improvement of his liver function test and amylase and lipase. The patient was seen by Orthopedics for left shoulder pain. Orthopedics felt an MRI to evaluate AC separation was a good plan. The patient continued to do well. MRI was consistent with AC joint separation. The patient then had an MRCP performed which showed gallbladder wall thickening, positive pericholecystic fluid, no evidence of choledocholithiasis, but cholelithiasis, mild distal dilatation of common bile duct. The patient did have increased abdominal pain and increased without compliant; however, the patient's LFTs were stable, and pancreatitis had resolved. The plan from a surgical standpoint was for an interval cholecystectomy to be performed at a later date; however, the patient continued to have an elevation in white blood cell count and amylase and lipase, and on hospital day 7, the patient was found to have increase in abdominal pain despite being on Levofloxacin and Flagyl and an increase in white blood cell count to 17.4. The patient's amylase was 1631, and lipase was 3084. The patient's total bilirubin was 4.5. A gastrointestinal consult was obtained, and the patient went for ERCP which revealed a blood clot in the common bile duct. A sphincterotomy was performed. Upon follow-up, the patient's white blood cell count had increased to 21.4, and the patient's total bilirubin was 5.9, amylase was 1014, and lipase was [**2140**]. The patient was afebrile, and vital signs were stable. The patient tolerated the ERCP and seemed to do better after ERCP. Post ERCP, the patient required blood transfusion for a low hematocrit. On hospital day 8, the patient continued to complain of some tenderness to palpation in the right lower quadrant. The patient was kept NPO on intravenous fluids. On hospital day 9, the patient received another unit of packed red blood cells for a low hematocrit. The patient had some guaiac positive stools which was felt to be secondary to ERCP sphincterotomy. Hematocrit was watched Aspirin and antiplatelet medications were held. The patient had resolution of white blood cell count and had improvement of his amylase and lipase. The patient continued to have guaiac positive, malonic stools, which were sometimes reported to be grossly positive. The patient returned, on hospital day 10, for ERCP, which identified bleeding at the sphincterotomy site. This bleeding was not able to be controlled. The patient went to angiography for embolization of the branch of the gastroduodenal artery. On hospital day 10, the patient's hematocrit had improved. The patient was still complaining of right upper quadrant pain. The patient's white blood cell count also had increased to 17.8. The patient was given additional units of cells. The patient continued to have requirement for blood transfusions. On hospital day 11, the patient's T-max was 100.6 degrees. The patient's hematocrit had dropped to 29.6, and he received another unit of packed red blood cells for a bump to 32.2. On patient examination, he still complained of tenderness over the right upper quadrant. The patient had positive [**Doctor Last Name 515**] sign and positive right upper quadrant guarding. The patient's laboratory values showed a white count now at 31.9, total bilirubin was 1.9 which was up from 1.3, alkaline phosphatase was 573, but in light of the patient's recent ERCP, was unpredictable. The decision was made to transfer the patient to the Surgical Service. The patient had a HIDA scan which was positive, and no gallbladder was seen. The patient was still having some bloody bowel movements. The patient had placement of a cholecystostomy tube on hospital day 12 for increasing white blood cell count. Over night, cholecystostomy tube did not drain more than 10 cc of fluid. At this point, the patient's plan was discussed with attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. With the patient's continued right upper quadrant pain and white blood cell count which had increased from 31 to 34.6, the decision was made to take the patient to the Operating Room for an open cholecystectomy. The patient tolerated the procedure well. He was transferred to the intensive care unit postoperatively. Postoperatively and status post open cholecystostomy and G- tube placement, the patient was afebrile, and vital signs were stable. The patient had a Swan-Ganz catheter in place, and cardiac enzymes was within normal limits. The patient was extubated on postoperative day 1. The patient's white blood cell count continued to be elevated to 34.5. The patient's cardiac enzymes were negative. [**Location (un) 1661**]-[**Location (un) 1662**] drain was in place which was draining serosanguinous fluid. The patient was ruled out for myocardial infarction. The patient's blood pressure was maintained and watched for elevation for carotid disease. The patient was continued on antibiotics. Nutrition consult was obtained for tube feed recommendations. The patient did not have any more rectal bleeding. On postoperative day 2, the patient was still on Vancomycin, Levofloxacin, and Flagyl. The patient was afebrile. Vital signs were stable. The patient's white blood cell count was 28.1, and hematocrit was stable at 30.3. The patient was transferred to the floor. On postoperative day 3, the patient was afebrile, and white blood cell count continued to trend down to 23.5, and hematocrit was stable at 30.8. Bile cultures grew out MRSA, and the patient was continued on Vancomycin. The patient's Aggrenox and Aspirin were resumed. On postoperative day 3, the patient had an episode of sinus tachycardia; however, white blood cell count was improving. The patient was otherwise afebrile. The patient was started on tube feeds and continued to advance towards goal. The patient had Physical Therapy evaluation. The patient was deemed most suitable for rehabilitation facility. The patient was continued to be seen by Neurology, and they felt agitation was possibly related to administration of Ativan. The patient was kept on a 1:1 sitter. On postoperative day 5, the patient was continued on intravenous antibiotics. The patient was afebrile. Vital signs were all stable. The patient's abdomen was soft and nontender. The patient's white blood cell count was now 17.2. Hematocrit was stable at 32.1. The patient's other laboratory values were all within normal limits. The patient did have some increased stool output, and the patient's tube feeds were dropped down to 60 cc/hr. The patient was screened for rehabilitation and was accepted to [**Hospital **] Rehabilitation. On postoperative day 6, the patient's C-diff was checked, and antibiotics were discontinued. The patient was tolerating tube feeds. The patient was screened for rehabilitation. On postoperative day 7, the patient was afebrile, and vital signs were stable. The patient's white blood cell count had decreased to 16. The patient was tolerating tube feeds well and was out of bed to a chair. The patient's Foley catheter was removed, and the patient was voiding on his own. It was determined that the patient would be suited for rehabilitation facility, and the patient was discharged to [**Hospital **] Rehabilitation in stable condition. DISCHARGE DIAGNOSIS: 1. Status post open cholecystectomy. 2. Status post ERCP with sphincterotomy. 3. Upper gastrointestinal bleed. 4. Status post Interventional Radiology embolization. 5. Coronary artery disease. 6. Hypertension. 7. Status post cerebrovascular accident. 8. Acute renal failure. 9. Congestive heart failure. 10. AC joint separation. 11. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: Neurontin 300 mg p.o. b.i.d., Lisinopril 20 mg p.o. b.i.d., Lipitor 20 mg p.o. q.d., Aggrenox 1 cap p.o. b.i.d., Aspirin 81 mg 1 tab p.o. q.d., Vitamin B 1 tab p.o. q.d., Protonix 40 mg 1 tab p.o. q.d., Metoprolol 100 mg p.o. t.i.d., Risperidone 0.5 mg p.o. q.h.s., Tylenol as needed. FOLLOW UP: The patient will follow-up with Dr. [**Last Name (STitle) **] in the Surgery Clinic in one week. The patient will follow-up with Dr. [**First Name (STitle) **] in the [**Hospital **] Clinic in three weeks; the patient will call to schedule an appointment. The patient will follow-up with primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.; the patient will call for an appointment. DISCHARGE STATUS: Discharged to rehabilitation in stable condition on tube feeds, working with Physical Therapy towards ambulation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 53871**] Dictated By:[**Last Name (NamePattern1) 53872**] MEDQUIST36 D: [**2172-5-6**] 10:11:44 T: [**2172-5-6**] 11:34:20 Job#: [**Job Number 53873**]

[ "496", "578.9", "414.01", "428.0", "584.9", "574.00", "401.9", "577.0", "263.9" ]

icd9cm

[ [ [] ] ]

[ "51.88", "51.85", "51.14", "51.22", "99.15", "45.13", "99.04", "43.19", "51.03", "96.6" ]

icd9pcs

[ [ [] ] ]

7438, 7456

18257, 18543

17849, 18233

2114, 2410

8311, 17828

18555, 19414

7479, 8293

5931, 6396

3814, 4874

6419, 7359

7376, 7421

15,551

135,045

30600

Discharge summary

report

Admission Date: [**2161-6-15**] Discharge Date: [**2161-6-22**] Date of Birth: [**2086-4-9**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Ampicillin Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p AVR(23mm [**Company 1543**] Mosaic porcine valve)/CABGx1(SVG->dRCA)/aortic endarterectomy [**2161-6-15**] History of Present Illness: 75 y/o male who suffered left femur fracture on [**10-17**] who needed surgical repair. But during cardiac clearance was found to have aortic stenosis and coronary artery disease. Past Medical History: Diabetes Mellitus, Hypertension, Hyperlipidemia, Arthritis, Obesity, h/o left Femur fracture, h/o ETOH abuse and post-op DT's, Sleep Apnea on CPAP, s/p left knee replacement, s/p TURP, s/p TUR of bladder tumor Social History: Rare cigar. Quit smoking cigs 40 yrs ago. Quit drinking 7 mos ago, prior abuse. Family History: Non-contributory Physical Exam: 78 20 140/70 5'5' 210# Gen: 75 y/o male in wheelchair HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -bruit Chest: CTAB -w/r/r Heart: RRR, +murmur Abd: Soft, NT/ND, +BS, obese Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**6-15**] Echo: PRE-BYPASS: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%).There are complex (>4mm) atheroma in the aortic root ascending, and descending thoraci caorta. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (mobile) atheroma in the descending aorta. An epiarotic scan was undertaken prebypass demonstrating an area of low profile/minimal plaque at the site of planned cannulation and clamping, but otherwise large plaques scattered through the ascending aorta. (please note that recorded loop demonstrates plaque above the proposed area of cannulation) There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Preserved biventricular function LVEF >55%. There is a bioprosthetic valve insitu in the aortic position. The valve appears well seated without peirvalvular leaks. Peak gradient 36, mean 18 mm Hg. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**6-17**] Head CT: No acute intracranial hemorrhage or mass effect. Please note that for detection of acute brain ischemia, MRI with diffusion weighting is more sensitive than CT. [**2161-6-15**] 02:22PM BLOOD WBC-7.4# RBC-2.61*# Hgb-8.4*# Hct-24.0*# MCV-92 MCH-32.4* MCHC-35.1* RDW-14.6 Plt Ct-111* [**2161-6-17**] 03:07AM BLOOD WBC-11.0 RBC-2.86* Hgb-9.2* Hct-26.5* MCV-93 MCH-32.0 MCHC-34.6 RDW-15.1 Plt Ct-106* [**2161-6-22**] 06:10AM BLOOD WBC-5.8 RBC-3.16* Hgb-10.1* Hct-28.9* MCV-91 MCH-31.9 MCHC-34.9 RDW-15.4 Plt Ct-236# [**2161-6-15**] 02:22PM BLOOD PT-15.5* PTT-50.2* INR(PT)-1.4* [**2161-6-19**] 02:02AM BLOOD PT-12.5 PTT-31.7 INR(PT)-1.1 [**2161-6-15**] 03:39PM BLOOD UreaN-15 Creat-0.7 Cl-113* HCO3-23 [**2161-6-20**] 03:55AM BLOOD Glucose-94 UreaN-33* Creat-1.0 Na-143 K-3.6 Cl-110* HCO3-23 AnGap-14 [**2161-6-22**] 06:10AM BLOOD UreaN-21* Creat-0.9 Na-140 K-3.9 Cl-107 HCO3-23 AnGap-14 Brief Hospital Course: Mr. [**Known firstname 35763**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a coronary artery bypass graft, aortic valve replacement and aortic endarterectomy. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke mostly neurologically intact and extubated. On post-op day one his chest tubes were removed. He was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. During initial post-operative days he did have periods of confusion and agitation in which a head CT was performed and he required an observer. Head CT r/o a stroke. Epicardial pacing wires were removed per protocol. Over the next several days he received aggressive pulmonary toilet and was then transferred to the telemetry floor on post-op day four. His confusion decreased over the next several days and he worked with physical therapy for strength and mobility. His electrolytes were repleted and beta blockers adjusted for maximum hemodynamics. On post-op day seven he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Diovan 80mg qd, Atenolol 25mg qd, Lipitor 10mg qd, Lexapro 10mg qd, Aspirin 81mg qd, Glyburide 2.5mg qd, Vesicare 5 qhs, Folic acid, Vit B1 Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:*56 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. 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. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: Take with food. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 Aortic stenosis s/p Aortic Valve Replacment PMH: Diabetes Mellitus, Hypertension, Hyperlipidemia, Arthritis, Obesity, h/o left Femur fracture, h/o ETOH abuse and post-op DT's, Sleep Apnea on CPAP, s/p left knee replacement, s/p TURP, s/p TUR of bladder tumor Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 37063**] in [**1-13**] weeks. Make an appointment with Dr. [**First Name (STitle) **] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Completed by:[**2161-6-22**]

[ "401.9", "414.01", "780.57", "250.00", "272.4", "440.0", "424.1", "293.0", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "38.14", "36.11", "39.61", "35.21", "00.40" ]

icd9pcs

[ [ [] ] ]

6217, 6275

3569, 4882

307, 418

6638, 6644

1290, 2653

7137, 7391

973, 991

5072, 6194

6296, 6617

4908, 5049

6668, 7114

1006, 1271

248, 269

446, 627

2662, 3546

649, 860

876, 957

62,457

152,355

33858

Discharge summary

report

Admission Date: [**2143-7-5**] Discharge Date: [**2143-7-6**] Date of Birth: [**2057-6-27**] Sex: F Service: MEDICINE Allergies: Egg / Lactose Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypotension, shock Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 4597**] is a 86 year old Creole-speaking woman with a history of hepatitis C, cirrhosis and HCC who presented to the ED today directly from [**Doctor Last Name 78251**] due to a systolic blood pressure in the 70s. She complained of [**2-28**] days of nausea and vomiting (non-bloody) and right upper quadrant pain. Her belly had also become distended and she developed worsening lower extremity edema. Today, she felt extremely cold all day. She was weak and has not been able to eat for 3 days. She has had two recent admissions. . The first was in [**4-5**] for trans-arterial chemoembolization, which was complicated by fever treated with a 7d course of cipro and low grade DIC which resolved. The second was in [**5-6**] when she presented with anemia requiring one unit of prbcs and also recieved a therapeutic paracentesis at that time. . In the ED, here initial vitals were T 97.8, HR 52, BP 72/42 (nl 120-140), 15, 100/RA. A RIJ CVC was placed with CVP 9-10. She received 5L NS and had reportedly gotten 4L of NS prior to that. She was initially started on levophed and then dopamine was also added due to a HR of 55. A foley was placed and she had 100cc of urine output. She was given hydrocortisone 100mg iv times one, CTX 1g iv times one, vancomycin 1g iv, levofloxacin 750mg iv. A diagnostic paracentesis was performed, showing WBC 74. Urine and blood cxs were sent. . An abdominal/pelvic CT scan showed Massive intra-abdominal ascites and anasarca, No bowel obstruction - but limited eval due to non-contrast technique, Shrunken nodular liver - lesions incompletely assessed, Evidence of prior chemoembolization, Large hiatal hernia (new from prior), andBilateral moderate pleural effusions. Her CXR showed a possible right base opacity. . Labs with UA neg, INR 1.6. Ascites with WBC 74, Poly pend lactate 2.0 . Creatinine 3.4 (1.4 prior). AST 127, ALT 59, AP 87, LDH 448 Lip 234 WBC 5, Hct 27.7, Platelets 105. . Upon transfer to the MICU, HR60, BP 71/50, CVP 11, 99/RA. Initial vitals in the MICU showed T 92F axillary, 95/58, HR 75, 91%RA. She was continued on levophed/dopa and volume rescusitation also initiated. She had no new complaints. A bear-hugger was placed. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Diagnosed with HCV 20 years ago, referred to [**Hospital1 18**] hepatology [**6-2**] when CT showed liver masses. She is status post radiofrequency ablation in 5/[**2140**]. She has been followed by CT scans since that time, most recently on [**2141-2-8**], which revealed progressive arterial enhancement at the site of her previous radiofrequency ablation, consistent with disease recurrence. . Other Past Medical History: - Hepatitis C cirrhosis, diagnosed 20 years ago - Chronic idiopathic calcific pancreatitis - Hepatocellular carcinoma, diagnosed on CT scan [**6-2**], s/p RFA [**6-2**] with disease recurrence detected [**1-/2141**] - Hypertension Social History: - EtOH: denies - Tobacco: denies - Drug Use: denies Pt lives alone but spends M-F with her son. She is able to care for herself. She is originially from [**Country 2045**] and first-language is Hatian-Creole and French. She has three children. Family History: denies hx of cancer. Physical Exam: Flowsheet Data as of [**2143-7-5**] 09:31 PM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since [**44**] AM Tmax: 35.6 ??????C (96.1 ??????F) Tcurrent: 35.6 ??????C (96.1 ??????F) HR: 75 (51 - 94) bpm BP: 107/59(69) {55/40(43) - 135/66(80)} mmHg RR: 21 (14 - 27) insp/min SpO2: 98% Respiratory O2 Delivery Device: Nasal cannula SpO2: 98% ABG: ///17/ Physical Examination General Appearance: Thin Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed), 2+ edema Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2143-7-5**] 08:31PM WBC-6.2 RBC-2.33* HGB-8.7* HCT-27.1* MCV-116* MCH-37.4* MCHC-32.2 RDW-16.7* [**2143-7-5**] 08:31PM PLT COUNT-124* [**2143-7-5**] 05:29PM LACTATE-4.3* [**2143-7-5**] 05:15PM GLUCOSE-138* UREA N-49* CREAT-3.1* SODIUM-133 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-17* ANION GAP-14 [**2143-7-5**] 05:15PM ALBUMIN-1.5* CALCIUM-6.6* PHOSPHATE-4.0 MAGNESIUM-1.8 [**2143-7-5**] 05:15PM URINE HOURS-RANDOM UREA N-481 CREAT-84 SODIUM-93 POTASSIUM-13 CHLORIDE-69 [**2143-7-5**] 05:15PM URINE EOS-NEGATIVE [**2143-7-5**] 01:30PM URINE HOURS-RANDOM UREA N-246 CREAT-78 SODIUM-84 POTASSIUM-20 CHLORIDE-79 [**2143-7-5**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2143-7-5**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2143-7-5**] 11:54AM PT-17.7* PTT-41.4* INR(PT)-1.6* [**2143-7-5**] 11:45AM ASCITES TOT PROT-1.0 GLUCOSE-119 LD(LDH)-89 [**2143-7-5**] 11:45AM ASCITES WBC-74* RBC-19* POLYS-42* LYMPHS-16* MONOS-0 MESOTHELI-1* MACROPHAG-41* [**2143-7-5**] 11:40AM LACTATE-2.0 [**2143-7-5**] 11:30AM GLUCOSE-107* UREA N-54* CREAT-3.4*# SODIUM-133 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-12 [**2143-7-5**] 11:30AM estGFR-Using this [**2143-7-5**] 11:30AM ALT(SGPT)-59* AST(SGOT)-127* LD(LDH)-448* ALK PHOS-87 TOT BILI-1.2 [**2143-7-5**] 11:30AM LIPASE-234* [**2143-7-5**] 11:30AM WBC-5.0 RBC-2.43* HGB-8.9* HCT-27.7* MCV-114* MCH-36.4* MCHC-32.0 RDW-17.0* [**2143-7-5**] 11:30AM NEUTS-66.6 LYMPHS-25.6 MONOS-7.1 EOS-0.4 BASOS-0.4 [**2143-7-5**] 11:30AM PLT COUNT-105* Brief Hospital Course: Ms. [**Known lastname 4597**] was a 86 year old Creole-speaking woman with a history of hepatitis C, cirrhosis and HCC who presented to the MICU with hypotension. . Severe shock -- Lactate of 4.2 and [**Last Name (un) **] represent end organ injury. Etiologies included septic, cardiogenic, hypovolemic. Given vomiting, some degree hypovolemic shock was likely. SBP unlikely given negative diagnostic tap. Pneumonia was a possibility. UA was negative making UTI unlikely. No neurological symptoms. Her EKG is unchanged from prior. Early volume resucitation initiated in the ED. Hypothermia, hypotn could be manifestation of hypo adrenal. In addition, tense ascites also playing a role. Upon admission to the MICU, patient clearly indicated that she no longer desired invasive procedures, at times preferring not be be examined. Following discussion with the patient's son, plan was to continue current level of care but no further aggressive measures. Patient received aggressive fluid resuscitation. She remained on norepinephrine and dopamine drips. Her blood pressure was labile. Serum lactate level began to rise dramatically and her respiratory status became tenuous over several hours. The family was updated several times through the night. Based on her poor prognosis and wishes, her code status was changed to DNR/DNI late in the evening. At about 5:45am, she began to have massive hematemesis and expired quietly within minutes. The medical examiner waived the case. The family was notified and counseled appropriately. A death note and death report were completed. The primary physicians were notified. Medications on Admission: Viokase 8 468 mg (8,000-30K-30K unit) Tab 3 Tablet(s) by mouth three times a day Atenolol 50 mg Tab one Tablet(s) by mouth twice a day ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) Mephyton 5 mg Tab one Tablet(s) by mouth daily ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) furosemide 40 mg Tab 1 Tablet(s) by mouth once a day ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) lisinopril 5 mg Tab 0.5 (One half) Tablet(s) by mouth DAILY (Daily) ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) alendronate 70 mg Tab One Tablet(s) by mouth weekly ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) simethicone 80 mg Chewable Tab 1 Tablet(s) by mouth three times a day as needed for gas ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) spironolactone 25 mg Tab 1 Tablet(s) by mouth twice a day ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) food supplement, lactose-free Oral Liquid 1 can by mouth three times a day ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) multivitamin Tab 1 Tablet(s) by mouth ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 78252**] [**2143-7-5**] 11:45) Zinc Sulfate 220 mg (50 mg) Cap 1 Capsule(s) by mouth once a day Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2143-7-9**]

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3962, 3985

9789, 9798

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233, 254

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15,301

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51719

Discharge summary

report

Admission Date: [**2134-4-23**] Discharge Date: [**2134-5-2**] Date of Birth: [**2060-1-15**] Sex: M Service: MEDICINE Allergies: Protamine Sulfate / Ambien Attending:[**First Name3 (LF) 9824**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: central line catheter left knee washout History of Present Illness: 74 y.o. male with COPD, CAD, DM with a chief complaint of shortness of breath. Patient reported subjective fevers, manifested by "feeling warm" along with additional symptoms of nausea and a largely unproductive cough x 3 days. On the day of admission, he woke up at 3 AM, "shaking" and feeling very cold. He also felt acutely short of breath and nauseous with one episode of bilious, non-bloody emesis. ROS otherwise significant for increased LE swelling compared to baseline and increased weight gain in general; one episode of loose stools without hematochezia or melena. In the [**Hospital1 18**] ED, vitals were T - 99.5, HR - 119, BP 84/49, RR - 19, O2 - 94% on 4L. He was given 4 L of NS for the hypotension with slow improvement so a CVL was placed, though no pressors were started as his BP eventually rebounded. CXR revealed a possible RLL PNA, for which patient was given Vancomycin, Ceftriaxone and Levofloxacin. BNP was not elevated. Patient was also felt to be wheezy and given ?history of COPD, Solumedrol 125 mg IV was given. Labs revealed a leukocytosis of 17 with 92% neutrophils and 1 band. Lactate was elevated to 3.7, but decreased to 3 with IVF. Given elevated lactate in the setting of respiratory distress, patient was admitted to the ICU for further management. Past Medical History: CAD s/p angioplasty in [**2121**], stress echo wnl [**8-4**] DM II- on insulin HTN Hyperlipidemia CRI AAA s/p repair, c/b acute renal failure now with CKD IV Darier disease OA thrombocytopenia of unclear etiology b/l knee replacement peripheral neuropathy lumbar spine stenosis claudication MGUS Social History: Former history of tobacco use, [**4-3**] ppd x 40-50 years, stopped in '[**16**]. Heavy alcohol use, though decreasing in recent months, last drink was a [**Location (un) 21601**], two days ago. No history of withdrawal. Denies illicit drug use. Family History: father died at 96. mother died at 93. Diabetes Physical Exam: Vitals: T - 98.9, BP - 109/50, HR - 103, RR - 19, O2 - 94% 4L General: Awake, alert, NAD HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous Neck: Supple, no LAD, unable to assess JVP given large neck Chest/CV: S1, S2 nl, no m/r/g appreciated Lungs: B/l inspiratory crackles Abd: Obese, soft, NT, ND, + BS Ext: No c/c; [**12-30**]+ pitting edema b/l in LEs with bruising of 3rd toe on right foot, NT, mildy erythematous, not appreciably warm. No areas of interdigital skin breakdown. Pulses difficult to appreciate given edema, but feet are warm and otherwise well-perfused; decreased proprioception of right foot, but sensation intact bilaterally Neuro: Grossly intact Skin: No lesions Pertinent Results: EKG: Sinus tachycardia with prolonged PR, but no ischemic changes [**2134-5-2**] 04:30AM BLOOD WBC-6.9 RBC-2.79* Hgb-8.7* Hct-24.6* MCV-88 MCH-31.3 MCHC-35.4* RDW-13.4 Plt Ct-114* [**2134-4-23**] 08:20AM BLOOD WBC-17.0*# RBC-3.65* Hgb-11.2* Hct-32.0* MCV-88 MCH-30.6 MCHC-34.8 RDW-13.5 Plt Ct-95* [**2134-4-27**] 06:31AM BLOOD PT-13.0 PTT-27.6 INR(PT)-1.1 [**2134-4-24**] 01:35PM BLOOD Fibrino-690*# D-Dimer-5343* [**2134-4-27**] 06:31AM BLOOD ESR-131* [**2134-4-24**] 01:35PM BLOOD Ret Aut-1.5 [**2134-5-2**] 04:30AM BLOOD Glucose-76 UreaN-44* Creat-2.4* Na-143 K-4.3 Cl-109* HCO3-27 AnGap-11 [**2134-4-24**] 01:35PM BLOOD LD(LDH)-182 TotBili-0.2 [**2134-4-24**] 12:44AM BLOOD CK(CPK)-225* [**2134-4-24**] 12:44AM BLOOD CK-MB-5 cTropnT-0.02* [**2134-5-1**] 05:32AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.6 [**2134-4-26**] 06:22AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1 Iron-40* [**2134-4-26**] 06:22AM BLOOD calTIBC-222* Ferritn-544* TRF-171* [**2134-4-24**] 01:35PM BLOOD Hapto-232* [**2134-4-27**] 06:31AM BLOOD CRP-131.8* [**2134-4-25**] 07:01AM BLOOD Lactate-1.2 [**2134-4-23**] 08:35AM BLOOD Glucose-212* Lactate-3.7* K-4.7 [**2134-4-28**] 05:49PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2134-4-28**] 05:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2134-4-26**] 04:07PM JOINT FLUID WBC-[**Numeric Identifier 25638**]* RBC-8750* Polys-77* Lymphs-3 Monos-14 Macro-6 [**2134-4-26**] 04:07PM JOINT FLUID Crystal-NONE [**2134-4-26**] 04:07PM JOINT FLUID TotProt-4.0 Glucose-23 LD(LDH)-2444 [**2134-4-23**] 8:20 am BLOOD CULTURE SET #1. **FINAL REPORT [**2134-4-25**]** Blood Culture, Routine (Final [**2134-4-25**]): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B | CLINDAMYCIN----------- S ERYTHROMYCIN---------- 4 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2134-4-23**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1900 [**2134-4-23**]. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [**2134-4-23**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. [**2134-4-26**] 6:22 am BLOOD CULTURE **FINAL REPORT [**2134-5-2**]** Blood Culture, Routine (Final [**2134-5-2**]): NO GROWTH. TISSUE Site: KNEE LEFT KNEE SYNOVIUM. GRAM STAIN (Final [**2134-4-27**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2134-4-30**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**Last Name (un) **] Not Noted Log-In Date/Time: [**2134-4-27**] 3:15 pm SWAB Site: KNEE LEFT KNEE FLUID Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. GRAM STAIN (Final [**2134-4-27**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2134-4-30**]): A swab is not the optimal specimen collection to evaluate body fluids. NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2134-4-23**] CXR: IMPRESSION: No evidence of pneumonia or volume overload. No acute cardiopulmonary process. [**2134-4-25**] CT ABDOMEN/PELVIS: IMPRESSION: 1. No intra-abdominal fluid collection. 2. No enlarged intra-abdominal lymph nodes. 3. Mildly enlarged bilateral inguinal lymph nodes, most likely reactive. 4. Gallstone in gallbladder. [**2134-4-26**] KNEE XRAY: IMPRESSION: 1. Small knee joint effusion. 2. No evidence of prosthetic loosening. 3. No fracture. [**2134-4-27**]: Synovium (left knee): 1. Synovial-like tissue with acute and chronic inflammation and fibrinopurulent exudate, consistent with infection. 2. Mono- and multinucleated histiocytic reaction to polyethylene fibers. [**2134-4-28**] RENAL US: IMPRESSION: No hydronephrosis. [**2134-4-28**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: A/P: 74 y.o. male with CAD, COPD, DM, CRI, admitted with SOB, cough, subjective fevers, and nausea likely from sepsis due to group B strep bacteremia. Source uncertain. # Sepsis: The patient initially was admitted to the MICU with hypotension/tachycardia and a lactate of 3.7. He had leukocytosis with a left shift. He was treated initially empirically with Levo/Vanco; WBC improved and fever trended down. Initially on insulin drip for poorly controlled glucose. He was then found to have group B strep bacteremia and GPC in sputum. Antibiotics changed to PCN on [**4-25**], insulin drip discontinued and home insulin regimen restarted [**4-25**]. A Torso CT [**4-25**] without evidence of abscess. The patient was then transferred to the floor for further management. He also had left knee pain, and was found to have an effusion. Orthopaedics was consulted and a arthrocentesis was performed which had signficant amounts of WBC, but no growth, though this was after antibiotic administration. Since he had had an arthoplasty to his knees, he was taken by Orthopedics for a knee washout. Tissue and cultures were sent which showed no growth. The biopsy was consistent with infection though. An ECHO was done which was negative for vegetations. The infectious disease service was consulted for length of therapy. They recommended at least 6 weeks, but also until his inflammatory (ESR/CRP) had normalized. He will followup with them in clinic as scheduled and then determine length of therapy. He will continue on penicillin IV 2 million units Q4H as renal (dosed per improved renal function). He had a PICC placed for his IV antibiotic course. # Hypoxia: Resolved. The patient initially had GPC's in sputum and had possible infiltrate on CXR, so presumably hypoxia secondary to pneumonia. Later, the CXR was found to be clear, and his sputum grew oropharyngeal flora. The patient has significant sleep apnea, and had been unable to tolerate his CPAP mask secondary to leak. He will need to followup with the sleep clinic for possible fitting of a nasal mask. At the time of discharge, he had good O2 sats on room air. # [**Last Name (un) **] on CKD4: The patient has chronic kidney disease, and is on calcitriol. Shortly after his surgery, he developed acute kidney injury and bumped his creatinine to 4.3 from baseline around 2.7. This was thought to be secondary to hypovolemia. His lasix was held, and he was given IVFs gently, and at the time of discharge, his creatinine improved to 2.4. He will continue his home medications. Calcium carbonate was also added TID with meals as a phosphate binder. # Anemia: The patient has chronic anemia. His stools were guiaic negative. He has refused colonoscopy in the past. He was transfused for a HCT <25 post operatively. His HCT otherwise remained stable. # Black Toe: The patient had a black tip to his second toe on the right foot which appeared to be a blood blister. It did not appear infected, and was improving at the time of discharge. # CAD: The patient did not have any chest pain during his hospitalizations. His ECG showed no evidence of new iscehmia, and his cardiac enzymes were negative. He will continue on his home regimen of ASA, BB, ACE-I, and statin. # DM2: The patient's blood sugars were initially very elevated, but after his insulin drip was stopped and he was transitioned back to his home regimen, his blood glucose levels would dip into the hypoglycemic range. His insulin was decreased, and this will need to be continually adjusted based on the patient's fingersticks. # Spinal Stenosis: The patient will continue his neurontin and TCA. # Communication: [**First Name8 (NamePattern2) 1123**] [**Known lastname 20741**], RN (daughter and HCP): [**Telephone/Fax (1) 107131**](h), [**Telephone/Fax (1) 106871**] (c) # Code status: FULL (confirmed with patient and family) #. Dispo: The patient will be discharged to a rehab facility for continued physical therapy. He will followup with orthopedics in 2 weeks to have his staples removed. He will also need to get his PICC line removed once he completes his antibiotic course as determined by infectious disease service. Medications on Admission: Albuterol Atrovent Amitriptyline 75 mg PO QD Calcitriol 0.25 mcg PO QD Fluticasone Lasix 120 mg PO QD Neurontin 600 mg PO BID Gemfibrozil 300 mg PO BID Lisinopril 10 mg PO QD Zaroxolyn 2.5 mg PO QD PRN with Lasix for weight > 305 lbs. Toprol XL 50 mg PO QD Pravastatin 10 mg PO QD ASA 81 mg PO QD MVI NPH 100 U QAM/93 U QPM Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous Q24H (every 24 hours) for 2 weeks. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for PICC. 18. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback Sig: 2 million units Intravenous every four (4) hours for 6 weeks: do not stop medication before speaking with ID specialist. 19. Lasix 40 mg Tablet Sig: Three (3) Tablet PO once a day. 20. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: AS DIRECTED units Subcutaneous twice a day: 70 units QAM, 50 units QPM. 21. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED units Subcutaneous four times a day: per sliding scale. 22. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Group B streptrococcus bacteremia Left Knee Septic Joint Secondary Diagnosis: Diabetes Hypertension Discharge Condition: stable, afebrile Discharge Instructions: You were admitted for a blood infection. You were treated with antibiotics. You also were found to have swelling in your knee which required a washout by the orthopedics service since it likely was infected. You will need to continue on the antibiotics for at least 6 weeks. YOu will need to followup with the infectious disease service in clinic to determine length of therapy. Please continue all medications as prescribed. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED chest pain, fevers, chills diarrhea, nausea, vomiting Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2134-5-19**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2134-5-31**] 12:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-5-20**] 11:40 Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1968**] [**Telephone/Fax (1) 250**] to schedule a follow up appointment in 2 weeks.

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icd9cm

[ [ [] ] ]

[ "38.93", "80.76", "00.84", "81.91" ]

icd9pcs

[ [ [] ] ]

15025, 15091

8351, 12537

294, 335

15255, 15274

3026, 5887

15942, 16584

2253, 2301

12912, 15002

15112, 15112

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247, 256

363, 1653

15210, 15234

15131, 15189

6519, 8328

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1990, 2237

53,152

182,753

30681

Discharge summary

report

Admission Date: [**2145-11-2**] Discharge Date: [**2145-11-11**] Date of Birth: [**2063-8-31**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 11839**] Chief Complaint: axHypotension Major Surgical or Invasive Procedure: Endoscopy to evaluate esophageal stent History of Present Illness: Mr. [**Known lastname 40258**] is an 82 M with a medical history notable for esophageal adenocarcinoma and recurrent DVTs. He was evaluated in his [**Hospital **] Clinic on [**2145-11-2**] and noted to have SBP 70. He was referred to the [**Hospital1 18**] ED. In the ED, initial vital signs were: T 98, HR 73, BP 95/40, RR 20, O2 sat 100% RA. BP came up with IV fulids. However, the patient had brief, self-limited episodes of a narrow-complex tachycardia to 130-140s and would drops his SBP during these episodes. Per report, the longest episode lasted 60 sec and SBP dropped to the 70s briefly and recovered with resumption of normal HR. Labs were notable for K 3.4, Mg 1.0, and Phos 2.6 with negative cardiac biomarkers. For this he was admitted to the [**Hospital Unit Name 153**]. While in the [**Hospital Unit Name 153**] his blood pressure responded to fluids and he continued to note brief runs of narrow-complex tachcardia. He remained hemodynamically stable and was transferred to the floor. Of note, he attempted to have a PE CT and contrast infiltrated his arm after an IV did not function appropriately. On arrival to the floor he noted persistent chest pain that he has noted for many months. He does not feel hungry but feels weak. He has noted poor intake for at least the past 2 weeks-not taking much fluids or food. No abdominal pain. ROS: No fevers, chills, change in stools, SOB. Other systems reviewed and otherwise negative. Past Medical History: 1. Esophageal adenocarcinoma: presented [**2-/2145**] with what sounds like stage III disease. Treated with [**Doctor Last Name **]/taxotere with good response by radiography but eventually developed obstructive esophageal mass requiring stenting on [**2145-9-9**]. He began XRT on [**2145-10-4**] and is also concurrently receiving chemotherapy with weekle [**Doctor Last Name **], last [**Doctor Last Name **] on [**2145-10-27**]. 2. Hypothyroidism 3. DVT: originally diagnosed in [**2142**] and briefly on anticoagulation. He re-presented [**4-/2145**] and was diagnosed with right-sided DVT. He has been treated with once-daily Lovenox since this time. 4. BPH Social History: Ex smoker quit 10 years ago, 2 ppd prior to then. Occasional ETOH. From [**Country 3587**]. Family History: No history of cancers in the family. Physical Exam: Vitals: T: 97.9 BP: 109/78 P: 79 R: 17 O2: 98% RA General: Alert, elderly male in no acute distress, frequently spitting up oral secretions into a basin HEENT: Sclera anicteric, MM dry, 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. Left-sided port-a-cath c/d/i. 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 or cyanosis, 1+ edema to above ankles bilaterally right>left. Pertinent Results: Admission Labs: [**2145-11-2**] 01:25PM BLOOD WBC-2.6* RBC-3.34* Hgb-11.2* Hct-33.1* MCV-99* MCH-33.4* MCHC-33.8 RDW-19.0* Plt Ct-65*# [**2145-11-2**] 01:25PM BLOOD Neuts-88* Bands-3 Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2145-11-2**] 01:25PM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL [**2145-11-2**] 01:25PM BLOOD PT-14.8* PTT-33.4 INR(PT)-1.3* [**2145-11-2**] 01:25PM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-137 K-3.4 Cl-103 HCO3-25 AnGap-12 [**2145-11-2**] 01:25PM BLOOD ALT-57* AST-34 AlkPhos-56 TotBili-0.5 [**2145-11-2**] 01:25PM BLOOD Albumin-3.2* Calcium-7.3* Phos-2.6* Mg-1.0* [**2145-11-2**] 01:25PM BLOOD cTropnT-<0.01 [**2145-11-2**] 01:36PM BLOOD Lactate-1.8 Studies: [**2145-11-2**] AP CXR - IMPRESSION: Relatively stable exam with low lung volumes but no acute pulmonary process noted. Stable left internal jugular approach central line. [**2145-11-2**] CT Chest w/o contrast -IMPRESSION: 1. ~100 cc of contrast infiltration in the right arm. Please see technique above for further details. When IV access is re-established, a CTA of the chest can be performed to evaluate for pulmonary embolus. 2. Clear lungs without evidence of pneumonia or congestive heart failure. 3. Distal esophageal thickening compatible with the patient's known esophageal cancer, with a stent present. Intraluminal soft tissue material within the stent may represent neoplastic infiltration, debris, or food material. 4. Bilateral renal hypodensities, grossly unchanged since [**2145-10-8**], likely cysts. 5. Colonic diverticulosis with no evidence of acute diverticulitis. Upper endoscopy revealing patent stent Discharge labs: [**2145-11-11**] 06:20AM BLOOD WBC-1.1* RBC-2.72* Hgb-9.3* Hct-26.7* MCV-98 MCH-34.1* MCHC-34.7 RDW-18.0* Plt Ct-47* [**2145-11-11**] 06:20AM BLOOD Gran Ct-968* [**2145-11-11**] 06:20AM BLOOD Glucose-143* UreaN-13 Creat-0.6 Na-134 K-3.8 Cl-99 HCO3-29 AnGap-10 [**2145-11-11**] 06:20AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.4* Brief Hospital Course: # Hypotension and tachycardia - Most likely related to dehydration and electrolyte disturbances from side effects of esophageal cancer treatment. He had significant ventricular ectopy that improved with electrolyte replacement and paroxysmal SVT that improved with uptitration of metoprolol and correction of electrolyte abnormalities.TSH level was also repeated and normal. Cardiology had evaluated pt and agreed with management. . # Stage IV esophageal adenocarcinoma - Patient completed XRT while hospitalized. He will need to continue follow-up with Dr. [**Last Name (STitle) 29514**].Chest CT and EGD showed no evidence of disease progression . # DVT - Pt diagnosed with a DVT on [**5-1**] and since then treated with enoxoparin daily dose. In-spite apparent compliance pt continues to have clinical evidence of a DVT as well as radiological evidence per LENI done on admission. Factor 10a was in lower end of therapeutic range( levels are per [**Hospital1 **]-daily dose).The daily dose was continued during hospitalization an dclinically there was a significant impprovement, therefore compliance at home still remains a question. Dose was adjusted to weight an dincreased to 150 sc daily. . # Pancytopenia - Most likely related to chemotherapy;however,if counts do not recover there might be another underlying process. Parvovirus antibodies and CMV viral load were obtained prior to discharge and will be followed by Dr [**Last Name (STitle) 23509**]. Pt did receive 1 unit PRBCS. He also received plts prior to discharge. Since pt is on lovenox goal of plt count is 50k .On discharge pt still neutropenic but ANC trending up and pt remained afebrile. . # Hypothyroidism - Continued levothyroxine at home dose.TSh checked and within normal range. . # BPH - Finasteride in place of dutasteride per hospital formulary and held terazosin given hypotension. During hospitalization pt had no difficulties urinating. . #Malnutrition/Nausea/Vomiting:An egd was done and showed a patent stent. Pt did have nausea and emesis initiailly, which could have been partly delayed CINV and secondary to radiation. Nausea and vomiting resolved , however , pt continued to have a lack of appetite without any odynophagia or dysphagia. Pt was started on remeron both as an appetite stimulant and for depression. . #Hypomagnesemia:Most likely secondary to carboplatin. Pt was monitored closely and supplemented with daily oral magnesium and IV as needed. Medications on Admission: Atenolol 12.5 mg daily Dutasteride [Avodart] 0.5 mg Capsule Enoxaparin 140 mg subcutaneous daily Levothyroxine 150 mcg daily Omeprazole 20 mg daily Terazosin 5 mg daily Discharge Medications: 1. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 5. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for secretions. 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours: do not give together with levothyroxine. 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. 12. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous once a day. 13. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day: please do not give togather with levothyroxine. Tablet(s) 14. potassium & sodium phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) for 5 days. Discharge Disposition: Extended Care Facility: Roscommon [**Location 1268**] Discharge Diagnosis: Esophageal adenocarcinoma Malnutrition Superior ventricular tachycardia Depression Deep venous thrombosis Pan-cytopenia Hypomagnesemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 40258**], You were admitted with low blood pressure and low electrolytes related to your recent chemotherapy and poor nutrition. You have just completed radiation treatment and may still have diffculty eating and feel weak. We encourage you to try to eat three meals a day with supplementing ensure or at least [**5-27**] ensures a day. We made multiple changes to your medications: - stopped your Atenolol and Terazosin - started metoprolol, Lidocaine patch, remeron, - Followup Instructions: 1. F/U with PCP at rehab. F/U CBC in [**3-25**] days to follow platelet count which should be above 50,000 since pt on lovenox for DVT. F/U electrolytes including magnesium , calcium and phosphate.Please send results of lab tests to pt's oncologist, Dr [**Last Name (STitle) 23509**] #[**Telephone/Fax (1) 72711**]; [**Telephone/Fax (1) 25517**]. 2.Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**] at [**Hospital6 17390**] 1-2 weeks after discharge from rehab Pending results: CMV DNA, parvo virus antibodies

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icd9cm

[ [ [] ] ]

[ "92.29", "45.13" ]

icd9pcs

[ [ [] ] ]

9484, 9540

5411, 7859

288, 329

9719, 9719

3349, 3349

10429, 10984

2623, 2662

8079, 9461

9561, 9698

7885, 8056

9902, 10284

5065, 5388

2677, 3330

10314, 10406

235, 250

357, 1810

3365, 5049

9734, 9878

1832, 2497

2513, 2607

60,303

198,759

54836

Discharge summary

report

Admission Date: [**2169-4-20**] Discharge Date: [**2169-5-1**] Date of Birth: [**2098-7-11**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headaches and Vision Changes Major Surgical or Invasive Procedure: [**2169-4-23**]: transphenoidal resection of Pituitary mass History of Present Illness: [**Known firstname **] [**Known lastname **] is a 70 yo male with PMHx of DM2 and CAD s/p stent placement in [**2156**] and [**2163**] who presented as an OSH transfer after 3 days of occipital headache with accompanying nausea and vomiting, as well as 1 day of double vision and ataxia found to have a pituitary macroadenoma with some displacement of the optic chiasm and hemorrhagic components. Past Medical History: - DM2 - R knee replacement - CAD s/p stents in [**2156**], [**2163**] - HTN - HL - gout Social History: Social Hx: lives alone is independent in all ADLs, retired floor intaller, denies EtOH, tobacco and illicits Family History: Family Hx: father lived to 103 and died of "natural causes", mother died at 98 of "old age" Physical Exam: On Admission: O: T: 100.1 BP: 133/64 HR: 64 R 15 O2Sats 94% on RA Gen: WD/WN, comfortable, NAD. HEENT: drooping R eye, frequently closing one eye at a time, vaseline like ointment in eyes bilaterally with some scleral/corneal erythema bilaterally. 20/50 bilaterally. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-21**] objects at 5 minutes, but only [**12-23**] words at 10 mins Language: Speech fluent with good comprehension and repetition. Naming intact, [**Location (un) 1131**] intact, mild dysarthria with slowed speech. No paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation, although patient has difficulty with vision given erythromycin eye ointment in eyes bilaterally and more formal visual field testing was difficult, but also showed full visual fields to finger wiggling III, IV, VI: R sided incomplete ptosis, mild difficulty with abduction of R eye and is unable to bury the sclera on that side, but otherwise EOMI despite disconjugate gaze (bilateral exotropia) on primary gaze. Pt with diplopia on primary gaze that disappears with covering of one eye or the other. 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 [**3-25**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 * 0 Left 2 2 2 1 0 * R knee replacement Toes mute bilaterally Coordination: normal on finger-nose-finger and rapid alternating movements At Discharge: mild 3rd nerve palsy, otherwise nonfocal Pertinent Results: Admission Labs: [**2169-4-20**] 08:01PM OSMOLAL-278 [**2169-4-20**] 08:01PM FSH-3.8 LH-2.2 PROLACTIN-1.2* TSH-0.30 [**2169-4-20**] 08:01PM T4-7.0 T3-86 [**2169-4-20**] 08:00PM URINE HOURS-RANDOM UREA N-427 CREAT-75 SODIUM-93 POTASSIUM-58 CHLORIDE-144 TOTAL CO2-LESS THAN [**2169-4-20**] 08:00PM URINE OSMOLAL-493 [**2169-4-20**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2169-4-20**] 08:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2169-4-20**] 08:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2169-4-20**] 08:00PM URINE HYALINE-1* [**2169-4-20**] 06:54PM GLUCOSE-198* UREA N-14 CREAT-1.0 SODIUM-130* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-26 ANION GAP-15 [**2169-4-20**] 06:54PM CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-1.6 [**2169-4-20**] 06:54PM WBC-7.3 RBC-4.35* HGB-13.7* HCT-39.0* MCV-90 MCH-31.5 MCHC-35.2* RDW-13.7 [**2169-4-20**] 06:54PM PLT COUNT-129* [**2169-4-19**] CT head /- contrast Intrasellar mass extending to the suprasellar region with possible mass effect and displacement of the optic chiasm. Heterogenous enhancement following contrast administration suggesting a pituitary macroadenoma. Hemorrhagic components cannot be completely excluded but are less obvious on the non-contrast CT than seen on the same day MRI. [**2169-4-21**] ECG Sinus bradycardia. Otherwise, normal tracing. No previous tracing available for comparison. [**2169-4-23**] MRI brain with gad Again a large pituitary mass is identified extending to suprasellar region and compressing the optic chiasm. The mass measures approximately 2 cm in size. The pre-gadolinium signal intensities could not be assessed as on the prior study demonstrated increased signal. The current examination demonstrates no evidence of lateral extension in the region of the cavernous sinuses lateral to the cavernous carotids. No abnormal brain enhancement is seen. There is somewhat prominent frontal sinuses identified. [**2169-4-23**] CT head 1. Foci of air and linear hyperdensities in the sella, likely expected postoperative changes. 2. Soft tissue density coursing along the nasal septum with partial opacification of the sphenoid sinuses, also likely post-operative. 3. No intra- or extra-axial hemorrhage, mass effect, or acute large territorial infarction. [**2169-4-27**] Lower extremity Doppler Ultrasound: Right Peroneal DVT [**2169-4-28**] Non-contrast Head CT at therapeuric PTT Stable, no hemorrhage ** [**2169-5-1**] 04:16AM BLOOD PT-22.5* PTT-71.9* INR(PT)-2.1* [**2169-5-1**] 12:45PM BLOOD Glucose-63* UreaN-26* Creat-1.5* Na-136 K-4.6 Cl-97 HCO3-31 AnGap-13 Brief Hospital Course: He presented to AJH with headaches and on the day of transfer he was found lethargic, with new double vision. MRI showed a 2.2cm tumor in his pituitary. He was newly ataxic as well. Follow up CT head suggested pituitary apoplexy. His outside lab work showed resolving hyponatremia but severe hyperglycemia. Mr. [**Known lastname **] was admitted to [**Hospital1 18**] to an ICU under the care of a medical service. Neurosurgery was consulted as was endocriniology and opthamology. He remained under the care of the MICU service until the day of surgery. He was started on insulin. They felt that a pituitary macroadenoma seems most probable given the 2.1-cm pituitary mass found on imaging with supra-sellar extension. The patient was started on steroid replacement. On [**4-19**] he continued to complain of frontal headache and fullness so he was started on a course of amoxicillin for presumed sinusitis. On [**4-20**] a conjunctival swab was performed due to drainage and it grew Group A strep. He was started on gentamicin drops for this (12 day course completed). Opthomology did visual field testing on [**2169-4-21**]. They found significant number of fixation losses, right eye greater than left eye. There was no definite temporal visual field loss noted in either eye. Vision was 20/30. Cardiology found him to be at low cardiac risk for surgery. He proceeded to the OR on [**2169-4-23**] with Dr. [**Last Name (STitle) **] for TSS resection of pituitary mass. Post-operatively his hydrocortisone dose was changed from 50 from 100, q 6. CT head showed expected post op changes. His diet was advanced. on POD 1, his nasal packing was removed. He was monitored at the ICU level care for concern for SIADH and low urine outputs. He was started postoperatively on Heparin SC TID on [**4-23**] for DVT prophylaxis. Hyperglycemia was an issue on [**4-25**] and he remained in the unit. He was well controlled on [**4-26**] and was transferred to the floor. On [**4-27**] he underwent screening LENIs that demonstrated a Right Peroneal DVT and the patient was started on a Heparin drip at 700 units/hour without bolus for treatment for a bridge to coumadin. Coumadin was started QHS on [**4-27**] with a dose of 7.5mg. Coags were followed every 6 hours while he ws on Heparin gtt with a PTT goal of 60-80 and INR goal of [**12-23**]. On [**2169-4-28**] when PTT was within therapeutic range a repeat non-contrast Head CT was performed which was stable without evidence of hemorrhage. His PTT elevated to 100 with an INR of 1.9 on the morning of [**4-28**] and thus the heparin drip was held for an hour and restarted at a lower dose of 500 units/hour. Overnight his PTT and INR dropped significantly and his coumadin and heparin gtt were adjusted to 750u/hr and 7.5mg. On [**4-29**], he was being screened for rehab. His INR on [**4-29**] was 1.2 and increased to 1.8 on [**4-30**]. On [**5-1**], patient remained stable, INR at 2.1. He was noted to have a mild nose bleed so his heparin gtt was discontinued and patient was safe to discharge home with PT. It was also noted that his creatinine was 1.5 so he was given an IVF bolus. Per endocrine's recommendation his metformin was discontinued. The patient's PCP office was [**Name (NI) 653**] and it was recommended that he follow up on Wednesday to have his INR and Cr checked (appt was made for patient). Medications on Admission: 1. Allopurinol 300 mg PO daily 2. Amlodipine 10 mg PO daily 3. Atenolol 50 mg PO daily 4. Simvastatin 80 mg PO daily 5. Benazepril 40 mg PO QAM 6. ASA 81 mg PO daily 7. Iron supplement 8. Flaxseed 9. Fish oil Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. benazepril 10 mg Tablet Sig: Four (4) Tablet PO qAM (). 5. gentamicin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q4H (every 4 hours) for 5 days. Disp:*5 ml* Refills:*0* 6. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**11-21**] Drops Ophthalmic Q2H (every 2 hours) as needed for dry eyes. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 11. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Serum Sodium, Potassium, BUN, Creat, Ca, Mg, Phos Please fax results to [**Hospital1 18**] Endocrinology at [**Telephone/Fax (1) 3541**] Diagnosis: Pitutary Adenoma 17. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pituitary adenoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: - You need your labs drawn in 1 week on Wednesday [**5-3**]. You have been given a prescription for this. Results should be faxed to the Endocrinology department at: [**Telephone/Fax (1) 3541**]. ?????? 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. ?????? Continue Sinus Precautions for an additional two weeks. This means, no use of straws, forceful blowing of your nose, or use of your incentive spirometer. ?????? If you have been discharged on Prednisone, take it daily as prescribed. If on any day, you are ill, take the prednisone as you have been instructed by the endocrine team. ?????? If you are required to take Prednisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Prednisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? It is normal for feel nasal fullness for a few days after surgery, but if you begin to experience drainage or salty taste at the back of your throat, that resembles a ??????dripping?????? sensation, or persistent, clear fluid that drains from your nose that was not present when you were sent home, please call. ?????? Fever greater than or equal to 101?????? F. ?????? If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: Follow-Up [**Telephone/Fax (1) **] Instructions - You need your labs drawn on [**5-3**]. You have been given a prescription for this. Results should be faxed to the Endocrinology department at: [**Telephone/Fax (1) 3541**] ??????Please call ([**Telephone/Fax (1) 88**] to schedule an [**Telephone/Fax (1) 648**] with your surgeon, Dr. [**Last Name (STitle) **] to be seen in two months. You will need an MRI with and without contrast at that time. ??????You have an [**Last Name (STitle) 648**] with your endocrinologist: [**2169-5-8**] 04:40p HE/[**Doctor Last Name **],ENDOCRINE SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] ENDOCRINOLOGY (SB) Please call ([**Telephone/Fax (1) 9072**] if you have questions. ??????You have an [**Telephone/Fax (1) 648**] for Formal vision testing: on [**2169-5-23**] at 11:00a with Dr. [**Last Name (STitle) **] in the SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HMFP- EYE. Please call ([**Telephone/Fax (1) 5120**] if you have questions. The Ophthalmology department is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] building, [**Location (un) 442**]. ?????? You have an appt with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54611**] on Wednesday [**5-3**] at 1PM to have your blood checked (INR and BUN/creatinine & endocrine labs-see script) and coumadin dose adjusted. Please do not miss [**First Name (Titles) **] [**Last Name (Titles) 648**]. Completed by:[**2169-5-1**]

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icd9cm

[ [ [] ] ]

[ "07.62", "22.64" ]

icd9pcs

[ [ [] ] ]

11382, 11388

6043, 9421

336, 397

11450, 11450

3330, 3330

13972, 15491

1079, 1173

9681, 11359

11409, 11429

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23,762

105,013

27843

Discharge summary

report

Admission Date: [**2101-9-21**] Discharge Date: [**2101-9-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18141**] Chief Complaint: fever and hypotension Major Surgical or Invasive Procedure: Insertion of peripherally inserted central catheter Revision of right nephrostomy tube History of Present Illness: This is an 86 year-old female with a history of Alzheimer's dementia, recurrent urinary tract infections and urosepsis in the setting of bilateral obstructing nephrolithiasis, S/P right nephrostomy tube placement who presented from nursing home with fever and hypotension. At baseline, she is non-verbal, G-tube dependent and unable to perform ADLs. Ms. [**Known lastname **] was previously admitted on [**5-10**] with urosepsis (E. coli & Strep milleri). She had bilateral obstructing renal stones requiring percutaneous nephrostomy tube on the right and also found to have a uterosigmoid fistula. She was treated with sepsis protocol, 1 week of steroids and 2 week antibiotic course. The pt's daughter notes that about 4 days prior to admission, her urine color has changed and she has been looking around the room less. She was started on ciprofloxacin and metronidazole 4 days PTA. In the ED temperature was 102.8, BP 66/48, HR 104. Lacatate was 6.0. After discussion with family regarding code status, she was started on the sepsis protocol, receiving 2L of NS, and started on piperacillin/tazobactam, vancomycin, and metronidazole as well as dopamine. On arrival to MICU, BP 97/44, HR 92, 99% on 100% NRB. Pt is non-conversant and so the daughter states that she would want the pt intubated if this was thought to be related to a reversible cause. . While in the MICU, patient was found to have mild right and moderate left hydronephrosis on renal ultrasound. She subsequently went to interventional radiology, where right nephrostomy tube was changed, and no new left nephrostomy inserted due to resolution of left hydronephrosis. She was initially started on broad spectrum antibiotics and pressors but was eventually stabilized and transferred on piperacillin/Tazobactam Past Medical History: 1. Alzheimers 2. Aspiration pneumonia 3. UTI 4. Uterosigmoid fistula 5. B/L obstructing renal stones s/p right nephrostomy tube 6. GERD 7. Osteoarthritis 8. Depression 9. vitamin B12 deficiency 10. hyperlipidemia 11. TB treated 50 years ago 12. DVTs in superficial veins [**5-10**] and [**6-9**] (superfical femoral and distal cephalic), on warfarin 13. apical cardiac thrombus Social History: Lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Daughter very involved in her care. Family History: non-contributory Physical Exam: T 96.9 HR 100 BP 74/34 RR 20 O2 sat 99% on 100% NRB, on 10 mcg/kg/min dopamine Gen: somnolent, responds to painful stimuli, but otherwise not responding. HEENT: PERRL. Neck: No LAD or thyromegly. CV: regular and tachycardic with no m/r/g Lungs: Crackles at bases bilaterally. Abd: soft, NT, ND active BS, no hepatosplenomegly, J tube in place, no drainage ext: warm and sweaty, with 2+ DP pulses, No clubbing, cyanosis or edema. neuro: increased tone in neck and arms with decreased tone in legs. Does not follow commands. Pertinent Results: Labs on admission: WBC 47.9 (90% neutrophils, 3% bands, 2% lymphs), Hgb 10.9, Hct 31.2, Plt 300 PT 54.3, PTT 49.7, INR 6.5 BMP remarkable for creatinine 3.1, BUN 61, glucose 116, potassium 5.8, bicarb 19, lactate 6 . TTE [**2101-6-9**]: Overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent) secondary to extensive apical akinesis. A moderate sized thrombus is seen in the apex of the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. Trivial MR, mod [**Last Name (un) 6879**], small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2101-5-31**], an apical left ventricular thrombus is now evident. . Renal ultrasound ([**9-21**]): 1. Right-sided nephrostomy tube with decompression of the right collecting system, with only mild upper pole hydronephrosis seen. 2. New moderate-to-severe left-sided hydronephrosis. Given patient's history of sepsis, this is concerning for an obstructing nephropathy. Discussed with Dr. [**Last Name (STitle) 6812**] following completion of the study. . CXR ([**9-21**]): 1. Fluid overload. 2. Indistinctness of the left hemidiaphragm, which may represent atelectasis and/or consolidation. . Nephrostomy check ([**9-23**]): Uneventful change of right percutaneous pigtail nephrostomy catheter. No hydronephrosis. Persistent obstruction of the distal right ureter. Interval resolution of left hydronephrosis, obviating the need for left percutaneous nephrostomy at this time. . PICC line placement ([**9-26**]): Successful placement of a 5-French double lumen 34 cm PICC by way of the right basilic vein with the tip in the distal SVC. The line is ready for use. . ECHO ([**9-27**]): 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is mildly depressed. Basal inferior hypokinesis is present. 3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 5. There is a small pericardial effusion with fibrin/thrombus on the surface of the heart. 6. Compared to prior study on [**2101-6-9**], the LV apical thrombus is no longer seen and the PA pressure is now normal. LV function may have improved. . Blood cultures: 10/18 1/4 bottles E coli sensitive to ceftriaxone & pip/tazo [**9-22**] negative . CVC Catheter tip no growth . Stool negative for C diff X 4 . Urine [**9-21**]: > 100,000 organisms/mL E coli sensitive to pip/tazo & ceftriaxone [**9-23**]: > 100,000 organisms/mL yeast . Labs at discharge: WBC 11.4, Hgb 11.1, Hct 32.4, Plt 307 PT 19.5, PTT 51.1, INR 1.9 BMP remarkable for creatinine 0.6, BUN 16, glucose 112, bicarb 30, sodium 136 lactate returned to [**Location 213**] 1.1 on [**9-21**] cortisol stim test within normal limits while in ICU Brief Hospital Course: Ms. [**Known lastname **] is a 87 year old female with a history of Alzheimer's and prior urosepsis who presented with sepsis from a urinary source once again and who is now status post right nephrostomy tube & on antibiotics. . # Sepsis: The patient's presentation was most consistent with urosepsis. Her right nephrostomy tube was changed by IR on [**9-23**]. Left hydronephrosis found on initial ultrasound was resolved by the time of IR intervention, and a left nephrostomy tube was not needed. The patient was initially in the MICU but was transferred on PIP/TAZO, having received 5 days, on [**9-25**]. Her blood cultures as well as urine cultures show E. Coli sensitive to PIP/TAZO and ceftriaxone. - On arrival to the floor, her antibiotic was changed to ceftriaxone 1g IV q24 since strain is susceptible on culture data. Ceftriaxone was started on [**9-25**], and the plan is to continue the antibiotic until [**10-4**]. - The patient had a PICC line placed without problem on [**9-26**] for IV antibiotics. - Her white count has steadily decreased and she has been afebrile for several days. - The patient should have an outpatient renal ultrasound in a few weeks in order to reassess the functionality of the nephrostomy tube and to ensure that hydronephrosis has not reaccumulated on the left side. . # Leukocytosis: The patient's white count continues to decrease, and the patient continues to be afebrile. A slight increase in her white blood cell count two days ago is likely related to blockage of nephrostomy tube (nurse [**First Name (Titles) **] [**Last Name (Titles) 67863**] in closed position and corrected this). Also, many white blood cells still in urine (nephrostomy < regular UA). - She is on ceftriaxone to continue until [**10-4**] as above. - As patient is afebrile, will not treat for yeast in the urine at this point. . # H/o DVTs and apical ventricular thrombus on last ECHO: The patient was on warfarin prior to admission but this was held temporarily due to high INR on admission. Her warfarin was restarted on the floor, and her INR is now 1.9. - There is no longer a thrombus seen on ECHO which was done on [**9-27**]. Therefore, the patient is to stop anticoagulation on [**10-5**] per Dr. [**First Name (STitle) **]. - Since the patient's INR is now 1.9, we will discontinue her heparin today. She will continue on coumadin 5 mg QHS with INR monitoring at her nursing home. - Her goal INR is 1.5-2.5. . #) FEN: The patient initially presented with hypernatremia, which has resolved. It is likely that her hypernatremia is related to dehydration and resolved once her free water deficit was repleted. - The patient should continue on tube feeds with free water replacement, which she is tolerating well. Changed on [**9-27**] to Replete with fiber with goal 55 cc/hour and decreased frequency of free water boluses (150 cc every 6 hours). . # Uterosigmoid Fistula: The patient was previously evaluated by gyn/surgery and thought to be not a candidate for surgery. . # ARF: The patient's acute renal failure seems to have resolved with stabilization of blood pressure and resolution of sepsis. Her creatinine is now back to normal. . # Code: After extensive discussion with patient's daughter, patient is DNR/DNI. . # comm: The patient's daughter is her HCP. - Daughter [**Name (NI) **]: [**Telephone/Fax (1) 67860**] OR [**Telephone/Fax (1) 67861**]. - Grandson [**Name (NI) **]: [**Telephone/Fax (1) 67862**] Medications on Admission: ASA 325mg PO Lansoprazole 30mg B12 1000mcg q 3 months Cipro 250mg PO Flagyl 500mg PO TID Coumadin 5mg PO MVI Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 150 mg/15 mL Liquid [**Telephone/Fax (1) **]: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day) as needed. 3. Warfarin 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at bedtime). 4. Albuterol Sulfate 0.083 % Solution [**Age over 90 **]: One (1) treatment Inhalation Q6H (every 6 hours). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed. 7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 8. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback [**Last Name (STitle) **]: One (1) g Intravenous Q24H (every 24 hours) for 6 days: Until [**2101-10-4**]. Disp:*QS solution* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Urosepsis now status post revision of right nephrostomy tube Discharge Condition: Hemodynamically stable and afebrile on room air Discharge Instructions: Please take all medications as prescribed. Please call your doctor or return to the emergency room should you experience any of the following symptoms: fever > 100.5, chills, abdominal pain or discomfort, difficulty breathing, decline in mental status, or any other concerning symptoms. Followup Instructions: You should see Dr. [**First Name (STitle) **] within the next one week. Her clinic number is [**Telephone/Fax (1) 18145**]. Completed by:[**2101-9-28**]

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icd9cm

[ [ [] ] ]

[ "96.6", "99.07", "99.04", "38.93", "55.93" ]

icd9pcs

[ [ [] ] ]

11136, 11209

6385, 9835

285, 373

11314, 11363

3311, 3316

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224, 247

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18,353

163,115

52583

Discharge summary

report

Admission Date: [**2167-1-8**] Discharge Date: [**2167-1-30**] Date of Birth: [**2101-6-19**] Sex: M Service: MEDICINE Allergies: Benadryl / Morphine / Ativan / Compazine / Dilaudid Attending:[**First Name3 (LF) 1674**] Chief Complaint: Chronic pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 65M w/ ESRD on HD, CAD, CHF (EF 20%), s/p recent anterior cervical discectomy, and recent hospitalization ([**Date range (1) 108570**]) for shoulder pain, with recurrent pain. Patient has chronic pain for which he takes oxycodone 10mg q4h. Pain got worse night prior to admission with no unusual activity or event. No relief with oxycodone. Pt unable to tolerate Morphine due to delirium and had hypotensive response to Dilaudid. Pupils pinpoint per report following 10 mg Oxycodone. Pt somnolent but complains of severe pain when woken. Pt came to the ED for pain management. Denies any trauma, change in activity level, fever, chills, n/v. No CP or SOB. Pain [**11-12**], ache going down both arms, back and shoulders. Pain is worse on turning his neck and moving his arms. Cervical collar helpful. Pt denies leg weakness, bowel incontinence. Past Medical History: 1. Coronary artery disease: MI in [**2155**], NSTEMI in [**2160**], s/p RCA and LCx stenting ([**10-7**]) 2. CHF: EF 20% 3. Diabetes Mellitus II: > 20 years, c/b nephropathy 4. Hypertension 5. ESRD on HD: MWF schedule, R AV fistula 6. PVD: S/p R PFA to BK [**Doctor Last Name **] bypass graft with vein, s/p L 1-5th toe and 1-3rd toe amputation, s/p left CFA to AK [**Doctor Last Name **] with PTFE 7. Hypothyroidism 8. Atrial fibrillation 9. COPD- by report, last PFTs here in [**2160**] w/ nl FEV1 and FEV1/FVC 10. Hepatitis C- last VL 623,000 in [**2160**] 11. Chronic pancreatitis 12. Peptic ulcer disease 13. Right perinephric hematoma; status post embolization 14. Obstructive sleep apnea on CPAP 15. Ruptured right groin abscess; recurrent right groin abscess [**12-6**] 16. Status post L inguinal hernia repair 17. Status post umbilical hernia repair Social History: Lives in [**Location 686**] with wife. [**Name (NI) 1139**]: 1 ppd x 60 yrs. quit 3 months ago. EtOH: denies Illicits: h/o narcotic abuse. Should avoid IV pain medications, especially dilaudid, morphine. Family History: Not assessed Physical Exam: Vitals- T 97 BP 130/80 HR 62 RR 20 O2Sat 96 General-Somnolent but arousable. Falling asleep mid-sentence. Pale and looks older than his stated age. HEENT-Pinpoint pupils. Pyterigium OD and OS Neck-In collar. No pain on palpation. Pulm-CTAB, no wheezes or crackles CV-RRR, nl S1 and S2. 2/6 systolic murmur heard best on right sternal border Abd-Soft, non-tender, Nl BS. + Scrotal hernia and umbilical hernia, reducible. Extrem-Hands and feel cool to touch. Pulses: DP and radial pulses undetectable. Significant pigmentation of LEs below the knee with several scars. Neuro-Exam limited patient's pain and somnolence. Pt is arousable, but falls asleep while talking. Pinpoint pupils. UE: 4-/5 bilaterally. Sensation to light touch intact. Amputation of 4th digit on the R hand. Radial pulses undectable w/o dopplers. Reflex: L biceps:1+. R not checked b/c of AV dialysis fistula. Surgical scar and graft palpable under the R shoulder. LE: 5/5 strength illiopoas bilaterally. Femoral Pulses undectable on R, 1+ on L. DP pulses undetectable bilaterally. Several surgical scars on L leg. All ten digits amputated bilaterally. Reflexes not detectable bilaterally. Skin below the knees pignmented and has several scars. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to touch below the knee. Pertinent Results: ADMISSION LABS [**2167-1-8**] 01:51PM GLUCOSE-105 UREA N-37* CREAT-4.9* SODIUM-141 POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-35* ANION GAP-17 [**2167-1-8**] 01:51PM CRP-25.0* [**2167-1-8**] 12:20PM GLUCOSE-98 UREA N-37* CREAT-4.7*# SODIUM-137 POTASSIUM-7.0* CHLORIDE-92* TOTAL CO2-34* ANION GAP-18 [**2167-1-8**] 12:20PM estGFR-Using this [**2167-1-8**] 12:20PM WBC-10.2# RBC-4.05* HGB-12.2* HCT-39.3* MCV-97 MCH-30.0 MCHC-31.0 RDW-16.8* [**2167-1-8**] 12:20PM PLT COUNT-230 [**2167-1-8**] 12:20PM SED RATE-2 DISCHARGE LABS [**2167-1-30**] 04:19AM BLOOD WBC-8.7 RBC-3.06* Hgb-9.9* Hct-31.0* MCV-101* MCH-32.5* MCHC-32.0 RDW-18.5* Plt Ct-314 [**2167-1-30**] 04:19AM BLOOD Plt Ct-314 [**2167-1-30**] 04:19AM BLOOD Glucose-69* UreaN-38* Creat-5.9*# Na-137 K-5.0 Cl-99 HCO3-27 AnGap-16 [**2167-1-30**] 04:19AM BLOOD [**Month/Day/Year 9409**]-7.8* Phos-5.0* Mg-1.9 EKG-NSR: Sinus rhythm. Left atrial abnormality. Frequent atrial ectopy. Left anterior fascicular block. Late precordial R wave transition. Non-specific ST-T wave changes. Compared to the prior tracing of [**2167-1-8**] no diagnostic interim change. C-spine xray: Extensive destructive changes centered at the C4 level and involving the contiguous endplates, with accompanying marked angular kyphosis and retrolisthesis, unchanged in extent since the [**12-19**] study, with interval increase in the already marked prevertebral soft tissue abnormality. These findings correspond to the apparently known listeria infection with osteomyelitis, and interval progression of, particularly the soft tissue component of this process would be best assessed by contrast-enhanced MR examination, when feasible. CT C-SPINE W/O CONTRAST [**2167-1-27**] 9:06 AM The patient is post anterior spinal fusion with 2 upper screws in the body of C3 and 2 lower screws in the body of C6 with anterior plate, and bone graft interposed between C3-C6.The bone graft is somewhat placed toward the left side of the plate. The right screw in the C6 body is in close proximity to the posterior cortex but there is no cortical break or extension into the spinal canal. Osteolytic destruction of parts of the C3-4 and C4- C5 disc/endplates is again noted with soft tissue/disc material extending into the spinal causing idnentation on the thecal sac. However, accurate assessment is limited on the present CT study. Brief Hospital Course: Patient is a 65 yr old man with DM2, CAD, OSA, ESRD on HD, s/p anterior cervical discectomy and fusion ([**12-11**]), with recurrent bilateral shoulder pain. On [**1-26**], the patient [**Month/Year (2) 1834**] a C4,5 corpectomy, anterior arthrodesis C3-C4, C4-C5, and C5-C6; anterior instrumentation C3-C6 and structural allograft with Dr. [**Last Name (STitle) 548**]. The patient was transferred to the SICU because he was intubated postoperatively due to his extensive medical history. Postoperative CT of the C-spine on [**Last Name (STitle) **] 1 showed post operative changes and opacification of the right lung apex. The patient was weaned off the ventilator after the CT scan on [**Last Name (STitle) **] 1. The patient received hemodialysis on [**Last Name (STitle) **] 1 with a resultant drop in blood pressure. Normal saline was given for a total of 900cc with a rebound in systolic blood pressure to 120s. Hemodialysis was completed and the patient was started on a phenylephrine drip to keep his SBP greater than 90mmHg. He was weaned off of the drip at 5am on [**Last Name (STitle) **] 2. He was transferred to the Medicine Service on [**Last Name (STitle) **] 2 prior to receiving his hemodialysis. While on the medicine service, the patient was stable, and his drain was removed on [**Last Name (STitle) **]#3, and sutures removed without a problem on [**Name2 (NI) **]#4. The patient was discharged off both his aspirin and [**Name2 (NI) 4532**] with close follow up at neurosurgery clinic on [**2167-2-4**] for follow up for his second surgery. After completion of his surgery, he will follow up with the neurosurgeons on when to restart his aspirin and [**Date Range 4532**] for stroke prevention. Shoulder pain: There was no significant change in neurological exam. Pain mostly like chronic because of destructive spondyloarthropathy--an amyloid deposition disease of cervical spine. (Final EM is pending.) However, it was important to rule out worsening cord compression or other acute process. Neurosurgery was consulted and no changes on neurological exam were noted. Repeat MRI was done, which suggested T2 hyperintensity in C4-C5, which was attributed motion artifact by Neurosurgery. Patient was set up for follow up appointment with Neurosurgery. He was in the C-collar throughout his stay. Dr. [**Last Name (STitle) 1007**] was consulted for 2nd opinion as requested by family. Patient was initially somnolent during the hospital stay and fell asleep while talking. He was started on oxycodone 5 mg q6h (home dose 5-10mg q6h) and ketoralac. He was very sensitive to narcotics. Pain service was consulted for better management of pain without narcotic use. He was started on provigil, tizanidine, ibuprofen and lidocaine patch. Dose of neurontin was increased to 200 mg TID (from 100 TID.) His mental status was continously monitored and narcotics dose was decreased to 2.5mg q6h. ABG suggested chronic carbon dioxide retention suggesting that OSA was contributing to patient's somnolence. Patient was fitted with CPAP and encouraged to wear it every night. His daytime somnolance significantly improved. He continued to complain of pain. However, he appeared comfortable, eating and walking/interacting on the floor and was easily distractable from his pain. On discharge, the patient's pain was controlled on his lower oxycodone dose and was interactive and appropriate. ESRD: Patient is on hemodialysis. He was kept on his home schedule and the renal team followed him. He was continued on cinacalcet and sevelamer and started on nephrocaps. CAD: He was stable from cardiovascular standpoint. Patient has severe PVD at baseline. EKG was unchanged. He was continued on Beta-blocker and statin. He was discharged off his [**Last Name (STitle) 4532**] and aspirin for now, as above. CHF: Patient was stable. He was continued on lisinopril and Beta-blocker. DM2: He was on insulin sliding scale and diabetic diet. Medications on Admission: 1. Albuterol Q6H prn 2. Amiodarone 100 mg DAILY 3. Citalopram 20 mg DAILY 4. Insulin Lispro sliding scale 5. Atorvastatin 10 mg DAILY 6. Lisinopril 2.5 mg DAILY 7. Clopidogrel 75 mg DAILY 8. Metoclopramide 5 mg TID 9. Metoprolol Succinate 25 mg DAILY 10. Levothyroxine 50 mcg DAILY 11. Vancomycin with HD, completed course [**2166-12-31**]. 12. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO daily 13. Colace 100 mg [**Hospital1 **] 14. Pantoprazole 40 mg Q24H 15. Acetaminophen 650 mg Q6H prn 16. Ibuprofen 400 mg PO Q8H 17. Cinacalcet 60 mg DAILY 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H prn 19. Sevelamer 1600 mg TID W/MEALS 20. Gabapentin 100 mg PO TID Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 5. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [**Hospital1 **]:*60 Tablet(s)* Refills:*0* 6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). [**Hospital1 **]:*90 Tablet(s)* Refills:*1* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Hospital1 **]:*60 Capsule(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). [**Hospital1 **]:*30 capsules* Refills:*0* 11. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Hospital1 **]:*60 Tablet(s)* Refills:*0* 12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). [**Hospital1 **]:*90 Capsule(s)* Refills:*1* 13. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. [**Hospital1 **]:*1 inhaler* Refills:*0* 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). [**Hospital1 **]:*30 Adhesive Patch, Medicated(s)* Refills:*0* 17. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 18. Insulin Lispro 100 unit/mL Solution Sig: Administer subcutaneously Subcutaneous ASDIR (AS DIRECTED): per sliding scale. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: 1. Cervical inflammatory process NOS. 2. Cervical myelopathy. 3. s/p anterior C4-5 corpectomy and fusion Secondary: 1. Coronary artery disease s/p multiple MI. 2. Chronic Systolic heart failure 3. Diabetes Mellitus type I. 4. Hypertension. 5. Chronic kidney disease stage V on HD 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin. 14. Peripheral [**Location (un) 1106**] disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. Atrial fibrillation - not anticoagulated due to bleeding. Discharge Condition: Stable Discharge Instructions: You were admitted because of chronic shoulder and arm pain. You were evaluated by Neurosurgery service who feel your symptoms and exam are stable. You were followed by the Renal service. You were also seen by the Chronic Pain Service to help with management of pain. They agree that you are very sensitive to narcotic medications like oxycodone, and taking too much of them can be dangerous to your breathing, and even life-threatening. We suggest decreasing your dose of oxycodone to 2.5mg (half a 5mg tablet), and taking it every 6 hours. We have also increased your Neurontin and added a medication called tizanidine to help with the pain. You [**Doctor Last Name 1834**] anterior cervical spine fusion by Neurosurgery. You will need to follow up with Neurosurgery for planning for posterior spinal fusion. Please temporarily do not take two of your home medications: [**Doctor Last Name 4532**] and aspirin for now, as you just had surgery. Please follow up with your neurosurgeon and primary care provider regarding when to restart these two medications. . You must wear your cervical collar at all times. . Please take all of your medications as prescribed. You were given a prescription for a limited amount of oxycodone. It is extremely important that you take this as directed only. You will need to speak to your primary care doctor if you need more oxycodone. . If you experience arm or leg weakness, difficulty breathing, acute worsening of pain, fever, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Neurosurgery: Dr. [**Last Name (STitle) 548**]. Date/Time: [**2167-2-4**] at 11:15 am. [**Hospital Unit Name **]. Phone: ([**Telephone/Fax (1) 56734**]. At this appointment, please follow up on your surgical date and also when to restart your aspirin and [**Telephone/Fax (1) 4532**] medications. 2) Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) 449**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**], to schedule a follow up appointment within 1-2 weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]

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icd9cm

[ [ [] ] ]

[ "81.02", "80.99", "93.90", "38.93", "77.77", "39.95", "81.62" ]

icd9pcs

[ [ [] ] ]

13035, 13092

6072, 10025

324, 331

14111, 14120

3686, 6049

15712, 16369

2339, 2353

10737, 13012

13113, 14090

10051, 10714

14144, 15001

2368, 3667

15019, 15689

272, 286

359, 1215

1237, 2101

2117, 2323

2,979

164,949

52385

Discharge summary

report

Admission Date: [**2186-4-2**] Discharge Date: [**2186-4-15**] Date of Birth: [**2126-10-12**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 57490**] Chief Complaint: body twitching and change in mental status Major Surgical or Invasive Procedure: PICC line MRI MR Spectroscopy History of Present Illness: Pt is a 59 year old male with pancreatic cancer diagnosed last [**Month (only) 359**], s/p Whipple's in [**2185-12-12**], who presents with90 minutes of R arm and leg twitching. Pt has been a bit fatigued since his chemotherapy was started, but had no seizure-like activity prior to yesterday, when his brother noted that his R hand would shake intermittently. He didn't make much of it, however, particularly as the pt's mental status seemed baseline. This afternoon, the patient was at home and suddenly developed diffuse R body rhythmic jerking. He seemed lucid to his brother but was unable to produce speech, although he seemed to follow simple commands. No LOC or loss of continence, no tongue biting. He was brought to [**Hospital1 18**] for further evaluation. Of note, his brother has noticed that over the past 2-3 weeks the patient has been more forgetful and overall less "sharp," often forgetting words, having trouble naming simple objects and often losing his train of thought. These changes were somewhat ignored b/c they were thought ot be due to the chemotherapy. Overall, otherwise, pt has been relatively well with no intercurrent infections or illness. Past Medical History: HTN PTSD depression plantar warts genital herpes GERD duodenal ulcer H pylori negative Social History: No tobacco now or in past. Drinks about [**5-16**] glasses of wine per week. No recreational drugs. Lives with his brother. Retired at this point for medical reasons, particularly PTSD (served in [**Country 3992**]). Worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] SW in the past. Family History: M died of colon Ca at 55y/o B died of pancreatic Ca at 40y/o Physical Exam: T afebrile, BP 115/60, HR 114, RR 19 O2 99 room air. Initial exam performed while patient having rhythmic jerking, likley partial seizures: at that time he was hypertonic, shaking his R upper and bilateral lower extremities, following commands but not producing speech. Repeat exam performed after ativan and dilantin given: HEENT thin, somewhat ill appearing male. Neck Increased tone overall in neck/shoulders, but neck supple with no pain with flexion/extension, no thyromegaly, no [**Doctor First Name **], no bruits Chest CTA B CVS RRR w/ 2/6 SEM at LSB. ABD soft, NTND, + BS. surgery site c/d/i. EXT no C/C/E, distal pulses full, no rashes or petechiae Neuro MS: awake, does not produce speech, follows simple commands but only intermittently. makes poor eye contact. responds to name. Able to show thumbs up, squeeze fingers, gaze horizontally bilaterally to command but does not follow many commands and unclear if he understands all fo them. CN: I-- not tested; II,III-- PERRLA, VFF by confrontation; III,IV,VI- EOMI w/o nystagmus, no ptosis; V--intact corneals, VII-- face symmetric without weakness; VIII--hears finger rub bilaterally Motor: exam limited by pt compliance and level of understanding. decreased bulk, increased tone throughout, no tremor, rigidity or bradykinesia.. Pt moves all four extremities equally antigravity, would not follow commands for strength testing except for grip, which is [**6-15**] bilaterally. Refl: |[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe | L | 2 | 2 | 2 | 2 | 2 | withdraws | R | 2 | 2 | 2 | 2 | 2 | dn | [**Last Name (un) **]: localizes to pinch in all 4 extremities. Pertinent Results: [**2186-4-14**] 05:55AM BLOOD WBC-7.8 RBC-3.24* Hgb-9.1* Hct-27.6* MCV-85 MCH-28.3 MCHC-33.2 RDW-17.9* Plt Ct-361 [**2186-4-6**] 05:50AM BLOOD Neuts-60.2 Lymphs-35.6 Monos-4.0 Eos-0 Baso-0.2 [**2186-4-6**] 05:50AM BLOOD Anisocy-1+ Microcy-1+ [**2186-4-1**] 09:42PM BLOOD WBC-6.7 RBC-3.89* Hgb-10.9* Hct-32.1* MCV-83 MCH-28.0 MCHC-33.9 RDW-15.4 Plt Ct-301 [**2186-4-11**] 06:00AM BLOOD PT-11.9 PTT-19.9* INR(PT)-0.9 [**2186-4-13**] 11:07AM BLOOD Ret Aut-3.7* [**2186-4-14**] 05:55AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-136 K-3.9 Cl-103 HCO3-27 AnGap-10 [**2186-4-1**] 09:42PM BLOOD Glucose-105 UreaN-14 Creat-0.7 Na-134 K-4.3 Cl-98 HCO3-24 AnGap-16 [**2186-4-13**] 06:54AM BLOOD ALT-44* AST-27 AlkPhos-90 Amylase-41 TotBili-0.2 [**2186-4-12**] 09:40AM BLOOD ALT-48* AST-18 AlkPhos-110 Amylase-169* TotBili-0.2 [**2186-4-13**] 06:54AM BLOOD Lipase-63* [**2186-4-12**] 09:40AM BLOOD Lipase-183* [**2186-4-3**] 04:37AM BLOOD CK-MB-2 cTropnT-<0.01 [**2186-4-14**] 05:55AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 [**2186-4-13**] 11:07AM BLOOD calTIBC-270 Ferritn-193 TRF-208 [**2186-4-1**] 10:15PM BLOOD Ammonia-25 [**2186-4-10**] 09:12AM BLOOD Vanco-10.4* MRI [**4-2**] Left frontal enhancing mass with surrounding edema. The differential diagnosis is discussed above and includes malignant glioma, primitive neuroectodermal tumor, lymphoma, and less likely, encephalitis. The growth pattern is not typical of a metastasis TRANS ESOPHAGEAL ECHO Mildly to moderately thickened mitral valve with moderate mitral regurgitation and probable vegetation. No abscess seen. MR SPECT There is no change in the enhancing infiltrating mass in the left frontal cortex, with surrounding vasogenic edema. There are no new mass lesions. Although the full multivoxel spectroscopy results are not available, the single- voxel spectroscopy results demonstrate a decreased NAA peak, but elevated choline, lactate/lipid, and myoinositol peaks suggestive of a malignant tumor CT ABD/PELVIS 1) Trace ascites. 2) Stable appearance of upper abdomen with no evidence of recurrent disease. 3) Stable peripancreatic fat stranding and small lymph nodes. Brief Hospital Course: 59 year old male with pancreatic cancer, presents in with right sided arm and leg twitching c/w with partial status. Found to have left frontal lobe mass. He was initially admitted to the ICU for ativan and EEG monitoring. 1. Neuro: He was initially given ativan and loaded with dilantin for seizure control. He was started on IV decadron, 10mg IV, then 6mg q 4h. His seizures became less frequent and resolved completely by hospital day #3. He was transfered to the neurology floor on [**4-5**] where he was started on Keppra. He has slowly been transitioned from dilantin to Keppra without recurrence of his seizures. At time of discharge, his dilantin was tapered to 100mg qd which he will continue for two days, then discontinue. He will continue on Keppra 1500mg [**Hospital1 **]. His steroids were also slowly tapered of the course of his admission. He was on Decadron, which is currently 6mg po q 6 hours. Will taper to 6mg po q 8h on discharge. Differential diagnosis of left frontal mass included metastasis, primary brain tumor, infection or stroke. Imaging seems most consistent with a primary CNS lesion such as glioma, PNET, or lymphoma. MRS [**Last Name (STitle) **] done to better evaluate etiology of this lesion. MRS [**Last Name (STitle) **] [**Name (STitle) 23765**] with tumor. The patient refused LP to look for malignant cells or infectious etiologies. He was evaluated by neuro-oncology and neurosurgery during his admission. He will follow up in brain tumor clinic for further diagnostic work-up, including biopsy by Dr. [**First Name (STitle) **]. FOLLOW UP PLAN: -Dilantin being tapered, off by Monday [**4-17**] -Continue Decadron now tapered to 6mg q8 on d/c. -Transitioning from dilantin to keppra (now at 1500BID) -Will follow up in brain tumor clinic next week (Monday) 2. GI: Pt did well from a GI perspective. Tolerated po intake. He did have one episode of nausea/vomiting on [**4-11**] which was associated with mildly elevated LFTs and [**Doctor First Name **]/lip. KUB was OK. Labs normalized. He had a CT scan of the Abd/Pelvis which showed no evidence of disease recurrence. FOLLOW UP PLAN -continue PPI, pancreatic enzymes -follow up with Dr. [**Last Name (STitle) 100239**] next week 3. CV: TEE was done to evaluate for possiblity of endocarditis, showed a tiny, mitral valve veg. Emperic abx (vanc and gent) was begun, but later d/c'd (on [**2186-4-12**]) given very low suspicion for endocarditis 4. ID: -Started Vanco and Gent for ? endocarditis -d/c'd [**4-12**], has remained afebrile since and blood cultures have been negative. Also rec'd Levofloxacin x3 days (start [**4-2**]) for traumatic foley insertion-now d/c'd. Started dapsone for PCP [**Name Initial (PRE) **]. FOLLOW UP PLAN: -dapsone for PCP [**Name9 (PRE) **] while on steroids and chemotherapy 5. Pancreatic CA: s/p #4 of 8 of gemcitabine-unsure if wants to continue chemo. This decision pending prognosis of pancreatic and brain lesion. CT showed no disease recurrence. FOLLOW UP PLAN -Follow up with DR. [**First Name (STitle) **] next week -Will decide about next cycle of gemcitabine (#4 of 8) at next week's appointment 7. Heme: HCt fluctuating, fe studies normal, guiaic trace positive on Thursday. Will need repeat Hct next week at f/u with PCP. FOLLOW UP PLAN -Repeat CBC at F/U with Dr. [**Last Name (STitle) 4844**] 8. Communication: With brother [**Name (NI) **] [**Telephone/Fax (1) 108253**] or [**Telephone/Fax (1) 108254**] Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lipram-CR5 Oral 3. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QHS: PRN as needed. Disp:*30 Suppository(s)* Refills:*0* 5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO once a day for 2 days: Continue for 2 days, then stop. Disp:*2 Capsule(s)* Refills:*0* 8. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. Disp:*80 Tablet, Chewable(s)* Refills:*0* 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:*50 ML(s)* Refills:*0* 10. Decadron 4 mg Tablet Sig: 1.5 Tablets PO every eight (8) hours. Disp:*135 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Seizure Left frontal lobe mass Pancreatic CA Discharge Condition: Improved-no seizures Discharge Instructions: Please continue to take your medications as directed. You will be tapered off of dilantin over the next two days. Please take 100mg by mouth once daily on Satuday and Sunday, then discontinue. You should notify either Dr.[**Last Name (STitle) 7994**] or Dr. [**Last Name (STitle) **] if you have any increase in the frequency of seizures ([**Telephone/Fax (1) 38349**]. Followup Instructions: 1. Brain [**Hospital 341**] Clinic-Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Where: [**Hospital 4054**] NEUROLOGY Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2186-4-17**] 4:00 2. Oncology-Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2186-4-21**] 1:30 3. Primary Care-Dr. [**Last Name (STitle) 4844**] Tuesday, [**4-25**] at 9:00AM [**Telephone/Fax (1) 250**] 4. Surgery-Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Where: [**Hospital 273**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 2833**] Date/Time:[**2186-4-21**] 10:30

[ "196.2", "401.9", "530.81", "780.39", "237.5", "157.8", "309.81", "424.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

10694, 10746

5990, 9476

340, 372

10835, 10857

3842, 5967

11278, 12040

2030, 2092

9499, 10671

10767, 10814

10881, 11255

2107, 3823

258, 302

400, 1576

1598, 1686

1702, 2014

24,977

137,546

13955

Discharge summary

report

Admission Date: [**2152-5-4**] Discharge Date: [**2152-6-14**] Date of Birth: [**2093-12-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 58 year old male transferred from [**Hospital3 **]. Patient presented to [**Hospital3 **] [**2152-4-13**] with symptoms of small bowel obstruction. He was taken to the OR the same day of presentation for lysis of adhesions- no distinct transition zone was found. Post operatively, patient remain intubated with septic/ARDs like picture and on [**2152-4-21**] began to leak bowel contents from midline wound. Patient was taken back for a second operation [**2152-4-21**] for repair of a small bowel perforation. A second episode of leakage from wound occurred on [**2152-4-28**]. Patient taken to the OR the third time the dame day for trach placement, repair of the second perforation (no resection performed in either case), and end ileostomy. Aproximately POD 4 from the third surgery, stool again began leaking from the incision. Patient was transferred to [**Hospital1 18**] per request of family and girlfriend and was on both TPN and tube feeds at time of transfer. Patient had received levo, zosyn and unasyn at [**Hospital3 **]. Past Medical History: bipolar disorder abdominal surgery as an infant hx of several episodes of bowel obstruction- resolved spontaneously cervical fusion Social History: 1 pack cigarettes per day [**3-17**] drinks per day Family History: no colorectal CA Physical Exam: On admission, 99.6 103 110/61 CPAP 500 X 30, PS 8, PEEP 5, satting 98% moves all 4 extremities and is responsive coarse breath sounds bilaterally tachy regular abdomen soft, NT with bowel sounds, viable ostomy with stool fistula at lower edge of incision with appliance in place lower extremities with 3+ edema Pertinent Results: [**2152-5-4**] 09:01PM HCT-28.8* [**2152-5-4**] 05:40PM TYPE-ART PO2-105 PCO2-37 PH-7.48* TOTAL CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-IMV [**2152-5-4**] 05:40PM GLUCOSE-96 [**2152-5-4**] 05:40PM freeCa-1.16 [**2152-5-4**] 03:05PM ALBUMIN-1.9* IRON-20* [**2152-5-4**] 03:05PM calTIBC-124* TRF-95* [**2152-5-4**] 05:27AM LACTATE-1.5 [**2152-5-4**] 05:15AM GLUCOSE-95 UREA N-19 CREAT-0.4* SODIUM-143 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-28 ANION GAP-10 [**2152-5-4**] 05:15AM ALT(SGPT)-30 AST(SGOT)-36 ALK PHOS-87 TOT BILI-0.9 [**2152-5-4**] 05:15AM ALBUMIN-1.7* CALCIUM-7.8* PHOSPHATE-2.7 MAGNESIUM-2.1 [**2152-5-4**] 05:15AM PT-13.5 PTT-28.2 INR(PT)-1.1 [**4-17**] abd wound- pan [**Last Name (un) 36**] E. coli [**4-29**] sputum- pseudomonas [**Doctor Last Name **] to [**Last Name (un) 2830**] and gent [**5-4**] sputum- pseudomonas, pan S [**5-4**] drain- psudomonas & yeast [**5-4**] blood coag neg staph [**5-4**] blood- pseudomonas [**5-4**] CT, leakage from small bowel, most like at anastomosis site, multiple enterocutaneous fistulas, bilateral pleural effusions [**5-9**] RUQ US- sludge in gallbladder Brief Hospital Course: Patient was admitted to the surgical intensive care unit on [**2152-5-4**]. Patient was continued on TPN, zosyn and levo. On HD 2, perc drainage of L flank extravasation was performed and blood pressure was continued to be supported with fluid boluses. Antibiotics was was changed to meropenum, gent and fluc based on clx results-pseudomonas grew from sputum cultures. Patient spiked and line was changed over wire. Tip was subsequently positive and the line was resited. Patient was also started on hydrocortisone for adrenal insuffciency. Infectious disease was consulted and vanc was added. On HD 6, echo demonstrated normal cardiac function, pateint started trach collar trials, octreotide was started, physical therapy was started and patient was evaluated for a passy muir valve. Also, RUQ US demonstrated GB sludge and repeat CT demonstrated near complete resolution of L fluid collection but persistent leakage of bowel contents in the anterior abdominal wall. No vegatations were noted on a repeat echo. NGT was discontinued on hospital day 8, steroid wean was begun and urine output responded well to lasix. Patient was transferred to the floor on hospital day 10, however, he returned to the unit on [**5-20**] for tachycardia, likely due to atrial fibrillation. He underwent another CT-guided drainage and aspiration. His atrial fibrillation was eventually contolled and he was transferred back to the floor on [**5-23**]. His fistula output steadily decreased, but never entirely ceased. He continued to work with physical therapy, and made excellent progress. His bowel required manual disimpaction, but he eventually recovered bowel movements. At the suggestion of ID, his meropenem and gentamicin were discontinued on [**5-29**], and Zosyn was started instead. He gradually tolerated clears for comfort. On [**5-30**], he developed respiratory distress and was again transferred to the SICU for tachycardia, hypotension, tachypnea, and hypoxia. Workup for PE was negative. Gentamicin was re-started. A repeat CT scan on [**6-2**] showed no new fluid collections. He was transferred to the floor on [**6-3**]. He gradually improved. A mild bump in his LFTs was attributed to his chronic TPN, and nutrient levels were adjusted. Vanco and gent were discontinued on [**6-9**], and his pain control was changed to a fentanyl patch and prn morphine.The timing of his fistulogram was discussed at great length, and it was decided the optimal time would be after his discharge to rehab, to allow him time to gain his strength and regain mobility in preparation for the fistulogram and resultant operative assessment. He was discharged to [**Hospital1 **] acute care rehab in stable condition on [**6-13**]. Medications on Admission: meds at OSH zosyn levaquin unasyn heparin sub q perioperative beta blockade home medication- depakote Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Valproate Sodium 100 mg/mL Solution Sig: Five (5) mL Intravenous Q6H (every 6 hours). mL 6. Fluconazole in Normal Saline 200 mg/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q24H (every 24 hours): Please call Dr[**Name (NI) 11471**] office for updates on duration of treatment. 7. Lorazepam 2 mg/mL Syringe Sig: 0.25 mg Injection HS (at bedtime) as needed. 8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): Please contact [**Name2 (NI) 15974**] office for updates on desired duration. 9. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 7.5 mL Intravenous Q6H (every 6 hours). 10. Diphenhydramine HCl 50 mg/mL Solution Sig: 0.5 mL Injection HS (at bedtime) as needed. 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: entercutaneous fistula pseuodomonis pneumonia line sepsis adrenal insufficieny Discharge Condition: stable Discharge Instructions: Pt will need optimization of respiratory status and possible transition to PM valve. Extensive physical therapy to restore mobility. Total parenteral nutrition. CLose wound care of midline fistula site. Routine ostomy care. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3573**] Call to schedule appointment Patient to call and make appointment to see Dr. [**First Name (STitle) 2819**] in [**2-17**] weeks.

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icd9cm

[ [ [] ] ]

[ "88.72", "99.15", "96.71", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

7274, 7346

3185, 5903

329, 335

7469, 7477

2020, 3162

7749, 7999

1655, 1673

6056, 7251

7367, 7448

5929, 6033

7501, 7726

1688, 2001

275, 291

363, 1415

1437, 1570

1586, 1639

68,813

147,496

4519

Discharge summary

report

Admission Date: [**2159-10-24**] Discharge Date: [**2159-11-2**] Date of Birth: [**2108-12-27**] Sex: F Service: PLASTIC Allergies: Latex Attending:[**First Name3 (LF) 5667**] Chief Complaint: Left buccal squamous cell carcinoma Major Surgical or Invasive Procedure: 1) Laryngoscopy 2) Modified radical neck dissection 3) Radical resection of buccal carcinoma involving soft tissue and overlying skin1) Reconstruction of oral cavity and cheek defect in buccal area with Left radial forearm free flap 4) Reconstruction of oral cavity and cheek defect with left radial forearm free flap 5) Split-thickness skin graft to left forearm donor site 6) Autologous fat grafting to pedicle History of Present Illness: Ms. [**Known lastname 19279**] is known to have breast cancer, which was diagnosed in [**2148**]. She had been treated with Doxil chemotherapy for it, when she relapsed, and at that time, she noticed some ulcers in her mouth, but everytime the chemotherapy was discontinued, the ulcers disappeared. However, during the last discontinuation of Adriamycin, there was one small persistent ulcer. This was not causing her much trouble. More recently, she had switched her chemotherapy from Taxotere to gemcitabine, and she noticed progressively over the summer that the soreness in her cheek was worsening and never got better. She was seen by an oral surgeon, and a biopsy was done, which was positive for squamous cell cancer. The tissue slides were evaluated in [**Hospital1 69**] and confirmed to be invasive moderately differentiated squamous cell cancer. The patient was then referred to [**Hospital1 1170**] and evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] for excision of the tumor and Dr. [**First Name (STitle) **] for reconstruction. Past Medical History: PAST ONCOLOGIC HISTORY: Infiltrating L breast carcinoma, with ductal and lobular features initially diagnosed in 2/98 with known bone and liver involvement per pt. Underwent mastectomy and BMT in 2/98 and then received tamoxifen 8/98-1/02. Presented with R leg pain in [**3-14**], eventually found to have widely metastatic bony disease. She has since received multiple chemotherapy regimens, including Zometa, Femara, Xeloda, Doxil, and most recently Taxotere and Faslodex. . PAST MEDICAL HISTORY: Graves' disease s/p thyroid radiation Social History: EtOH: Occasional Tobacco: None Family History: Mother died of breast cancer in her 50s. 2 healthy sisters with negative genetic testing. Pt has not had genetic testing herself as not covered by insurance. Physical Exam: VS: Afebrile, VSS Constitutional: Well appearing, no acute distress Face: Left cheek RFFF with good color, warm, +cap refill, dopplerable pulse over pedicle, sutures c/d/i Neck: Suture line c/d/i CV: RRR, no murmurs Resp: CTAB, no wheezes or crackles Ext: Warm, distal pulses palpable bilaterally Psychiatric: Normal to judgment, insight, memory, mood and affect Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2159-10-24**] and had a Laryngoscopy, Modified radical neck dissection, Radical resection of buccal carrcinoma involving soft tissue and overlying skin, Reconstruction of oral cavity and cheek defect in buccal area with Left radial forearm free flap, Split-thickness skin graft to left forearm donor site, Autologous fat grafting to pedicle. The patient tolerated the procedure well. Neuro: Post-operatively, the patient received IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient went to the ICU intubated. After extubation the Pt was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating tube feeds/oral intake. Her diet was advanced when appropriate to a full liquid diet which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed and Pt was able to void without difficulty. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV unasyn. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. Skin: Left radial forearm free flap to Left cheek was closely monitored with doppler checks/vioptix and maintained good blood flow throughout hospitalization. Sutures remained intact without evidence of infection. At the time of discharge on POD#9, the patient was doing well, afebrile with stable vital signs, tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Percocet, Levoxyl, fentanyl patch, Peridex Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). 2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*0* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 4. Levoxyl Oral 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain: Do not drink, drive or operate machinery while taking this medication. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Left buccal squamous cell carcinoma status post reconstruction with left radial forearm free flap to buccal area, split-thickness sckin graft and autologous fat grafting Discharge Condition: Good/Stable Discharge Instructions: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. *Do not chew or put anything in the left side of your mouth Followup Instructions: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2159-11-6**] 1:40

[ "197.7", "244.1", "V42.82", "145.0", "198.5", "V15.82", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "31.42", "86.69", "40.41", "96.72", "27.49", "96.6", "27.57", "93.56", "86.89" ]

icd9pcs

[ [ [] ] ]

5582, 5665

3021, 4949

303, 718

5879, 5893

6764, 6904

2459, 2618

5042, 5559

5686, 5858

4975, 5019

5917, 6741

2633, 2998

228, 265

746, 1834

2355, 2394

2410, 2443

52,641

162,564

7844

Discharge summary

report

Admission Date: [**2121-9-1**] Discharge Date: [**2121-9-18**] Date of Birth: [**2041-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath and malaise Major Surgical or Invasive Procedure: AVR (#25 St. [**Male First Name (un) 923**] porcine/ MV (28 [**Company **] ring)/CABG x3(LIMA-LAD, SVG to OM, SVG to PDA) [**2121-9-8**] History of Present Illness: 80 year old male presented over the weekend to Good Samaritians with general malaise and shortness of breath. He ruled in for NSTEMI trop 1.26. ck 154. Echo at OSH shows EF of 45, moderate AS [**Location (un) **] 1.0, mod to severe MR, inferior hypokinesis. Dr. [**Last Name (STitle) **] referred him for a right and left heart catheterization. He was found to have coronary artery disease and is now being referred to cardiac surgery evaluation Past Medical History: Aortic Stenosis, Coronary Artery Disease, Diabetes, Dyslipidemia, Hypertension, PPM, DM II, retinopathy, neuropathy, gastroparesis, Obesity, peripheral vascular disease with RLE stent placed [**4-/2121**], Presyncope, BPH, Ulcerative colitis, b/l cataract extraction Social History: Lives with 2 grandchildren in a large house. Has a girlfriend. Pt has a dry cleaning business that's closing down soon due to the poor economy. Major source of stress. -Tobacco history: None -ETOH: Occasional -Illicit drugs: None Family History: FAMILY HISTORY: Mother died of breast cancer at age 59, does not know father. Daughter has thyroid cancer, currently on treatment. Physical Exam: Admission Physical Exam Pulse:60 resp:13 O2 sat:97/RA B/P Right:118/70 Left:120/68 Height:5'8" Weight:182 lbs General: No acute distress, well nourished Skin: Dry [x] intact [x] small area of redness right second toe HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear but diminished at left base no rales/rhonchi Heart: RRR [x] Irregular [] Murmur [x] grade 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Cool, no edema, no varicosities Neuro: Alert and oriented x3 non focal Pulses: Femoral Right: cath site +1 Left: +1 DP Right: doppler Left: doppler PT [**Name (NI) 167**]: doppler Left: doppler Radial Right: +1 Left: +1 Carotid Bruit Right: none Left: + bruit Pertinent Results: [**2121-9-18**] 06:28AM BLOOD WBC-14.4* RBC-3.44* Hgb-10.8* Hct-31.4* MCV-91 MCH-31.3 MCHC-34.3 RDW-17.1* Plt Ct-166 [**2121-9-17**] 05:56AM BLOOD WBC-14.3* RBC-3.44* Hgb-10.7* Hct-31.7* MCV-92 MCH-30.9 MCHC-33.6 RDW-15.5 Plt Ct-151 [**2121-9-18**] 06:28AM BLOOD Glucose-80 UreaN-46* Creat-1.1 Na-138 K-3.1* Cl-94* HCO3-36* AnGap-11 [**2121-9-17**] 05:56AM BLOOD Glucose-64* UreaN-45* Creat-1.2 Na-138 K-3.2* Cl-97 HCO3-33* AnGap-11 [**2121-9-16**] 10:50AM BLOOD Glucose-262* UreaN-50* Creat-1.2 Na-138 K-4.4 Cl-98 HCO3-34* AnGap-10 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Indication: Aortic valve disease. Congestive heart failure. Coronary artery disease. Left ventricular function. Preoperative assessment. Valvular heart disease. ICD-9 Codes: 428.0, 410.91, 786.05, 424.1, 424.0 Test Information Date/Time: [**2121-9-8**] at 08:55 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-1: Machine: us2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Left Ventricle - Stroke Volume: 65 ml/beat Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 6 < 15 Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *24 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 16 mm Hg Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 0.78 Findings LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild thickening of mitral valve chordae. No MS. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild to moderate [[**1-12**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic 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 is in a ventricularly paced rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the inferor and anterolateral walls There is akinesis of the apex. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40% %). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is on epinephrine, milrinone, and norepinephrine infusions. There is a bioprosthetic valve in the aortic position. Trace aortic regurgitation is seen. There is a peak gradient of 17 mmHg and a mean gradient 10 mmHg across the aortic valve with a cardiac output of 6.1 L/min. There is a mitral annuloplasty ring in place. Trace mitral regurgitation is seen. There is a peak gradient of 6 mmHg with a mean gradient of 3mmHg across the mitral valve at a cardiac output of 6.4 L/min. Left ventricular function is slightly improved (LVEF 40-45%). Right ventricular function is unchanged. The aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician ?????? [**2113**] CareGroup IS. All rights reserved. Brief Hospital Course: Mr. [**Known lastname **] is an 80 year-old male with history of Permanent Pacemaker, Diabetes Mellitus II with retinopathy, neuropathy, and gastroparesis, Hypertension, hyperlipidemia, and history of right lower extremity stent placed on [**4-/2121**] who presented to [**Hospital3 417**] hospital [**2121-8-22**] with exertional shortness of breath. He ruled in for NSTEMI. The patient underwent ECHO showing [**Location (un) 109**] of 1.0, moderate to severe MR, and inferior wall hypokinesis. He was transferred to [**Hospital1 18**] to undergo cardiac catheterization which revealed heavily calcified 3 vessel disease, and moderate aortic stenosis. Cardiac surgery evaluated for coronary revascularization and Aortic Valve replacement. He was deemed to be an appropriate candidate with a tentative OR date of [**2121-9-2**], due to the necessity of a clopidogrel washout. Prior to his discharge, surgical workup included an echocardiogram, non-contrast CT chest, bilateral carotid ultrasounds, and bilateral lower extremity vein mapping.On [**8-29**] he was discharged to a skilled nursing facility with scheduled follow up with Dr.[**First Name (STitle) **] preoperatively to evaluate a local infection on his right second toe which developed during his hospital admission. On [**9-1**] when seen by Dr.[**First Name (STitle) **] in clinic, the toe infection appeared worse. Mr.[**Known lastname **] was admitted for IV antibiotics and a vascular consult secondary to his history of Right femoral artery stent in [**4-/2121**] and this new cellulitis in his Right second toe. Per vascular, treat coronary issues first, then readdress PVD once resolved, with plan for follow up as outpt w/ Dr.[**Last Name (STitle) 28285**]. On [**2121-9-8**] Mr.[**Known lastname **] was taken to the operating room and underwent Coronary artery bypass graft x3,(left internal mammary artery to left anterior descending artery and saphenous vein graft to obtuse marginal and posterior descending arteries/Aortic valve replacement with size 25 St. [**Male First Name (un) 923**] Epic tissue valve/ Mitral valve repair with a size 28 CG future band) with Dr.[**First Name (STitle) **]. Please see operative report for further surgical details. The patient had a significant amount of bleeding intra and post-op and received multiple blood products. On POD1 the patient remained on inotropes and vasopressors to support hemodynamics. His ETT tube was dislodged, and he was re-intubated without incident. [**Last Name (un) **] continued to follow along and the patient remained on an insulin drip in the ICU. The patient's permanent pacer was interrogated post-operatively and base rate was set to 85bpm to further support hemodynamics. He was put on a lasix drip for volume overload. Flagyl was started empirically for loose stool. CDiff would return negative and Flagyl was discontinued. Unasyn was continued for preop left toe cellulitis. Chest tubes and pacing wires were discontinued without complication. The patient has a history of ulcerative colitis and developed loose stool/diarrhea post-operatively. GI was consulted and followed along. CDiff PCR was negative and the patient was started on Loperamide. The patient remained intubated and was started on tube feeds. Thrombocytopenia developed and HIT was sent which would return negative. He was pan-cultured for a fever on POD 3. There was no significant growth and cellulitis of toe resolved, therefore Unasyn was discontinued. The patient was extubated on POD 5 following sufficient diuresis. GI recommended outpatient abdominal CT to assess for Crohn's disease and to follow up with PCP for results. [**Last Name (un) **] continued to follow, insulin drip was weaned and the patient was transitioned to Lantus and sliding scale insulin. The patient was transferred to the step down unit on POD 8. He was worked with physical therapy and continued to progress. He will be discharged on IV Lasix, 40mg TID x 1 week, then should be re-assessed for ongoing diuretic requirement. Foley catheter was re-inserted for urinary retention, and the patient should have a void trial within a week of discharge. Bilateral vein harvest sites had serosanguinous drainage without further signs of infection- these should be monitored. On POD 10 he was discharged to Newbridge on the [**Doctor Last Name **] for further rehab. All follow-up appointments were advised. Medications on Admission: Insulin sliding scale 10 units in am, 10 units at lunch, 15 units at dinner - will vary dose based on BG Lantus 15-25 units at HS varies dose based on BG Atenolol 25mg Daily Zocor 80mg Daily Metformin 500mg Daily Asacol 2 Tablets TID OSH Medications: ecasa 325mg today plavix 75mg today =s/p loading on Saturday with 300mg lovenox 80 [**Hospital1 **] yesterday proscar 5 lasix 40mg levaquin 750 atenolol 25mg Plavix - last dose:300g [**2121-8-23**], 75mg [**2121-8-25**] Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or temp >38.4. 6. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. mesalamine 250 mg Capsule, Extended Release Sig: Three (3) Capsule, Extended Release PO QID (4 times a day). 8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 15. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: 16units qam. 16. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: see attached sliding scale. 17. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day for 1 weeks. 19. furosemide 10 mg/mL Solution Sig: Four (4) Injection three times a day for 1 weeks: 40mg IV Lasix TID x week, the re-assess for ongoing diuretic need. 20. Outpatient Lab Work Finger stick blood glucose at 2am, [**2121-9-19**] 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN IV flush Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Aortic Stenosis, Coronary Artery Disease, Diabetes, Dyslipidemia, Hypertension, PPM, DM II, retinopathy, neuropathy, gastroparesis, Obesity, peripheral vascular disease with RLE stent placed [**4-/2121**], Presyncope, BPH, Ulcerative colitis, b/l cataract extraction Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right and Left - serosanguinous drainage without signs of infection Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**2121-10-13**] 2:00 in the [**Hospital **] medical office building [**Hospital Unit Name **] Cardiologist:Dr. [**Last Name (STitle) 4541**] [**9-19**] at 10:30am Please call to schedule appointments with your Primary Care Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 7164**] in [**4-15**] weeks **CT Abdomen to evaluate for Ulcerative Colitis- follow up with PCP regarding results** **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2121-9-18**]

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icd9cm

[ [ [] ] ]

[ "35.12", "35.21", "96.6", "39.61", "36.12", "96.72", "36.15" ]

icd9pcs

[ [ [] ] ]

15528, 15622

8563, 12992

341, 480

15933, 16177

2480, 6219

17017, 17826

1528, 1645

13513, 15505

15643, 15912

13018, 13490

16201, 16994

6268, 8540

1660, 2461

269, 303

508, 957

979, 1248

1264, 1496

74,418

194,969

2416

Discharge summary

report

Admission Date: [**2130-4-25**] Discharge Date: [**2130-5-12**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: speech difficulty, hemiparesis Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] was unable to speak earlier today, according to family and is now sedated with Olanzapine 20 mg. History obtained from family and review of medical records. Ms. [**Known lastname **] is a [**Age over 90 **] year-old right-handed [**Location 7972**] woman with PMH significant for HTN, DMII, moderate dementia and admission in [**1-/2130**] for multiple rib fractures and small SAH (though no witnessed or reported trauma) who presents with right sided weakness and aphasia. She was brought to the ED yesterday with chest pain and was ruled out for MI. She was discharged home yesterday evening; her daughter-in-law noted at that time that when she went to use her walker, she was able to use her left hand normally to put her hand on top of the walker, but was unable to place her right hand on top of the walker as usual, but was rather grabbing on to the walker lower down with her right hand and she seemed to have difficulty controlling her right arm. She went home and did not sleep well overnight. This morning, her daughter, with whom she lives, noted that she was dragging her right foot when walking and was not using her right arm well. Her daughter-in-law then came over and saw that her right arm appeared further impaired than yesterday evening. Her family also noted that she was not able to say any words today; they said words were just not coming out and they were unable to understand anything she was trying to say. Her daughter-in-law is unsure if she was able to comprehend anything, but she says it did not appear she was paying attention to her family. Her family also notes that it appeared at times as if she was trying to catch something in the air; it is unclear is she was having visual hallucinations. She was brought into the ED for further evaluation. In the ED, she was very agitated and pulling at lines so received Zyprexa 10 mg x 2. ROS: Unable to obtain from patient as she was previously noted to be aphasic by family and is now sedated. Past Medical History: 1. Hypertension 2. Diabetes mellitus, type 2 3. Moderate dementia 4. Osteopenia 5. s/p right distal radial fracture ([**2123**]) 6. h/o acute cholesystitis s/p open cholecystectomy ([**2122**]) 7. recent admission [**2130-1-4**] for multiple rib fractures and small SAH, family unaware of a fall 8. small bowel tumor s/p resection Social History: Per OMR, lives with daughter [**Name (NI) **]. [**Name2 (NI) 4084**] attended school, cannot read or write well. Smokes a pipe, no EtOH. Of note, at baseline, she is able to ambulate, engage in limited conversation and is oriented to person. Family History: Per family, no known family history of strokes or seizures. Physical Exam: ADMISSION Physical Exam: Vitals: T: 96.8 P: 90 R: 16 BP: 182/111 SaO2: 99% RA General: somnolent, difficult to arouse (had previously received Olanzapine 10 mg x 2). HEENT: NC/AT, no scleral icterus noted,no lesions noted in oropharynx Neck: Supple Pulmonary: anterior lung fields cta b/l Cardiac: RRR, S1S2, II/VI systolic murmur Abdomen: soft, nondistended, +BS Extremities: warm, well perfused Neurologic: no eye opening. no commands (commands were given in her native language by her family). PERRL 2-->1 mm. Pupils in midline. She would resist Doll's Eyes maneuver, so unable to assess. Blinks to threat on left but not on right. Face appears symmetric at rest. She spontaneously moves left upper extremity more than right upper extremity, though there is spontaneous movement on the left. Moves LE spontaneously b/l. Withdraws all exttremities to noxious stimuli briskly. During noxious stimuli testing, she did say "devil" in her native language, which is first word family says they understood her say all day. Reflexes were 1+ and symmetric throughout. She had a withdrawal response with plantar testing b/l. DISCHARGE PHYSICAL EXAM: Vitals: 98.5, 136/80, 70, 20, 100% on RA GEN: lying in bed in NAD HEENT: OP clear CV: RRR PULM: CTAB ABD: soft, NT, ND, PEG in place with c/d/i dressing EXT: no edema NEURO: MS - AAOx1 (with interpreter), unable to follow commands except to open and close eyes with miming CN - forced eye closure, pupils 2->1.5, tracks examiner MOTOR - MAEE to tickle bilaterally SENSATION - intact to tickle as above COORDINATION - pt unable to cooperate GAIT - deferred Pertinent Results: ADMISSION LABS: [**2130-4-24**] 11:55AM BLOOD WBC-8.7 RBC-4.62 Hgb-13.9 Hct-42.5 MCV-92 MCH-30.0 MCHC-32.6 RDW-14.0 Plt Ct-234 [**2130-4-28**] 05:05AM BLOOD WBC-5.8 RBC-3.94* Hgb-11.8* Hct-35.5* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.8 Plt Ct-255 [**2130-4-24**] 11:55AM BLOOD Neuts-84.8* Lymphs-11.9* Monos-2.4 Eos-0.5 Baso-0.4 [**2130-4-24**] 11:55AM BLOOD Plt Ct-234 [**2130-4-25**] 04:09PM BLOOD PT-10.5 PTT-29.0 INR(PT)-1.0 [**2130-4-24**] 11:55AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-142 K-4.0 Cl-103 HCO3-27 AnGap-16 [**2130-4-27**] 05:01AM BLOOD Glucose-124* UreaN-12 Creat-0.8 Na-141 K-3.4 Cl-106 HCO3-24 AnGap-14 [**2130-4-26**] 02:01AM BLOOD ALT-17 AST-27 AlkPhos-91 TotBili-0.7 [**2130-4-26**] 12:08PM BLOOD CK(CPK)-343* [**2130-4-27**] 05:01AM BLOOD CK(CPK)-250* [**2130-4-24**] 11:55AM BLOOD proBNP-276 [**2130-4-24**] 11:55AM BLOOD cTropnT-<0.01 [**2130-4-27**] 05:01AM BLOOD CK-MB-5 cTropnT-0.01 [**2130-4-26**] 02:01AM BLOOD Albumin-4.4 Calcium-9.4 Phos-2.8# Mg-1.9 Cholest-185 [**2130-4-28**] 05:05AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.9 [**2130-4-26**] 12:13AM BLOOD %HbA1c-5.5 eAG-111 [**2130-4-26**] 02:01AM BLOOD Triglyc-48 HDL-93 CHOL/HD-2.0 LDLcalc-82 DISCHARGE LABS: [**2130-5-10**] 04:25AM BLOOD WBC-7.8 RBC-4.06* Hgb-12.1 Hct-36.5 MCV-90 MCH-29.7 MCHC-33.1 RDW-14.3 Plt Ct-452* [**2130-5-10**] 04:25AM BLOOD Glucose-142* UreaN-21* Creat-0.9 Na-134 K-4.3 Cl-98 HCO3-27 AnGap-13 [**2130-5-10**] 04:25AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.8 REPORTS: [**2130-4-25**] NCHCT FINDINGS: There is a large left 4.8 x 3.4 parieto-occipital intraparenchymal hemorrhage with surrounding edema and intraventricular extension into the left lateral ventricle and occipital [**Doctor Last Name 534**] (2:18, 601:51). There is no shift of midline structures or evidence of central herniation. Prominent ventricles and sulci are consistent with age-related atrophy, without evidence of hydrocephalus. Periventricular white matter hypoattenuation is compatible with chronic small vessel infarciton. The basal cisterns are patent. There is no fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Large 4.8-cm left parieto-occipital acute intraparenchymal hemorrhage with surrounding edema and intraventricular extension. No evidence of central herniation. [**2130-4-26**] CXR FINDINGS: As compared to the previous radiograph, the patient has received a Dobbhoff catheter. The tip of the catheter projects over the middle parts of the stomach, the course of the catheter is unremarkable, there is no evidence of complications, notably no pneumothorax. Borderline size of the cardiac silhouette. Mild areas of atelectasis at the left and right lung bases. No evidence of other parenchymal opacities, notably no evidence of pneumonia. [**2130-4-28**] CXR FINDINGS: As compared to the previous radiograph, the lung volumes have decreased. There is mild fluid overload and a plate-like atelectasis at the left lung bases that has minimally increased in extent. The pre-existing minimal left pleural effusion is unchanged. Unchanged course of the nasogastric tube. No pneumothorax. [**2130-5-1**] CXR FINDINGS: Comparison is made to previous study from [**2130-4-28**]. The Dobbhoff tube has been removed. There has been placement of nasogastric tube whose tip and side port are well below the gastroesophageal junction in the distal body of the stomach. However, there is a loop in the distal nasogastric tube. The cardiac silhouette and mediastinum is prominent but stable. There is improvement of the atelectasis at the lung bases. There remains low lung volumes. There are no pneumothoraces. Brief Hospital Course: [**Age over 90 **] yo RHF with HTN, DM, moderate dementia, with acute onset R sided weakness and facial droop and found to have large IPH on NCHCT. Neurological exam is significant for fluctuating agitation/drowsiness, inattention, inability to follow commands, ?facial droop, decreased spontaneous movement on the right. Etiology most likely amyloid angiopathy. Other causes include underlying vascular abnormalities (eg. AVM). Localization of IPH was not typical for hypertensive bleed. . ICU course [**Date range (3) 12449**]: Overnight patient was agitated with hypertension and tachycardia and received olanzepine. She was given standing IV tylenol for presumed pain which made her drowsy and less agitated. She did not demonstrate clinical seizure activity. Patient underwent repeat NCHCT which showed stable L parieto-occipital hemorrhage and she was transfered to the floor for further monitoring and treatment. . Floor [**2130-4-26**]: The patient was transferred to the Neurology floor from the ICU in stable condition. She as kept on contact precautions for prior [**Name (NI) 12450**] Staphylococcus aureus infection with one negative MRSA isolate on screening on this admission. Her blood pressure medications were uptitrated to maintain an SBP < 140. She was noted to have intermittent nonsustained VT which lessened after repleting electrolytes. She was placed on low-dose beta-blocker therapy. She was evaluated by PT/OT/Speech. She would not cooperate with Speech therapy. She was continued on tube feeds via NGT. Her family agreed to have a gastrostomy placed. ACS was consulted who recommended IR-guided placement due to a prior abdominal surgery. This was placed on [**5-8**] without complication. She was discharged to rehab once her restraints were able to be stopped for 24 hours. . PENDING STUDIES: None . TRANSITIONAL CARE ISSUES: [ ] Please continue to titrate her blood pressure medications to maintain SBP < 140. [ ] Please continue PT/OT for maximal functional recovery. [ ] Please avoid long-term antithrombotic medications such as aspirin or warfarin. ** AHA/ASA Core Measures for Intracerebral Hemorrhage ** 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No (Reason () non-smoker - (x) unable to participate) 4. Stroke education given? (x) Yes - () No 5. Assessment for rehabilitation? (x) Yes - () No Medications on Admission: -Lisinopril 30 mg daily -Calcium + D 500 mg-200 units -Proair 2 puffs q6h prn -Senna 8.6 mg qhs -Docusate 100 mg [**Hospital1 **] -Tylenol 650 mg tid Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Oral 6. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 7. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Intracerebral hemorrhage (intraparenchymal), Amyloid Angiopathy Secondary Diagnosis: Hypertension, Diabetes Mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. NEURO EXAM: AAOx1 (chronic dementia), moves all extremities spontaneously Discharge Instructions: Dear Mrs. [**Known lastname **], You were hospitalized due to symptoms of SPEECH DIFFICULTY and WEAKNESS resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. We are changing your medications as follows: 1. Please do NOT take any blood thinners such as aspirin or warfarin. 2. We are INCREASING your LISINOPRIL to 40 mg one tablet daily for better blood pressure control. 3. We have started METOPROLOL TARTRATE to help control your blood pressure and heart rate. 4. We have started you on SUBCUTANEOUS HEPARIN three times a day to prevent DVTs while you are at rehab. 5. We have started you on DOCUSATE 100mg twice a day to prevent constipation. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek medical attention. In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: PRIMARY CARE Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2130-5-12**] 12:00 NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2130-6-9**] 2:30pm, [**Hospital1 69**], [**Hospital Ward Name 23**] [**Location (un) 858**] [**Hospital Ward Name 516**], [**Location (un) 86**], MA [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "38.91" ]

icd9pcs

[ [ [] ] ]

11784, 11938

8361, 10193

283, 289

12118, 12118

4659, 4659

14575, 15182

2956, 3019

11014, 11761

11959, 11959

10840, 10991

12370, 14552

5848, 8338

3060, 4157

213, 245

10219, 10814

317, 2325

12063, 12097

4675, 5831

11978, 12042

12133, 12346

2347, 2680

2696, 2940

4182, 4640

4,113

177,001

4898

Discharge summary

report

Admission Date: [**2148-10-15**] Discharge Date: [**2148-10-18**] Date of Birth: [**2103-6-23**] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance / Adhesive Tape Attending:[**First Name3 (LF) 8587**] Chief Complaint: Left ankle pain Major Surgical or Invasive Procedure: [**2148-10-15**]: s/p Open Reduction Internal Fixation of Left Bimalleolar Fracture. [**2148-10-15**]: s/p Removal of Hardware, Left Patella. History of Present Illness: Ms [**Known lastname 19419**] is a 45 year old female who inverted her left ankle on [**2148-10-15**] resulting in a left bimalleolar ankle fracture requiring surgical fixation. Past Medical History: CAD s/p coronary bypass surgery [**5-1**]- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal occluded. Diastolic Heart Failure Diabetes Mellitus-type I s/p living-related kidney transplant [**2140-10-31**] (baseline Cr 0.8-1.1 over the last year) s/p MI tobacco use osteoporosis gastroparesis s/p right tibial fracture peripheral [**Year (4 digits) 1106**] disease: s/p right femoropopliteal bypass and left SFA drug-eluting [**Last Name (LF) **], [**2147-5-2**] retinopathy- legally blind s/p left patella open reduction and fixation, [**2147**] s/p right leg fracture (cast), [**2147**] s/p left wrist fracture, [**2147**] s/p fall and intracranial bleed, [**2147**] s/p cholecystectomy sarcoid, reported lung nodule neuropathy depression hypertension blood group specific substance. Blood products (red cells and platelets) should be leukoreduced. chronic heel ulcers hyponatremia Social History: -Tobacco history: smokes half a pack per day -ETOH: none -Illicit drugs: smokes marijuana several times per week to help with nausea and appetite Family History: There is no history of diabetes or kidney disease. Her father had an MI at 74 and mother has hypertension. Grandfather had leukemia and hypertension. Physical Exam: Physical examination on admission: Afebrile with stable vital signs. No acute distress, Non-toxic. Alert and Oriented x 3 No lymphadenopathy, Neck has full range of motion. Pupils equal, reactive to light and extra-ocular motion intact bilaterally. Lungs Clear bilaterally. Cardiac regular rate and rhythm. Abdomen soft, non-tender, non-distended, + bowel sounds. Extremities: Neurovascular intact throughout. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2148-10-16**] 06:00AM 3.7* 2.83* 8.2* 27.5* 97#1 29.0 29.8* 13.0 164# BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2148-10-16**] 06:00AM 164# Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2148-10-16**] 06:00AM 79 24* 1.0 136 4.9 107 19* 15 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2148-10-16**] 06:00AM 8.6 3.7 1.7 Brief Hospital Course: Ms [**Known lastname 19419**] is a 45 year old female who inverted her left ankle on [**2148-10-15**] resulting in a left bimalleolar ankle fracture requiring surgical fixation. She was admitted to the Orthopedic service via the emergency room and underwent open reduction internal fixation of her left ankle and hardware removal of her left patella without complication. She was transferred to the recovery room in stable condition and subsequently transferred to the floor in stable condition. She had adequate pain management throughout her hospital course. She worked with physical therapy. The remainder of her hospital course was uneventful. She is being discharged today in stable condition. Medications on Admission: Senna 1 TAB PO BID:PRN Constipation Multivitamins 1 CAP PO DAILY Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Vitamin D 400 UNIT PO DAILY Calcium Carbonate 500 mg PO TID Milk of Magnesia 30 ml PO BID:PRN Constipation Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN Dyspepsia Acetaminophen 650 mg PO Q6H Ipratropium Bromide MDI 2 PUFF IH Q6H coughing Lisinopril 2.5 mg PO DAILY Metoclopramide 10 mg PO QIDACHS Metoprolol Succinate XL 25 mg PO DAILY PredniSONE 4 mg PO DAILY Prochlorperazine 25 mg PR Q12H:PRN nausea Ranitidine 150 mg PO BID Sirolimus 3 mg PO DAILY Tacrolimus 2 mg PO Q12H Dose to be admin. at 6am and 6pm TraMADOL (Ultram) 25 mg PO Q6H:PRN pain traZODONE 100 mg PO HS Sulfameth/Trimethoprim SS 1 TAB PO QMOWEFR Aspirin 325 mg PO DAILY Atorvastatin 40 mg PO DAILY BuPROPion 75 mg PO DAILY Citalopram Hydrobromide 60 mg PO DAILY Clopidogrel 75 mg PO DAILY Furosemide 40 mg PO DAILY Insulin SC Sliding Scale & Fixed Dose Gabapentin 800 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. Disp:*56 syringe* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not operate any motor vehicle or machinary. do not drink alcohol. Disp:*90 Tablet(s)* Refills:*0* 4. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Please take a 5 pm every day . 5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 7. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for coughing. 15. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. 16. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 19. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 24. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 26. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 27. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 28. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 29. Insulin Sliding Scale Insulin SC Fixed Dose Orders Bedtime Glargine : 25 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 4 oz. Juice and 15 gm crackers 71-150 mg/dL 0Units 0Units 0Units 0Units 151-200 mg/dL 2Units 2Units 2Units 2Units 201-250 mg/dL 4Units 4Units 4Units 4Units 251-300 mg/dL 6Units 6Units 6Units 6Units 301-350 mg/dL 8Units 8Units 8Units 8Units 351-400 mg/dL 10Units 10Units 10Units 10Units > 400 mg/dL Notify M.D. Discharge Disposition: Home With Service Facility: Southshore VNA Discharge Diagnosis: Left Bimalleolar Fracture Discharge Condition: Stable Discharge Instructions: Keep incision and splint dry to prevent infection. Do not soak in tub. Sponge bath until your first follow-up appointment. Continue to be non weight bearing on your left leg. Do not remove splint. Elevate your left leg to reduce swelling and pain Resume your regular diet. Avoid nicotine products to optimize healing. Resume your home medications. Take all medications as instructed. Continue taking the Lovenox to prevent blood clots. You have been given narcotic pain medication, which may cause drowsiness, dizziness, nausea, vomiting and constipation. Do NOT operate any motor vehicle or machinery while taking narcotic pain medication. Do drink alcohol while taking narcotic pain medication. Take a stool softener to prevent constipation. If you have questions or concerns please call your doctor at [**Telephone/Fax (1) 1228**]. If your experience fevers greater than 101.2, incisional drainage, bleeding or redness, nausea, vomiting, calf pain, chest pain or shortness of breath, then call your doctor or go to your local emergency room For your congestive heart failure: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Physical Therapy: 1. Non-weight bearing, left lower extremity 2. Keep splint on left lower extremity until follow up in the [**Hospital **] clinic. Treatments Frequency: 1. Keep splint and incision dry. 2. Keep splint on at all times. 3. Elevate left leg to reduce swelling and pain Followup Instructions: 2 weeks in the Orthopedic office with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this appoinment. Completed by:[**2148-10-18**]

[ "824.4", "V45.81", "428.30", "707.14", "250.01", "414.00", "V42.0", "E927.8", "428.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "78.66", "79.36" ]

icd9pcs

[ [ [] ] ]

7955, 8000

2913, 3618

353, 498

8070, 8079

2424, 2890

9624, 9831

1826, 1977

4642, 7932

8021, 8049

3644, 4619

8103, 9317

1992, 2013

9335, 9465

9487, 9601

298, 315

526, 705

2028, 2405

727, 1646

1662, 1810

57,686

135,075

46268

Discharge summary

report

Admission Date: [**2139-2-6**] Discharge Date: [**2139-2-17**] Date of Birth: [**2084-2-18**] Sex: F Service: MEDICINE Allergies: morphine / Demerol / Oxycodone / Bactrim / aspirin Attending:[**First Name3 (LF) 5606**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: None History of Present Illness: 54F w/ history of [**First Name3 (LF) 14165**] cell disease presenting with worsening shortness of breath and cough. She has not been feeling well for the past 3 weeks, initially with a cough productive of yellow phlegm. She developed joint and chest pain c/w her [**First Name3 (LF) 14165**] crises and became febrile to 101.2 on [**1-30**] with chills. She went to see her PCP (w/ who she established in [**Month (only) 404**]) and was told to go to the hospital. She reports she was admitted to [**Hospital **] Hospital in [**Location (un) 8973**] through [**2-3**] and was treated with three days of levofloxacin without significant improvement. Per her report she was told she had to leave and so she drove to [**Location (un) 86**]. She has been living in her car since [**Month (only) 404**] due to problems with her finances. In [**Location (un) 86**] she went to the Women's Lunch Place and was seen by a physician who was concerned about her symptoms and encouraged her to go to the [**Hospital1 18**] for evaluation. . In the ED, initial VS were: 97.9 77 122/78 O2 sat 83% on RA, 100% on NRB. She triggered on arrival for hypoxia, but sats came up 1o 100% on non rebreather. Dialed down to NC- 97% on 4L. Patient underwent CXR which showed mild interstitial edema and bibasilar atelectasis. She had CTA chest which showed subsegmental bilateral pulmonary emboli, evidence of pulmonary hypertension with a dilated PA (3.5 cm), and pulmonary edema and dilated hepatic veins suggestive of heart failure. She received 1 g of cefepime, zofran, 0.5 mg dilaudid, and was started on a heparin gtt w/ bolus. One liter of NS was hung prior to admission. VS on transfer were: HR 62 109/61 RR 18 100% on non-rebreather. . On arrival to the MICU, the patient denies pain. She exhibits increased latency of speech and a restricted affect. She denies h/o recent immobility, surgery or malignancy. Past Medical History: [**Hospital1 **] cell disease Social History: Currently living in car due to financial issues. Is divorced and has one son who lives in [**State 2690**] w/ whom she is not in touch. She was previously self-employed in the greeting card business. - Tobacco: Smokes [**12-15**] cigarettes daily. Has smoked for [**4-19**] years. - Alcohol: Denies. - Illicits: Denies. Family History: Father and mother with [**Name2 (NI) 14165**] cell trait. Physical Exam: ADMISSION PHYSICAL EXAM: General: Awake, oriented, slow speech, restricted affect HEENT: Mildly icteric sclerae, dry membranes, non rebreather in place, EOMI, pupils 3 mm --> 2 mm Neck: supple, JVP not elevated, no LAD CV: regular slow rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Mild bibasilar crackles, but otherwise clear w/o rhonchi or wheezes Abdomen: soft, mildly tender to palpation in RUQ; marked hepatomegaly; non-distended, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength upper/lower extremities, grossly normal sensation . DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: [**2139-2-6**] 07:43PM BLOOD WBC-11.5* RBC-2.33* Hgb-9.1* Hct-24.3* MCV-105* MCH-39.2* MCHC-37.5* RDW-25.2* Plt Ct-549* [**2139-2-6**] 07:43PM BLOOD Neuts-49* Bands-0 Lymphs-44* Monos-3 Eos-3 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-18* [**2139-2-6**] 07:43PM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-3+ Macrocy-2+ Microcy-OCCASIONAL Polychr-2+ Ovalocy-1+ [**Month/Day/Year **]-2+ Schisto-2+ Stipple-2+ MacroOv-OCCASIONAL Tear Dr[**Last Name (STitle) **]2+ Fragmen-1+ Ellipto-1+ [**2139-2-6**] 07:50PM BLOOD PT-10.9 PTT-25.1 INR(PT)-1.0 [**2139-2-6**] 07:43PM BLOOD Ret Man-24.4* [**2139-2-6**] 07:43PM BLOOD Glucose-106* UreaN-31* Creat-1.0 Na-144 K-4.3 Cl-110* HCO3-22 AnGap-16 [**2139-2-6**] 07:43PM BLOOD ALT-32 AST-49* LD(LDH)-574* AlkPhos-117* TotBili-7.6* [**2139-2-6**] 07:43PM BLOOD cTropnT-<0.01 [**2139-2-6**] 07:43PM BLOOD Albumin-4.3 [**2139-2-6**] 07:55PM BLOOD Lactate-1.3 . RELEVANT LABS: [**2139-2-7**] 05:24AM BLOOD calTIBC-178 Ferritn-3320* TRF-137* [**2139-2-7**] 05:24AM BLOOD TSH-7.6* [**2139-2-7**] 01:43PM BLOOD Free T4-1.1 [**2139-2-7**] 05:24AM BLOOD 25VitD-20* [**2139-2-7**] 05:24AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2139-2-7**] 05:24AM BLOOD HCV Ab-NEGATIVE [**2139-2-10**] Hemoglobin electrophoresis: pending at the time of discharge [**2139-2-16**] 05:39AM BLOOD ALT-32 AST-36 LD(LDH)-441* AlkPhos-72 TotBili-3.0* . DISCHARGE LABS: [**2139-2-17**] 09:16AM BLOOD WBC-9.9 RBC-2.28* Hgb-7.6* Hct-21.5* MCV-95 MCH-33.3* MCHC-35.2* RDW-21.1* Plt Ct-461* [**2139-2-17**] 09:16AM BLOOD PT-11.1 PTT-31.3 INR(PT)-1.0 [**2139-2-17**] 09:16AM BLOOD Glucose-90 UreaN-28* Creat-0.8 Na-143 K-4.9 Cl-109* HCO3-26 AnGap-13 [**2139-2-17**] 09:16AM BLOOD Calcium-9.3 Phos-5.4* Mg-1.8 . MICROBIOLOGY: [**2139-2-6**] Blood cultures x2: no growth [**2139-2-6**] Urine culture: no growth [**2139-2-7**] MRSA screen: negative [**2139-2-7**] Influenza virus antigen screen and culture: negative . IMAGING: CTA CHEST W&W/O C&RECONS, [**2139-2-6**]: 1. Multiple subsegmental pulmonary emboli in the upper and lower lobes bilaterally. No CT evidence of right heart strain. 2. Mildly dilated main pulmonary artery and intrapulmonary arterial branches, findings suggestive of pulmonary hypertension. 3. Evidence of moderate pulmonary edema. 4. Band-like basilar opacities which could reflect atelectasis though are nonspecific. 5. Right medial lower lobe pleural based mass consistent with extramedullary hematopoiesis. . PORTABLE ABDOMEN [**2139-2-7**]: Nonspecific bowel gas pattern. No dilated air-filled loops of bowel to suggest obstruction or ileus. No definite free air. If clinically indicated, CT may help for more detailed assessment . BILAT LOWER EXT VEINS [**2139-2-7**]: No evidence of DVT . LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2139-2-7**]: 1. Nonvisualization of the gallbladder is likely secondary to prior cholecystectomy reported by patient. 2. Spleen not well visualized, possibly shrunken secondary to autosplenectomy in the setting of [**Month/Day/Year 14165**] cell disease. 3. Normal-appearing liver. . CXR portable [**2139-2-8**]: 1. CHF with interstitial edema, similar to [**2139-2-6**]. 2. Patchy opacities at both bases, similar but slightly worse compared with [**2139-2-6**]. These could represent atelectasis or scarring, though the possibility of infectious infiltrate, cannot be excluded. . TTE [**2139-2-9**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Dilated ascending aorta. Borderline PA systolic hypertension. . [**2139-2-15**] CT ABD/PELVIS WITH CONTRAST: There are increased interstitial markings within the lung bases bilaterally suggestive of pulmonary edema. There is cardiomegaly. No pleural effusion. A calcified granuloma within the right lung base (2:8), is stable measuring 3 mm. The liver is diffusely increased in attenuation. No ill-defined hypodensity within the dome of the liver at the junction of segments IV-A and VIII measuring 9 mm which is too small to characterize. No other focal liver lesions identified. Previous cholecystectomy noted. Likely previous autosplenectomy with no residual splenic tissue identified within the left upper quadrant. Both adrenal glands are normal in appearance. Both kidneys are lobulated in contour. No hydronephrosis or renal lesion identified. There is moderate atherosclerotic calcification of the aorta. Medial to the lesser curvature of the stomach, there is a 1.9 x 3 cm cystic area (2:15), which does not appear to communicate with the stomach. This may represent a duplication cyst, mesenteric or omental cyst. It appears benign. There is no retroperitoneal or mesenteric adenopathy. The mesenteric vessels opacify normally. The visualized small and large bowel are normal. No evidence of obstruction or free intraperitoneal air. No free fluid. CT PELVIS: The urinary bladder, uterus, rectum and sigmoid are normal in appearance. There is no free fluid or free air. OSSEOUS STRUCTURES: There is minor loss of anterior vertebral height of L1 of 10%. This is age indeterminate. No suspicious osseous sclerotic or lucent lesions identified. . IMPRESSION: 1. No cause identified for patient's pain. 2. Previous autosplenectomy. 3. Cystic area adjacent to the lesser curvature of the stomach which most likely represents a benign finding such as a duplication cyst, mesenteric or omental cyst. 4. Moderate atherosclerotic calcification. Brief Hospital Course: Ms. [**Known lastname 87027**] is a 54 year old female with PMH of [**Known lastname 14165**] cell anemia who presented with fever, cough, chest pain, and hypoxia, found to have bilateral subsegmental pulmonary embolism, [**Known lastname 14165**] cell crisis, and concern for acute chest. . . ACTIVE ISSUES: # Pulmonary embolism: Patient presented with subacute pleuritic chest pain and was found to be hypoxic, responsive to supplemental oxygen by non-rebreather. She remained clinically stable. LENIs were negative. There was no evidence of right heart strain on CT or TTE. Troponin was negative, and BNP essentially negative at 350. Likely provoked by underlying [**Known lastname 14165**] cell as no other risk factors. Heparin drip was started, and patient bridged to anticoagulation with warfarin. This was discontinued, per advice of Pulmonary and Hematology/Oncology consults, who thought the subsegmental PEs were more likely chronic and not the etiology of acute chest pain and hypoxia. Patient was discharged with plan to follow up with Pulmonology and Hematology/Oncology. . # Acute chest syndrome: Patient complained on substernal chest pain on presentation acute chest given [**Known lastname 14165**] cell crisis, along with reticulocyte count of 24.4 and Hct of 19.4 on admission (from baseline ~23-25). Tranfused 3 units of pRBCs over the course of hospitlization, and provided supplemental oxygen and IV pain medication (nalbuphine worked best). Patient was treated empirically with vanco/cefepime/levofloxacin, then levofloxacin only for a 7 day course. Additionally, she was treated for subsegemental PE's, as described above. . # Abdominal pain waxing and [**Doctor Last Name 688**], most likely secondary to constipation/gas and abdominal adhesions (secondary to previous sugeries). CT abdomen without acute pathology, but showed a lot of stool. RUQ U/S and liver labs not revealing. [**Doctor Last Name **] cell often associated w/ hepatomegaly. Found to be Hep B non-immune. Will be communicated to future PCP. . # Possible intent to self-harm: At the time of discharge, medical team was alerted that patient may have expressed intent to self harm to her homeless advocacy group. She was evaluated by Psychiatry and contract for safety. Denies intent to self harm. . . CHRONIC ISSUES: # Vitamin D deficiency: Found to be severely vitamin D deficient. Does take supplements at home, continued in house but increased to 800 units daily. She should continue high dose supplementation. . # Social situation: Patient currently unemployed and living in her car [**1-15**] lack of resources. Has limited social supports and restricted affect. She was seen by social workers while in house, and provided with information for resources. . . TRANSITIONAL ISSUES: # Code: DNR/DNI (confirmed w/ pt) # Should ensure vaccination for encapsulated bacteria (S. pneumo, HIB, Neisseria) # Patient found not to be immune to hepatitis; should undergo vaccination. # Hemoglobin electrophoresis was pending at the time of discharge, though patient has outside records confirming presence of HbS ~50% on prior electrophoresis. Medications on Admission: vitamin B12 multivitamin folic acid vitamin D Discharge Medications: None prescribed Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute chest syndrome Multiple subsegmental pulmonary embolisms . Secondary diagnosis: [**Month/Day (2) **] cell disease Borderline pulmonary arterial hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 87027**], It was a pleasure to participate in your care here at [**Hospital 61**] [**Hospital 1225**] Medical Center! You were admitted with chest pain and low oxygen levels. You were also found to have multiple small blood clots in your lungs. We believe your pain was from an acute pain crisis from your [**Hospital 14165**] cell disease, and also from the small blood clots in your lungs. Your pain was controlled with intravenous pain medication. Your blood clots were treated with intravenous heparin and oral warfarin. Also, we treated you for a possible lung infection with levofloxacin for seven days. After evaluation by Hematology and Pulmonology, it was determined that you did not need to continue warfarin for treatment of these clots. Please continue the following over-the-counter medications to improve your constipation: Colace (docusate sodium), senna, and Miralax. We also recommend that you continue to take vitamin D 800 units every day. It is important that you keep the follow up appointments that have been made for you, as listed below. The contact number for [**Name (NI) 86**] Health Care for the Homeless is [**Telephone/Fax (1) 29654**], in case you would like to contact them. Wishing you all the best! Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] E Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Street Address(2) 98360**], [**Location (un) **],[**Numeric Identifier 17156**] Phone: [**Telephone/Fax (1) 98361**] Please call Dr [**Last Name (STitle) 98362**] office to set up an appt for follow up within one week of discharge. Department: HEMATOLOGY/BMT When: MONDAY [**2139-2-23**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2139-3-5**] at 12:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2139-3-5**] at 1 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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50786

Discharge summary

report

Admission Date: [**2192-4-20**] Discharge Date: [**2192-4-24**] Date of Birth: [**2124-9-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Methotrexate / Fosamax Attending:[**First Name3 (LF) 1974**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Arthrocentesis PICC placement. History of Present Illness: 67 year old female with history of rheumatoid arthritis on low-dose prednisone, CAD s/p stent, HTN presents with 2 days of chills, headache, fevers. Patient says she was in store 2 days PTA and had sudden onset chills followed quickly by onset of severe headache. The patient says she had been feeling otherwise well. Headache characterized as severe, associated with photophobia, no neck stiffness. Says feeling very weak, light-headed over this time with chills and therefore presented to [**Hospital1 18**] ER. . Says intermittent, non-productive cough. Denies shortness of breath, chest pain. No dysuria. No abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, melena. . Also reports development of right second toe pain last night. . In the emergency department, fever to 104.5, initially sBP's in ED 170's. Treated with vancomycin, levoquin for possible pneumonia (penicillin allergy). Also got morphine for pain and then over a few hours BP's down to 80's. Got 3L NS and sBP increased to 110's. However, when pt would fall asleep BP would fall to 90's. ECG, CXR, CT torso unrevealing as to etiology. Was given Vanco, levofloxacin, Dexamethasone 10mg IV, Naloxone 0.4, Ibuprofren 600mg, Acetominophen 1g, Morphine 6mg IV. Past Medical History: 1) Rheumatoid Arthritis 2) Coronary Artery Disease: Unstable angina in [**2188**]-- C-cath mid LAD 30%, mid LCx 50%, Om1 and OM2 70% (stented via kissing stents) - [**5-2**] ETT MIBI: [**Doctor Last Name 4001**] X 3.75 min, 57% PMHR, no myocardial perfusion defects 3) Hypertension 4) Renal Artery Stenosis 5) PUD 6) Iron deficiency Anemia 7) h/o (+) PPD: prior CXR w/ RLL calcified granuloma 8) psoriasis 9) hypercholesterolemia 10)Compression fractures 11)?COPD Social History: Pt. lives in apartment with her grandson. She has a roughly 96 pack year history of cigarette use. She denied use of alcohol or illicit drugs. She walks for exercise approximately 30 minutes/day. Family History: Pt. had a brother who suffered from an MI at age 58. She could not recall any other significant family h/o disease. Physical Exam: PE: Temperature: 104.5/99 HR: 92 BP: 110/72 RR: 14 95%2l General: Spanish-speaking female, A&OX3 but somnolent, coughing occasionally, speaking in complete sentences, NAD HEENT: anicteric, pale conjunctiva, MMM, OP clear, neck supple Cardiac: RR, +murmur (previously noted) Pulmonary: minimal crackles left base Abd: +b/s, obese, soft, NT/ND, no masses Ext: trace ankle edema, no cyanosis Integument: warm, dry Heme/Lymph: shotty anterior cervical LAD Back: No tenderness to percussion over spine Neuro: AAOx3 but somnolent, CNII-XII intac t rectal: nl tone, guiaic negative. Pertinent Results: [**2192-4-19**] 10:53PM WBC-12.2*# RBC-3.99* HGB-11.2* HCT-34.1* MCV-86 MCH-28.0 MCHC-32.7 RDW-15.7* [**2192-4-19**] 10:53PM NEUTS-85.4* BANDS-0 LYMPHS-10.4* MONOS-3.2 EOS-0.6 BASOS-0.5 [**2192-4-19**] 10:53PM PLT COUNT-198 [**2192-4-19**] 10:53PM GLUCOSE-112* UREA N-18 CREAT-1.3* SODIUM-136 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [**2192-4-19**] 10:53PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-91 TOT BILI-0.4 [**2192-4-20**] 02:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.021 [**2192-4-20**] 02:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD [**2192-4-20**] 02:30AM URINE RBC-[**1-30**]* WBC-[**5-6**]* BACTERIA-MANY YEAST-NONE EPI-[**10-16**] [**2192-4-20**] 06:46AM LACTATE-1.0 [**2192-4-20**] 06:35PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-4* POLYS-0 LYMPHS-80 MONOS-0 MACROPHAG-20 [**2192-4-20**] 06:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-39 GLUCOSE-69 . . CT TORSO: 1) No CT findings to explain the patient's fever. 2) No lymphadenopathy within the chest to correlate with chest x-ray findings of hilar fullness. 3) Diverticulosis without diverticulitis. 4) Cholelithiasis. . . TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 80%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. . . BLOOD Cultures ([**4-22**]): 4/4 bottles beta strep group A Brief Hospital Course: 1) SEPSIS: Patient was admitted to [**Hospital Unit Name 153**]. Never required pressors as BP responded to fluids. Started on vanco, ceftriaxone, and levaquin. Initially, there was no clear source of infection. She had a painful erythematous toe on right foot. Admission blood cultures grew out group A strep in high grade. Her antibiotics were narrowed to Ctx only. ID was consulted. It was felt that the toe was the likely source of infection. Surveillance blood cultures were clear except for [**12-1**] CNS on [**4-22**] that was a likely contaminant. Pt's fevers and leukocytosis resolved with antibiotics. She will complete a 4 week course of Ctx and f/u with ID. . 2) Septic Arthritis/Cellulitis: Rheumatology was consulted regarding the 2nd digit on her right foot. An athrocentesis was done with scant fluid which was negative on culture. However, it was felt that the pt may have had a septic arthritis there so pt's abx course was plannned for 4 weeks. The joint was small and there was no fluid there so a surgical washout was not necessary. . 3) R.A: Per rheum, leflunomide was stopped and prednisone was continued. . 4) CAD/HTN: Initially, her BP meds were held due to sepsis. After she was on the floor, her BP rose and her meds were restarted. On discharge, she is to resume all her pervious cardiac meds. Medications on Admission: 1. Advair 2. Albuterol 3. Arava 20mg daily 4. Atenolole 100mg daily 5. Asprin 81 mg daily 6. Plavix 75 mg daily 7. Diovan 160 mg daily 8. lasix 40 mg daily 9. lipitor 40mg daily 10. mylanta prn 11. nitro sl prn 12. prilosec 40 mg daily 13. prednisone 5mg daily 14. colace 15. calcium carbonate Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 26 days. Disp:*26 gram* Refills:*0* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for foot pain. 16. PICC care as per NEHT protocol 17. Outpatient Lab Work Weekly CBC, BUN, Creatinine, AST, ALT, alk phos, Total bili starting [**4-30**]. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID at [**Hospital1 18**]) at [**Telephone/Fax (1) 11959**]. Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: PRIMARY: 1) Strep bacteremia 2) Septic arthritis, foot SECONDARY: Hypertension CAD Rheumatoid arthritis Discharge Condition: Good--afebrile, vital signs stable. Discharge Instructions: 1. Take medications as prescribed. DO NOT take Arava until instructed to restart by Dr. [**Last Name (STitle) 6426**] 2. Follow up as below. 3. Please seek medical attention for fevers, chills, chest pain, shortness of breath, worsening pain on your toe, abdominal pain. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-5-21**] 11:30 . Please call Dr. [**Last Name (STitle) 6426**] to set up a follow up appointment. . Please call Dr. [**Last Name (STitle) **] in [**Company 191**] to set up a follow up appointment in [**11-29**] weeks.

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icd9cm

[ [ [] ] ]

[ "81.91", "38.93" ]

icd9pcs

[ [ [] ] ]

8433, 8485

5106, 6444

304, 337

8634, 8672

3065, 5083

8995, 9377

2335, 2453

6789, 8410

8506, 8613

6470, 6766

8696, 8972

2468, 3046

258, 266

365, 1614

1636, 2102

2118, 2319

49,844

153,531

38857

Discharge summary

report

Admission Date: [**2136-5-8**] Discharge Date: [**2136-5-22**] Date of Birth: [**2097-7-3**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Bactrim / Shellfish Derived / Dilaudid Attending:[**First Name3 (LF) 1835**] Chief Complaint: Neck Pain Major Surgical or Invasive Procedure: [**2136-5-11**]: Anterior T1 corpectomy(full) C7, T2 corpectomy(partial) [**2136-5-16**]: Posterior C5-T4 fusion with ICBG History of Present Illness: The patient is a 38 year old female who saw Dr. [**Last Name (STitle) 957**] in neurosurgery clinic on [**5-8**], for neck pain radiating to the right scapula. The pain began in [**Month (only) 956**] and has become increasingly worse. She also has weakness in the right hand. She reports decreased sensation in the lateral aspect of the RUE. The patient has no known cancer history. She has no bowel or bladder abnormalities. She has no SOB or chest pain. Past Medical History: allergies and asthma s/p c-section Social History: Married, resides at home with twin four-year olds Family History: no history of malignancy Physical Exam: Exam on Discharge: Awake, alert to person, place and date. Full strength/sensation in all extremities with the following exception: Right finger intrinsics are [**4-16**] and and right grip is 5-/5. there is decreased sensation to light touch over the right 4th and 5th digits. Anterior and posterior wounds are clean, dry and intact. Pertinent Results: Labs on Admission: [**2136-5-8**] 03:30PM BLOOD WBC-10.0 RBC-4.67 Hgb-13.3 Hct-40.8 MCV-87 MCH-28.5 MCHC-32.6 RDW-13.5 Plt Ct-367 [**2136-5-8**] 03:30PM BLOOD PT-12.4 PTT-32.4 INR(PT)-1.0 [**2136-5-8**] 03:30PM BLOOD Glucose-91 UreaN-9 Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 [**2136-5-10**] 04:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 Labs on Discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2136-5-21**] 06:05AM 10.4 3.16* 9.4* 27.9* 88 29.7 33.6 13.9 608 -------------------- IMAGING: -------------------- CT TORSO [**2136-5-9**] CT THORAX: Thyroid gland is unremarkable in appearance. Heart is normal in size. There is no pericardial effusion. The abdominal aorta has a normal course and caliber. Pulmonary vasculature is within normal limits. No enlarged hilar, mediastinal or axillary lymph nodes are identified. Airways are patent. Lungs are clear. There is mild atelectasis at the right lung base. No pleural effusions. Of note, there is heterogeneous enhancement of the breast tissue, with areas of tiny nodular enhancement, bilaterally. CT ABDOMEN: The liver is homogeneous in contrast enhancement without abnormal enhancing mass identified. There is no intrahepatic biliary ductal dilatation. Portal and hepatic veins are patent. Spleen, gallbladder, pancreas, and adrenal glands are unremarkable in appearance. Kidneys demonstrate prompt and symmetric uptake and excretion of contrast. The visualized bowel is unremarkable in appearance without bowel wall thickening, inflammatory changes or obstruction. The abdominal aorta has a normal course and caliber. No enlarged intraperitoneal, retroperitoneal or mesenteric lymph nodes are identified. CT PELVIS: Bowel loops are unremarkable in appearance. Uterus and ovaries are visualized. There is a nabothian cyst. No free fluid within the pelvis. No enlarged pelvic lymph nodes are identified. There is large destructive lesion eroding the T1 vertebral body and right pedicle. There is a soft tissue mass associated with this which is extending posteriorly into the cervical canal resulting in superior and leftward displacement of the thecal sac. This mass extends into the right neural foramen. No other osseous lesions are identified. IMPRESSION: 1. Large soft tissue mass eroding the entire T1 vertebral body and extending posteriorly into the central canal with posterior and leftward displacement of the thecal sac and complete effacement of the right neural foramen. 2. No other osseous lesions or metastasis within the chest, abdomen or pelvis. 3. Heterogeneous nodular enhancement of the breast tissue bilaterally. multifocal DCIS [**Last Name (un) 5798**] to be excluded and correlation with mammogram is recommended, especially in the setting of a lytic osseous lesion. [**2136-5-12**] CT C-spine 1. Expected post-operative findings, immediately status post T1 corpectomy. 2. Overall alignment maintained. 3. Continued extensive bone destruction of the right pedicle and lamina of the T1 vertebral body with associated soft tissue density, better-evaluated very recent (MetroNorth MRI) non-enhanced MRI of [**2136-5-7**]. [**2136-5-16**] CT C-spine Interval posterior spinal fusion from C4-T3 without immediate hardware complication. Unchanged anterior spinal fusion at C6-T1. [**2136-5-20**] CT C-spine prelim IMPRESSION: Unchanged postop appearance of cervical and thoracic spine with no fractures noted. The imaging extends down from the craniocervical junction down to T8 vertebral body. NOTE ADDED AT ATTNEDING REVIEW: I agree with the above interpretation, but note that the artifacts arising from fusion hardware obscure nearly all intraspinal soft tissue detail at the surgical levels. There is no evidence of hardware loosening or fracture. Brief Hospital Course: Patient was admitted from NSURG office for further evaluation of newly identified T1 lesion. Upon admission, she was placed in a cervical collar, and CT torso obtained to evaluate for alternate solid mass disease. This was grossly unremarkable. Mammogram was also obtained of the bilateral breasts on [**5-10**] to evaluate for possible lesions. This was negative for any malignancy. Cardiothoracic surgery was consulted for possibility of providing exposure of T1 body anteriorly, but it was decided that it was not necessary, and neurosurgery performed the procedure independently. On [**5-11**], Ms. [**Known lastname 14129**] went to the OR for T1 and T2 corpectomies. She tolerated the procedure well and was transferred to the ICU to recover. Her neurological exam remained stable, in fact slightly improved, and her pain was well controlled as well. She was transferred out of the unit to the floor on [**5-12**]. The patient continued to have weakness in the intrinsic muscles on the RUE as well as numbness in the last 2 digits in that hand. She had some difficulty swallowing and was placed on a modified diet. She had a swallowing evaluation and they agreed with the modified diet. On [**5-16**] the patient went back to the OR for stage II of her procedure, which was a posterior fusion from C5-T3. She tolerated the procedure well and a hemovac drain was placed. This remained in until [**5-18**]. She was out of bed with PT and ambulated well. Her pain was well controlled on a MSO4 PCA, which was weaned off to PO on [**5-18**]. She was ambulating well and voiding and doing well with a regular diet. She developed a new LUE numbness at her forearm and 5th digit. CT imaging was unchnaged. She was on a bowel regimen for constipation buthad flatus. She was discharged to home on [**5-22**], with follow up arranged for [**Hospital3 328**] the same day. Medications on Admission: claritin 10neurontin 300 TID, vicodin PRN, flonase 200 mcg, Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 2. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: For breakthrough pain only. Disp:*60 Tablet(s)* Refills:*0* 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0* 8. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). Disp:*180 Tablet(s)* Refills:*0* 9. 3 way cammode Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: T1 osteolytic lesion **Path: Giant Cell tumor of Bone Discharge Condition: Neurologically Stable Discharge Instructions: 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 hard 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 [**5-21**] pound weight lifting restriction ?????? half days might be better at first. Wound Care: ?????? You may shower(incisional area down), 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 [**First Name3 (LF) 2729**] 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(this is for the front part of your neck). You have [**First Name3 (LF) 2729**] in the back of your neck that MUST BE REMOVED. ?????? You may remove the dressing after 2 days after surgery. If there is still a small amount of bloody drainage, you can place a new sterile gauze dressing, otherwise you can leave the wound open to air. 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 return to the office in [**7-21**] days (from your date of surgery) for removal of your staples/[**Date Range 2729**] and a wound check. Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. ??????You will need an MRI of the cervical spine(Levels C1-T5) with & without gadolinium contrast. You also have an appointment scheduled with [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) 86246**], MD at the [**Hospital3 328**] Cancer Institute on [**5-22**] at 4pm. His office is located at: [**Hospital Ward Name 86247**]. The office phone number and fax are: [**Telephone/Fax (1) 86248**] (office), [**Telephone/Fax (1) 86249**](fax), should you need to change your appointment or need additional directions to the building. Completed by:[**2136-5-22**]

[ "564.09", "731.3", "238.0", "493.00", "336.3" ]

icd9cm

[ [ [] ] ]

[ "81.03", "81.63", "81.04", "77.79", "80.99", "84.51", "81.62", "03.4", "81.05" ]

icd9pcs

[ [ [] ] ]

8225, 8300

5275, 7155

325, 450

8398, 8422

1476, 1481

13363, 14550

1079, 1105

7265, 8202

8321, 8377

7181, 7242

8446, 9863

1120, 1120

276, 287

1837, 5252

9875, 13340

478, 937

1139, 1457

1495, 1818

959, 996

1012, 1063

9,802

143,587

29305

Discharge summary

report

Admission Date: [**2118-12-18**] Discharge Date: [**2118-12-23**] Date of Birth: [**2096-1-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: EtOH intoxication Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms. [**Known lastname 70418**] is a 22-year-old woman transferred from [**Hospital 11694**] Hospital where she was evaluated on [**2118-12-18**] after being found unresponsive and surrounded by evidence of alcohol consumption. She acknowledges significant drinking but has no memory of how much she drank or how she got to the hospital. (Per report, it was a cousin who brought her to the [**Name (NI) **].) She states this was not a suicide attempt and not associated with any particular stressors. She says this is abnormal for her, reporting that she normally drinks once every 2 to 3 months and this is the first time she has drunk to the point of losing consciousness. . At OSH, her EtOH level was found to be approximately 550. She was hypoxic and was therefore intubated for respiratory failure. An ABG obtained there was 6.99/11/25/2.8. CK was elevated at over 2500. Her temp was 93F. There was concern for cerebral edema there and she received mannitol, Decadron, and possibly a diuretic. She also received 2 amps of bicarb, Narcan (with no effect), and moxifloxacin and clindamycin for presumed aspiration after a chest x-ray showed a "diffuse bilateral perihilar process." . At the [**Hospital1 18**] ED, VS on arrival were: T: 98; HR: 127; BP:164/75; and on AC 600/12/5/1.00. She was admitted to the MICU. There, she was treated with Unasyn for 3 days for aspiration pneumonia. She was extubated the day after admission and has done well. Her CK peaked at over 8000, attributed to rhabdomyolysis. . ROS: She reports a mild sore throat. She denies cough, dyspnea, chest pain, nausea, vomiting, diarrhea, tremors, and visual and auditory hallucinations. She denies a depressed mood and suicidal ideations. Past Medical History: None Social History: EtOH as above. She denies tobacco or illicit drugs. She lives with her father and sister, and she is studying English at Baccale (sp?). Family History: Non-contributory Physical Exam: Vitals: 99.0F 140/100 80 20 100%2L Gen: Well-appearing woman in NAD. HEENT: NC/AT. MMM no erythema/exudate. JVP normal. Neck supple w/o LAD. Pulm: Clear to auscultation bilaterally. CV: Regular Rate and Rhythm, with no murmurs, rubs, or gallops. Abd: Soft, non-tender and non-distended. Bowel sounds are normoactive. Ext: 2+ dorsalis pedis pulses; no edema, clubbing, or cyanosis. Neuro: AAOx3. Speech fluent, comprehension intact. CNII-XII grossly intact. Strength 5/5 throughout. Intact F->N and [**Doctor First Name **]. Gait intact, ambulating independently without difficulty. Romberg negative. Pertinent Results: Notable Labs: CK: 4729 -> 6890 -> 8717 -> 6839 -> 5688 -> 4307 Cr: ranged 0.7 - 0.9 WBC: 16.2 -> 17.7 -> 13.2 -> 9.8 . Chem-7 on transfer to floor: 141 108 6 101 AGap=13 4.3 24 0.7 Ca: 8.4 Mg: 1.9 P: 3.6 . LFTs from [**12-21**]: ALT: 60 AP: 64 Tbili: 0.6 Alb: 2.9 AST: 174 LDH: 431 Dbili: TProt: [**Doctor First Name **]: 79 Lip: 54 . ABG on Admission: PO2-393* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS--2 . Studies: - EKG: ? sinus rhythm (no discernible p waves) vs junctional. Nl axis. nl interval. TWI III, AvF, AVL, V3-V6. - CXR [**12-18**]: 1. Support tubes in place. ETT 4.2 cm above carina, OG tube 2. Perihilar and right middle lobe opacities suggestive of pulmonary edema and/or infectious consolidation. - Head CT: No evidence of hemorrhage. No mass effect. Sinus disease. There is no evidence of edema. - CXR [**12-22**]: Dense right middle and lower lobe opacification consistent with bulbar collapse or dense consolidation. . . Brief Hospital Course: Ms. [**Known lastname 70418**] is a 22-year-old woman with no significant medical history who presented unconscious with severe alcohol intoxication. Her brief hospital course by problem is as follows: . 1. Alcohol intoxication. Ms. [**Known lastname 70418**] [**Last Name (Titles) 70419**] denied chronic drinking, saying that she drinks only once every couple of months. This is the first time she has drunk to the point of unconsciousness. She was placed on a CIWA scale with valium but did not require any. Psychiatry was involved and felt that her binge drinking was not a suicidal gesture. She was counseled on the dangers of binge drinking. . *** A long term social work connection is likely indicated. It is unclear exactly what her drinking patterns are, as her description of her alcohol habits changes. It is also uncertain what social stressors have precipitated her drinking, although she does acknowledge recent attempts to lose weight using OTC medications. *** . 2. Respiratory failure. This was attributed to pneumonia seen on CXR; this in turn was felt to be the result of aspiration secondary to her alcohol intoxication. She was tachypneic to the 50s on arrival and initially in the MICU. As a result, Ms. [**Known lastname 70418**] was intubated and mechanically ventilated over the first night of her hospitalization. She was extubated on her second hospital day. She was subsequently weaned from supplemental oxygen and was satting well on room air at discharge. She was afebrile for the final 24 hours of hospitalization, and her WBC count normalized from a peak of over 17,000. Sputum culture showed only OP flora. She was treated initially with Unasyn and then Augmentin; she was discharged with a prescription for Augmentin for a full two weeks of antibiotic therapy. . *** It is advised that her PCP obtain [**Name Initial (PRE) **] chest x-ray in [**4-7**] weeks. *** . 3. Increased CK. This was likely the result of rhabdomyolysis after being down for an indeterminate amount of time. She had no evidence of renal failure. She was aggressively hydrated, and her CK trended down for the three days prior to discharge. . 4. Elevated LFTs. This was likely due to alcohol. Her LFTs were followed and showed improvement. . 5. Question of cerebral edema. This was reportedly seen on Head CT at the OSH. However, it was not seen on a stat Head CT performed at [**Hospital1 18**]. . 6. Communication: Sister [**Name (NI) **] [**Name (NI) 70418**] ([**Telephone/Fax (1) 70420**]) acted as her primary contact, though the whole family was involved. . 7. CODE: FULL . 8. Dispo: She was discharged to home with follow-up advised. She was ambulating independently. Medications on Admission: None . Allergies: NKDA Discharge Medications: 1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Alcohol intoxication, severe 2. Aspiration pneumonia 3. Rhabdomyolysis . Secondary: None. Discharge Condition: Good condition, vital signs stable, no signs of withdrawal, neurologically intact, ambulating independently. Discharge Instructions: You have been treated for severe alcohol intoxication. You were intubated due to respiratory failure that occurred as a consequence of alcohol intoxication. You were also found to have a pneumonia as a result of aspirating while intoxicated. You were treated with two antibiotics, Unasyn and Augmentin, and have been given a prescription for Augmentin to take at home. Please take all the pills provided of this antibiotic as directed, even if you feel better. Take all other medications as previously prescribed and keep all follow-up appointments. . You should be aware that alcohol intoxication can be fatal, as this episode nearly was for you. Drinking to excess again in the future may lead to your death. If you develop any tremulousness, shakiness, visual or auditory hallucinations, severe vomiting or diarrhea, an inability to tolerate fluids by mouth, or any other symptom that is concerning to you, please call your PCP or go to the nearest hospital emergency department. Followup Instructions: A follow-up appointment has been made for you on [**1-6**] at 2:30 pm with the Nurse Practitioner in your PCP's office, Foimise Magney. Their office is located at [**Hospital1 70421**] in [**Hospital1 8**]. If you cannot keep this appointment, please call [**Telephone/Fax (1) 45347**] to reschedule. . You have also been scheduled to see Dr. [**Last Name (STitle) 70422**] in the same office on [**Last Name (LF) 766**], [**1-23**], at 3:00 pm. At this time, she will likely wish to get a repeat chest x-ray. Again, please call [**Telephone/Fax (1) 45347**] if you need to reschedule. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2118-12-23**]

[ "305.00", "785.0", "518.81", "728.88", "507.0", "293.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

6856, 6862

3937, 6620

334, 347

7008, 7119

2959, 3307

8150, 8889

2292, 2311

6694, 6833

6883, 6987

6646, 6671

7143, 8127

2327, 2940

276, 296

375, 2093

3693, 3914

3321, 3684

2115, 2122

2138, 2276

23,535

100,598

45818

Discharge summary

report

Admission Date: [**2179-10-21**] Discharge Date: [**2179-11-5**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2840**] Chief Complaint: Fever and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: The pt is an 84 yo female with past hx significant for DM type II, CHF, HTN, hypothyroidism, A-fib, chronic leg ulcers, and chronic renal insufficiency who presented to the ED on [**10-21**] with fever to 102 F and hypotension. She was transferred to the ICU where the hospital course was as follows: Sepsis protocol was initiated. Coverage of multiple possible sources was begun with vancomycin, levofloxacin, and metronidazole. Pt was aggressively fluid resuscitated. Norepinephrine drip was required to maintain blood pressure in adequate range. Urine culture was positive for Klebsiella pneumoniae, and the patient also had stool positive for C. diff toxin. Vancomyin was discontinued after osteomyelitis was ruled out as a possible infection in this patient. The patient's blood pressure was stable and the norepinephrine drip was discontinued. She was transferred to 12R on the am of [**2179-10-26**]. On arrival to the floor her temp was 100, hr 90-110, bp 100/60. Past Medical History: - Hypertension - DM II - Atrial Fibrillation - Gastroesophageal Reflux Disease - Total abdominal hysterectomy, bilateral salpingoophorectomy - Anemia - Chronic renal insufficiency (baseline 1.4 - 1.5) - Chronic leg ulcers - Anemia - Hypothyroidism Social History: - Denies smoking, EtOH, or drinking history. - Pt was independent until recent stay at [**Hospital3 2558**] - POA is [**Name (NI) **] [**Name (NI) 71227**] Family History: Non-contributory Physical Exam: Exam on arrival to the floors: VS: 97.8, 110/80, 78, 18, 98% on 4L NC Gen: lying in bed moaning, leaning to the right side, with preferential right gaze, difficult to understand speech HEENT: NC/AT, perrl, mmd, o/p clear Neck: L IJ CVL in place CV: irreg irreg, s1 and s2, no m/r/g Pulm: crackles bilaterally Abd: obese, soft, nt, nd, active bs Extr: 2+ edema throughout arms, legs, eye-lids; multiple deep ulcers bilaterally that are bandaged, bandages c/d/i Pertinent Results: [**2179-10-21**] 05:00PM GLUCOSE-98 UREA N-89* CREAT-2.9*# SODIUM-153* POTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-25 ANION GAP-20 [**2179-10-21**] 05:00PM WBC-21.7*# RBC-5.41* HGB-13.4 HCT-43.0 MCV-79* MCH-24.7* MCHC-31.2 RDW-18.9* [**2179-10-21**] 05:00PM NEUTS-87.9* BANDS-0 LYMPHS-7.1* MONOS-3.1 EOS-1.3 BASOS-0.4 [**2179-10-21**] 05:00PM PLT SMR-NORMAL PLT COUNT-323 [**2179-10-21**] 05:00PM PT-13.8* PTT-25.7 INR(PT)-1.2 [**2179-10-21**] 05:00PM ALT(SGPT)-13 AST(SGOT)-18 CK(CPK)-35 ALK PHOS-110 AMYLASE-69 TOT BILI-0.4 [**2179-10-21**] 05:18PM LACTATE-3.8* [**2179-10-21**] 05:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2179-10-21**] 05:55PM URINE RBC-[**3-19**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2179-10-21**] 06:55PM DIGOXIN-1.7 [**2179-10-21**] 06:55PM CORTISOL-24.9* [**2179-10-21**] 11:15PM CK-MB-3 cTropnT-0.03* [**2179-10-21**] 05:00PM cTropnT-0.02* [**2179-10-22**] 12:00AM CORTISOL-42.9* On discharge: [**2179-11-5**] 05:49AM BLOOD WBC-12.5* RBC-3.59* Hgb-9.2* Hct-28.6* MCV-80* MCH-25.6* MCHC-32.1 RDW-26.4* Plt Ct-316 [**2179-11-5**] 05:49AM BLOOD PT-13.0 PTT-31.8 INR(PT)-1.1 [**2179-11-5**] 05:49AM BLOOD Glucose-147* UreaN-29* Creat-0.6 Na-143 K-3.7 Cl-110* HCO3-28 AnGap-9 [**2179-10-27**] 10:45AM BLOOD calTIBC-131* Ferritn-196* TRF-101* TSH: [**2179-10-21**] 09:16PM BLOOD TSH-8.0* [**2179-10-27**] 10:45AM BLOOD TSH-16* [**2179-11-3**] 06:19AM BLOOD TSH-30* [**2179-10-27**] 10:45AM BLOOD Free T4-0.6* Digoxin: [**2179-10-21**] 06:55PM BLOOD Digoxin-1.7 [**2179-11-3**] 06:19AM BLOOD Digoxin-0.9 CXR [**11-2**]: A left internal jugular vascular catheter remains in satisfactory position. The cardiac silhouette is enlarged but stable. There is some degree of respiratory motion present, resulting in blurring of the pulmonary vasculature. This limits assessment for mild congestive heart failure. Bilateral pleural effusions are present and are partially layering on this semi-erect study. Increased opacity persists in the left retrocardiac region. AXR [**11-2**]: Gas present in colon. No abnormalities. Brief Hospital Course: 84 yo F presented with sepsis, transfered to ICU on arrival. In the ICU, a sepsis protocol was initiated. Coverage of multiple possible sources was begun with vancomycin, levofloxacin, and metronidazole. She was aggressively fluid resuscitated. A norepinephrine drip was required to maintain blood pressure in adequate range. Urine culture was positive for Klebsiella pneumoniae, and the patient also had stool positive for C. diff toxin. Vancomyin was discontinued after osteomyelitis was ruled out as a possible infection in this patient. The patient's blood pressure was stable and the norepinephrine drip was discontinued. She was transferred to 12R on the am of [**2179-10-26**]. On arrival to the floor her temp was 100, hr 90-110, bp 100/60. 1) ID: On the floors she completed 14 day courses of both flagyl and meropenem, and remained afebrile and hemodynamically stable throughout the remainder of her hospital course. 2) Leg Ulcers: The patient was seen by vascular surgery who felt that her ulcers were a combination of venous stasis and pressure ulcers. ABIs were not done as it would cause the patient too much pain, and the patient was not felt to be a surgical candidate regardless in light of her condition and comorbidities. Her dressings were changed once a day, however this was causing her extreme pain, despite morphine and ativan premedication, and dressing changes were decreased to every three days, and then not at all. She should not have any further dressing changes, as the pain is excrutiating for her. 3) Anasarca/fluid balance/hypernatremia: Ms. [**Known lastname 97599**] was found to be intravascularly depleted (high sodium), but total body fluid overloaded. We attempted diuresis, but this only elevated her sodium. We therefore fluid resuscitated her to lower her sodium, and then began diuresis once her hypernatremia had resolved. We had hoped that her fluid balance would improve with initiation of TPN to raise her albumin, however, after a week of TPN, her albumin continues to decrease, and she is not eating anything. Her anasarca persists. She will get maintenance IVF at [**Hospital3 2558**] with D5, in the absence of other forms of nutrition. 4) Nutrition: TPN was initiated through her central line on [**10-29**]. Her albumin was 2.6 on [**10-21**], declining to 1.9 on [**11-3**]. She occasionally ate spoonfulls of pudding, however largely refused food and PO medications. 5) Anemia: The patient had a baseline hct ranging from 35-43 prior to admission, while declined to 29-31 for much of her stay. Her iron studies indicated anemia of chronic disease, and her stool was guaiac negative. She did not receive any transfusions. 6) Hypothyroidism: Ms. [**Known lastname 95808**] was profoundly hypothyroid, with a TSH of 8 on admission, increasing to 16 and then 30 at discharge despite increasing her thyroxine dose (it takes [**6-22**] weeks for the new dose to take effect, however the TSH should not continue to rise to such an extent). 7) Pain: Ms. [**Known lastname 95808**] [**Last Name (Titles) 97600**] anytime she was touched. She persistenly denied pain, only admitting to pain during her dressing changes. Despite this, she [**Last Name (Titles) 97600**] anytime anyone touched her. We decreased the frequency of her dressing changes secondary to her extreme pain, and used morphine concentrated solution 4 mg Q 4 hours for pain. She should be given tylenol 1000 mg PR Q 6 hours as needed for pain, as well as morphine concentrated solution 5 mg Q 4 hours around the clock. 8) Atrial fibrillation: Her a-fib was poorly controlled with digoxin in the unit, and not responsive to amiodarone. On the floors her rate was well-controlled in the 60s, though her pulse was irregularly irregular. She was therefore maintained on digoxin and coumadin for anticoagulation. Her coumadin was maintained at 1 mg qhs and INR was therapeutic for the most part. 9) Mental status: The patient had waxing and [**Doctor Last Name 688**] mental status, but mostly was delirious. She leaned to the right side, with R lateral gaze preference. A head CT was performed due to concern for stroke, and was negative for any acute intracranial process. 10) Code status: She was DNR/DNI during the hospitalization. During a family meeting with her long-time boyfriend [**Name (NI) **], for whom she cares a lot, and who cares for her, on her last day of hospitalization it was decided that in light of her failure to demonstrate any improvement, persistent refusal to eat and worsening albumin in spite of TPN, along with continued extreme pain and incredibly poor prognosis, the best thing for her would be comfort care only. She should be given pain medications, with PRN zyprexa for aggitation for the next 3 weeks. Her boyfriend, [**Name (NI) **], would like her to receive fluids for the time being, in order to try to buy her a little bit more time to see if she will eat. It has been explained that this may only prolong her life for a little while, and he will consider stopping the fluids in the future. She will get maintenance fluids through her central line, which can be flushed with heparin to keep it patent. Medications on Admission: citalopram 20 mg po daily mirtazapine 15 mg qhs docusate 100 mg po senna po bid bisacodyl 2 mg daily prn levothyroxine 125 mcg daily glipizide 25 mg daily regular insulin protonix 40 mg daily albuterol MDI q6 prn simethicone qid prn metoprolol 75 mg tid tylenol750 mg q6 tramadol 25 mg q6 prn coumadin 1 mg qhs enalapril 10 mg daily lasix 40 mg po daily oxycodone/APAP fentanyl zinc keflex MVI Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). 2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD (once a day) as needed: 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen QD and PRN. . 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for aggitation for 3 weeks. 4. Acetaminophen 650 mg Suppository Sig: 1-2 tabs Rectal Q6H (every 6 hours) as needed for pain. 5. IV fluids Please give IVF: D5, [**1-15**] normal saline at a rate of 50 cc/hr continuously. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: urosepsis c. difficile colitis venous stasis/pressure ulcers on legs b/l Anasarca DM type 2 Hypothyroidism A-fib Hypertension Discharge Condition: poor Discharge Instructions: Comfort care only. Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "38.91" ]

icd9pcs

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17201

Discharge summary

report

Admission Date: [**2124-8-11**] Discharge Date: [**2124-9-12**] Date of Birth: [**2055-3-29**] Sex: M Service: [**Doctor First Name 147**] Allergies: Penicillins Attending:[**First Name3 (LF) 473**] Chief Complaint: Drainage around CT guided drain Major Surgical or Invasive Procedure: colonic resection CT guided abscess drainage History of Present Illness: This patient is a 69-year-old male who has had several episodes of idiopathic pancreatitis. The previous summer, he was found to have a 5 x 3 cm mass in the pancreatic body, which was biopsied by ultrasound guidance. This aspiration revealed unremarkable ductal cells and Strep and E. coli. It was decided that the patient would best undergo resection of the pancreatic mass on [**6-6**]. His post operative course was complicated by a Pulmonary embolus. He also has had postoperative fluid collections in his pancreas and a low output fistula measuring at most 40 cc of pus-type fluid a day. Most recently, the patient presented to [**Hospital6 **] with a fever to 103, runny nose, cough, nausea, shortness of breath. He had a CT scan done at an outside facility that demonstrated a subdiaphragmatic abscess on the left which was bilobed and measturing 9.8 x 6.3 cm in size. This is contiguous with a focal collection along the pancreatic remnant measuring 5.8 x 5.1 cm. He was transfered to [**Hospital1 18**] for drain placement for the fluid collection on [**2124-7-31**]. He was discharged to home on [**2124-8-7**] in stable condition with a drain in place and on antibiotics. The patient now returns with increased drainage around the drain, without other symptoms including fever, abdominal pain, nausea, vomiting, diarrhea, chest pain, or shortness of breath. Past Medical History: 1. Hypertension 2. insulin dependent diabetes mellitus 3. Status post subtotal pancreatectomy and splenectomy 4. Obesity 5. Recent history of pulmonary embolus 6. Vertigo 7. Congestive Heart failure 8. History of Supraventricular tachycardia 9. klebsiella bacteremia Social History: non smoker, no alcohol Family History: Sister with Diabetes Father Mi at 62 years old Physical Exam: Temperatuer 99.5, Pulse 84, Blood pressure: 101/57 Respirations 16, oxygen saturation General: Obese male in No apparent distress Head and Neck: Pupils equal round and reactive to light Neck supple, trachea midline. No cervical lymphadenopathy Card: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, nontender nondistended. Extremities: no clubbing cyanosis or edema Drain: in place, with yellow/cream colored discharge coming around tube, no erythema Brief Hospital Course: Once the INR level was subtherapeutic, the patient underwent another CT guided drainage of abscess. Clinically, the patient output from the drain looked suspicious, and it was decided that it would be best to drain the abscess in the or. Mr. [**Known lastname **] [**Last Name (Titles) 8783**]t an exploratory laparotomy with drainage of subphrenic and subdiaphragmatic (left) abscess on [**2124-8-16**]. The patient underwent Mobilization and takedown of the colonic splenic flexure, extended colectomy with primary anastomosis, extensive lysis of adhesions, creation and mobilization of omental pedicle flap. Postoperatively, the patient continued to receive antibiotic linezolid and was started on levaquin/flagyl. Patient initially improved, but had a code purple on POD 5. Pt was evaluated by psychiatry in house and though the psychosis, and disorientation that was thought to be multi-factorial. On POD 12, the patient began to be tachypneic and decrease 02 sat. Pt was transferred to T/SICU for more monitored care. Repeat CT scan showed a new fluid collection in the abdomen which was subsequenty drained and new pulmonary embolus -- RLL. Pt was started on heparin, and antibiotics were continued. The new fluid collection was drained by CT guided draiange. In addition, blood culture illustrated klebsiella bacteremia for which he was treated with miropenen. Pt continued to improve in the T/SICU and was weaned from the VENT and started on TPN. Pt was transferred to the floor with two drains on the left side. On POD 19, the pt accidently pulled the pigtail catheder and began to take pos. Physical therapy begain to work with the patient and assist with balance after a prolonged hospital admission. Patient was continued on Heparin and is awaiting antiocoagulation by coumadin. Pt was treated with a total of mirponen 14 days, linezolid 22, and flagyl 24 days. Patient continued to do well, until one day prior to discharge. patient's tpn was stopped and did not take po for lack of appetite. Pt had two episodes of emesis 500-100cc, but was otherwise clinically stable. Patient underwent a repeat CT scan and picc was placed for TPN prior to discharge to rehab facility. CT showed improvement in abscess and pt began to tolerate a house diet. Patient is going to rehab center and will follow up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Medications on Admission: Insulin, coumadin 5, Valium 2, Lasix 25, colase, ibuprofen, Linezolid 600 mg Tablet once [**Hospital1 **] Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 4. Valium 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED). Disp:*qs qs* Refills:*2* day. Disp:*60 Tablet(s)* Refills:*2* 7. Lovenox 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous once a day for 10 days: until therapeutic on INR. Disp:*10 0.4ml* Refills:*1* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: s/p distal pancretectomy complicated by abscess, subsequent colonic resection Discharge Condition: Fair Discharge Instructions: Keep drain are clean and dry. Please call if you have fevers>100.5, chills or vomitting Followup Instructions: Follow up with Dr. [**Last Name (STitle) 468**] in 2 weeks - please call [**Telephone/Fax (1) 2835**] Completed by:[**2124-9-12**]

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icd9cm

[ [ [] ] ]

[ "54.91", "99.15", "99.04", "38.93", "54.19", "99.07", "39.50", "45.79", "00.14" ]

icd9pcs

[ [ [] ] ]

5939, 6084

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6105, 6185

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251, 284

397, 1782

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50,440

104,897

50985

Discharge summary

report

Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-11**] Date of Birth: [**2049-2-4**] Sex: F Service: MEDICINE Allergies: Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone Attending:[**First Name3 (LF) 45**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD, moderate mitral and tricuspid regurgitation, atrial fibrillation on coumadin s/p PPM placement who presents s/p fall at home. The patient said that she had just recently been discharged from Rehab. She said that she was doing well there, walking freely and at times with a walker or a cane. She went home, where she lives alone, but has frequent visitors. She was sitting on her bed trying to put her sock on and she slipped off the bed and fell. She hit her coccyx. She was on the ground for 3 hours, until she was found by a friend who brought her to [**Hospital1 18**]. She said that at the time of the fall, she had no lightheadedness or dizziness, no palpitations, diaphoresis, chest pain, SOB, LOC. She repeatedly said she just slipped off the bed. She said that this year she has fallen 3 times, but prior to that she had not had a history of falls. She said the other 2 times were also mechanical. One time she slipped in the rain outside and the other time she was walking with tea in her hand at home and she tripped over a stool. She says that usually she is able to walk well. She manages her own finances. She says she does her own cooking and cleaning. She has friends shop for her. She has had visiting nurses in the past, but no permanent home care attendent because she felt there was no need for that. She has lots of friends and family who visit. In the ED, initial vitals are as follows: 97.6 80 96/56 16. Labs notable for trop 0.02 with 2nd trop 0.01, INR - 1.8, H/H: 11.3/38.6 The pt underwent CT head - No acute intracranial process, CT C-spine - No fracture. Large bilateral pleural effusions, CXR - Mild pulmonary edema, with b/l pl effusions (stable). L basilar opacification, atelectasis vs infxn, Lumbar spine, pelvis plain films - No acute fracture or subluxation The pt received ceftriaxone and azithromycin in the ED for lactate of 3.0. Vitals prior to transfer: T 98.3 p 75 rr 18 bp 137/88 sa02 unable (blood gas drawn and pending) 92 % on abg, patient was not suitable for PT/CM in the ED so being admitted to the floor. Currently, lying in bed, upset that she is being asked all the same questions. ROS: Per HPI Past Medical History: - Hypertension - s/p BMS to proximal LAD on [**2131-12-17**] - CAD s/p NSTEMI in [**11/2131**] - Dilated cardiomyopathy, EF 25% on [**2133-2-9**] TTE - Valvular Disease: 2+ MR, 2+ TR on [**2133-2-9**] TTE - s/p BMS to proximal LAD on [**2131-12-17**] - Atrial fibrillation, diagnosed [**10/2132**] s/p failed cardioversion and s/p PPM placement, on Coumadin - Hypertension - Arthritis - Left breast cancer s/p mastectomy, node dissection, radiation in [**2113**] - h/o gastritis/GI bleed - Macular degeneration - presumed SIADH (see d/c summary from [**11/2131**]) s/p tolvaptan at that time Social History: Lives alone, never married, no children. Nephew [**Name (NI) **] [**Name (NI) 7049**] is her HCP. Denies alcohol, tobacco, or illicit drug use. Former dancer-singer on the [**First Name8 (NamePattern2) **] [**Location (un) **] Show. Family History: Mother died of ? stomach cancer in her 70s. Father died of natural causes in his 70s. 9 siblings, all deceased, no medical problems. Denies family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T: 97.4 BP: 97/50 HR: 73 RR: 20 02 sat: 92% on ABG as difficult to get pulse ox GENERAL: Pleasant, tired appearing woman, lying flat in bed and speaking comfortably HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Very dry MM. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Holosystolic murmur heard throughout LUNGS: CTAB anteriorly (patient did not want to sit up for full lung exam) ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Left arm larger than right. Patient with 3-4+ pitting edema of feet and slowly tapers up to knees. Also with sacral edema. PT pulses dopplerable, unable to doppler DP pulses (nurse able to doppler [**12-29**] DP pulses, patient hands cool to touch and slightly cyanotic. Patients feet were cold to touch and cyanotic, she was able to move her feet with full range of motion and 5/5 strength although her sensation to light touch was depressed. She had skin tears on her feet bilaterally that weren't healing, toenails were long, her feet were tender to touch NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. PSYCH: Listens and responds to questions appropriately, pleasant . DISCHARGE PHYSICAL EXAM: Vitals (CMO): RR 14-20 I&Os: [**Telephone/Fax (1) 105938**] General: Awake patient lying in bed in NAD, comfortable. HEENT: EOMI. Dry MM. Tongue midlline CV: Regular rate and rhythm. 2/6 systolic murmur appreciated at the LLSB and at the cardiac apex. Lungs: Absent breath sounds at the bases bilaterally. Crackles in the mid-lung fields bilaterally, posteriorly. No wheezes. No increased work of breathing. Abdomen: Soft. ND. BS+. Tenderness in RUQ. Ext: Cyanosis present of the R hand. No clubbing. 2+ pitting edema of the ankles bilaterally, with pitting edema extended to the mid-shins bilaterally, worse on the left (2+) than on the right. Pertinent Results: ADMISSION LABS [**2133-5-28**] 12:00PM BLOOD WBC-6.0 RBC-4.20 Hgb-11.3* Hct-38.6 MCV-92 MCH-27.0 MCHC-29.3* RDW-16.8* Plt Ct-359 [**2133-5-28**] 12:00PM BLOOD Neuts-73.9* Lymphs-19.9 Monos-5.5 Eos-0.3 Baso-0.5 [**2133-5-28**] 12:00PM BLOOD PT-19.0* PTT-33.2 INR(PT)-1.8* [**2133-5-28**] 12:00PM BLOOD Glucose-78 UreaN-28* Creat-1.0 Na-135 K-4.4 Cl-97 HCO3-24 AnGap-18 [**2133-5-28**] 12:00PM BLOOD CK(CPK)-189 [**2133-5-28**] 12:00PM BLOOD cTropnT-0.02* [**2133-5-28**] 05:52PM BLOOD cTropnT-0.01 [**2133-5-29**] 07:50AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.2 Mg-1.8 [**2133-5-28**] 12:00PM BLOOD Digoxin-2.0 [**2133-5-28**] 11:11PM BLOOD Type-ART pO2-76* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 [**2133-5-28**] 09:31PM BLOOD Lactate-3.0* [**2133-5-28**] 11:11PM BLOOD Lactate-1.4 [**2133-5-28**] 03:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2133-5-28**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2133-5-28**] 03:20PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0. MICRO [**2133-5-29**] 1:00 am BLOOD CULTURE **FINAL REPORT [**2133-6-4**]** Blood Culture, Routine (Final [**2133-6-4**]): NO GROWTH. [**2133-5-28**] 9:20 pm BLOOD CULTURE **FINAL REPORT [**2133-6-3**]** Blood Culture, Routine (Final [**2133-6-3**]): NO GROWTH. . IMAGING -[**5-28**] PELVIS XR: FINDINGS: No acute fracture or dislocation is present. Diffuse demineralization of the osseous structures is noted. There is no diastasis of the pubic symphysis or sacroiliac joints. No suspicious lytic or sclerotic osseous abnormalities are seen. Scattered phleboliths are seen within the left hemipelvis. There are surgical clips noted pelvis. There are mild degenerative changes with joint space narrowing of the hips. IMPRESSION: No acute fracture or dislocation. . 5/31 L-spine XR IMPRESSION: No acute fracture or subluxation. . [**5-28**] CXR: IMPRESSION: Mild pulmonary edema, with continued bilateral pleural effusions, moderate on the left and small on the right. Fluid is noted to track over the apices bilaterally. Left basilar opacification may reflect compressive atelectasis though infection is difficult to exclude. . [**5-28**] C-spine w/ contrast: IMPRESSION: 1. No fracture or change in alignment. 2. Bilateral pleural effusions. . [**5-28**] Head CT: FINDINGS: There is no acute hemorrhage, edema, or shift of normally midline structures. Prominence of the ventricles and sulci is compatible with age-related atrophy. There is no large territorial vascular infarction. Diffuse periventricular white matter hypodensities, though nonspecific, likely relate to chronic small vessel ischemic disease. Again noted are small air-fluid levels within the mastoid air cells associated with mild sclerosis suggesting a chronic inflammatory process. The remaining visualized paranasal sinuses are well aerated. Calcifications are seen within the carotid siphons and within the subcutaneous portion of the skin overlying the anterior skull. There is no fracture identified. IMPRESSION: No acute intracranial process. . [**6-4**] TTE The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to global hypokinesis as well as marked ventricular interaction. The right ventricular free wall thickness is normal. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload with consequent ventricular interaction. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2133-2-19**], mitral and tricuspid regurgitation are significantly increased. Right ventricular pressure and volume overload are much more prominent, with consequent increased ventricular interaction further reducing left ventricular systolic and diastolic performance. [**6-5**] Head CT: FINDINGS: There is no hemorrhage, edema, shift of midline structures, or territorial infarction. The ventricles and sulci are prominent, consistent with global atrophy. Subcortical and periventricular white matter hypodensities, most marked in the frontal lobes are unchanged and consistent with chronic small vessel ischemic disease. The calvaria are unremarkable. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. Brief Hospital Course: 84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD, moderate mitral and tricuspid regurgitation, atrial fibrillation on coumadin s/p PPM placement who presents s/p fall at home. She was r/o for traumatic fractures in the ED, and was admitted for monitoring and eval prior to dispo to rehab. On [**6-2**], she triggered for SBP's to the 70's amidst a presyncopal episode, likely vasovagal in the setting of orthostasis/intravascular depletion and having a large bowel movement (her BP's improved shortly after being returned to bed). On 6/6am, she became abruptly unresponsive while being assisted to go to the bathroom, and was transferred to the MICU for unresponsiveness and then subsequently transferred to the cardiology service for diuresis and continued management for end-stage heart failure, who was later made CMO. ============================================================ General Medicine Floor Course: . # Unresponsiveness: On 6/6am, she became abruptly unresponsive while being assisted to go to the bathroom, and did not respond to painful stimuli. She was afeb with SBP's in the 100s; EKG's and CXR were unremarkable other than mild pulmonary edema; she was given 1mg IV ativan for empiric seizure treatment. After about an hour, she began slowly regaining responsiveness and was moving all 4 limbs with nonfocal neuro exam, but did not regain full baseline cognition. She was transferred to the MICU. # Delirium: The patient was delirious o/n on [**5-29**] when she required a small dose of IM haldol for extreme agitation (calling 911 from room). The delirium was likely [**1-29**] hospital delirium, possibly exacerbated by the diazepam which the patient consistently takes. Toxic metabolic etiology was unlikley as her labs were largely unremarkable; infection or injury were also unlikely given no localizing evidence (clean UA, CXR, no fever). Per the patient's PCP, [**Name10 (NameIs) **] patient insists on taking and needs her diazepam so this likely cannot be down-titrated, although it may contribute to her underlying delirium. The patient was monitored on fall precautions, aspiration precautions. . # s/p Mechanical Fall: Upon presentation, the patient had no active sign/symptoms of bleeding, fracture, or other acute process; all trauma scans were unremarkable. Patient's fall may have been mechanical, although she has had increased number of falls at home this year. Her feet have decreased sensation and poor blood flow likely worsening her ambulatory abilities. In addition, while her strength was intact, at rest, her legs appeared limp as if very weak. She lives at home with no help for most of the day, but particularly at night. She is a high risk for repeated fall, but she may not be amenable to placement. PT eval recommended dispo to rehab. . ============================================================= ICU Course ([**6-3**] -> [**6-5**]) The patient was transferred to the ICU on the morning of [**6-3**] after an episode of unresponsiveness and for worsening cyanosis. Neurology was consulted and thought the picture was most consistent with either a metabolic encephalopathy - possibly related to hypoxia and cardiogenic shock. A diagnosis of hypoactive delirium was also entertained. EEG showed R temporal epileptic discharges. Neurology recommended repeat Head CT - both were unremarkable for acute causes. Her mental status improved over the course of her ICU stay, and she was conversant and oriented x 2 prior to being called-out. For her worsening cyanosis, cardiology recommended optimizing her systolic function. CXR showed volume overload and TTE showed worsening MR, TR and volume overload. She was bolused with lasix and then started on a lasix drip as well as metolazone to try and improve diuresis. The patient's urine output remained poor at the time of call-out. Vascular surgery was also consulted for the patient's peripheral cyanosis - they thought it to be most consistent with global hypoperfusion with superimposed PVD. Coumadin was held for an INR of 5.3. Digoxin level was sent with plans to restart reduced dose. Her chronic valium was held due to altered mental status and had not been restarted prior to call-out. . =============================================================== Cardiology Floor Course: . # CARDIOGENIC SHOCK: Upon transfer from the unit, the patient was on a lasix drip but appeared to be in cardiogenic shock with cold extremities and cyanosis. Urine output was monitored, and the patient made a great deal of urine to the lasix drip. Her color and temperature of extremities improved. Electrolytes were monitored and repleted as needed to maintain potassium of 4 and magnesium of 2. Lasix drip was discontinued after the patient pulled her PICC line. She was subsequently transitioned to an oral dose of torsemide. Medical team met w/ patient's HCP, her nephew [**Name (NI) **]. Discussed with [**Doctor Last Name **] the end-stage nature of her heart failure. Palliative care became involved during this [**Hospital 228**] hospital course, and the decision was made to transition to comfort measures only. Initially, she was given oral torsemide at a daily dose, but the patient consistently made approximately 3 liters of fluid daily with poor oral intake. Thus standing doses of torsemide were discontinued with the plan to give the patient 40mg of oral torsemide as needed for shortness breath. ****** The following issues were also addressed initially during the patient's Cardiology floor stay prior to the decision to make the patient comfort measures only: # ELEVATED INR: Etiology was unclear; differential included DIC (in light of elevated PTT and falling HCT) versus congestive hepatopathy in light of worsening heart failure. DIC was ruled out. With rising LFTs, the cause of the elevated INR was attributed to congestive heaptopathy in light of systolic heart failure. LFTs were initially trended and noted to be decreasing with downtrending INR. With the decision to transition care towards comfort, no further INRs were drawn. # ATRIAL FIBRILLATION: INR supratherapeutic upon admission to the cardiology service. Coumadin was held as was the digoxin. Patient's INR downtrended. With decision to focus care on comfort, no other lab draws were done. # CAD: Initially continue ASA 81mg daily, losartan, metoprolol (with holding parameters) until the decision was made to focus care of comfort. # ARTHRITIS: Acetaminophen PRN for management of pain control. # LEFT BREAST CANCER S/P MASTECTOMY: Chronic lymphedema in left arm, no BP checks in left arm or lab draws were attempted. # HYPOTHYROIDISM: Normal TSH on [**6-2**]. Continued home levothyroxine, until the decision was made to transition care to comfort measures only. TRANSITION OF CARE: --Focus of patient's care is towards comfort measures only. All medications with the exception of her diuretic and rate regulating medication were discontinued. --Administer torsemide 40mg orally as needed for symptoms of shorntess of breath. Medications on Admission: - Adult Low Dose Aspirin 81 mg Tab, Delayed Release 1 Tablet(s) by mouth once a day - acetaminophen 500 mg Tab 1 Tablet(s) by mouth four times a day as needed - diazepam 2 mg Tab 1 (One) Tablet(s) by mouth four times a day - furosemide 20 mg Tab 4 Tablet(s) by mouth daily - losartan 25 mg Tab 0.5 (One half) Tablet(s) by mouth daily - digoxin 125 mcg Tab 1 Tablet(s) by mouth daily - Lo-Peramide 2 mg Tab 1 Tablet(s) by mouth twice daily as needed for diarrhea - levothyroxine 25 mcg Tab 1 Tablet(s) by mouth daily - warfarin 2 mg Tab [**12-29**] Tablet(s) by mouth daily or as directed - multivitamin Tab 1 Tablet(s) by mouth daily - metoprolol succinate ER 50 mg 24 hr Tab one and [**12-29**] Tablet(s) by mouth once a day Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Anxiety. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day as needed for shortness of breath or wheezing. 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: HOLD for HR < 60 . Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary diagnosis: --status post fall --Cardiogenic shock Secondary diagnoses: - Hypertension - Coronary artery disase - Atrial fibrillation - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 7049**], It was a privilege to provide care for you here at the [**Hospital1 1535**]. You were admitted because you had a fall at home. You received various X-rays and CT-scans, which did not show fractures. During this admission, you had a very serious heart failure exacerbation. You were diuresed initially and responded well. Family meetings were conducted during this admission, and the decision was made to transition your care to comfort meausres only. Medications that focus on your comfort have been continued, including medications for anxiety, pain, and shortness of breath. Followup Instructions: Patient will be managed symptomatically at [**Hospital1 1501**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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30042

Discharge summary

report

Admission Date: [**2179-9-30**] Discharge Date: [**2179-10-3**] Date of Birth: [**2140-6-29**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 458**] Chief Complaint: Fevers and Chest Tightness Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Patient is a 39 year old male who presented with fevers, chest tightness, and shortness of breath. Patient began experiencing fevers and joint aches in late-[**Month (only) **]. He visited the [**Hospital **] clinic and was placed on a two-week course of Doxycycline, given his previous history of Lyme Disease. Patient continued to have fevers despite his antibiotic treatment. Serologies were sent for Lyme and Babesiosis, which were both negative. In the beginning of [**Month (only) 216**], the patient began to experience fevers of 102, neck stiffness, and palpitations. He again visited the [**Hospital **] clinic, where it was thought that he may be having a reaction to Doxycycline. This medication was thus discontinued. This week, the patient developed chest tightness and increasing shortness of breath. He states that his chest pain is worse He called the [**Hospital **] clinic and was told to go immediately to the ED. . In the ED, the patient's VS were T 99.8, P 107, BP 137/78, O2 100% on RA. The patient had a CXR performed, which showed a markedly enlarged cardiac silhouette. An ECHO was then performed, which showed a large pericardial effusion and sustained right atrial collapse. The patient went to the cath lab, where he had a pericardialcentesis. Patient's pericardial pressure was found to be 14. 900 cc of serosanguinous fluid were successfully removed. Of note, the post-pericardiocentesis right-sided pressures remained mildly elevated. Patient was then admitted to the CCU for further workup and evaluation. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies cough, diarrhea, rashes, and lower extremity swelling. Patient endorses recent nausea and vomiting. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Migraines Adrenal Hypoplasis: Treated with Florinef and Cortef until his mid-20s Exercise-induced asthma Seasonal allergies s/p hand surgery in [**2-16**] Social History: Patient finished graduate school in chemistry and left academics for woodworking. He does not smoke cigarettes, he drinks alcohol occasionally, and he does not use illicit drugs. Patient has not had any recent travel. He has one dog, a border collie. He is frequently in the [**Doctor Last Name 6641**], as he enjoys trail running, [**Location (un) **]-watching, and hiking. Patient is originally from [**Location 71665**], PA and moved to [**Location (un) 86**] 20 years ago. Family History: Non-contributory. Patient's parents are both alive and well. Physical Exam: VS: T 101.8, BP 112/56 , HR 102, RR 29, O2 94% on RA Gen: Young man, pleasant, well-nourished, in NAD. HEENT: PERRL, EOMI. No pallor or cyanosis of the oral mucosa. Neck: Supple, no appreciable LAD, no elevated JVD. CV: Tachycardic, normal S1 and S2. No appreciable rubs. Chest: Patient was using accessory muscles. Breath sounds not well appreciated secondary to pain with inspiration. Abd: +BS, non-tender, non-distended. No HSM. Ext: No rashes. No edema or cyanosis. 2+ PT pulses bilaterally and 1+ DP pulses. Skin: No rashes appreciated. Pulses: Right: Carotid 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; 1+ DP Pertinent Results: ADMISSION LABS: [**2179-9-30**] 12:10PM BLOOD WBC-10.9 RBC-4.26* Hgb-12.8* Hct-37.7* MCV-88 MCH-30.0 MCHC-33.9 RDW-12.5 Plt Ct-531* [**2179-9-30**] 12:10PM BLOOD Neuts-85.8* Lymphs-7.8* Monos-6.0 Eos-0.3 Baso-0.1 [**2179-9-30**] 12:10PM BLOOD Plt Ct-531* [**2179-9-30**] 12:10PM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-136 K-4.0 Cl-98 HCO3-25 AnGap-17 [**2179-9-30**] 12:10PM BLOOD LD(LDH)-274* TotBili-1.3 [**2179-10-1**] 05:48AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8 [**2179-9-30**] 12:10PM BLOOD Hapto-374* [**2179-10-1**] 05:48AM BLOOD TSH-2.2 [**2179-10-1**] 05:48AM BLOOD T4-5.5 [**2179-10-1**] 01:00PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2179-10-1**] 06:34AM BLOOD HIV Ab-NEGATIVE [**2179-9-30**] 03:10PM BLOOD Lactate-1.4 ***************** PERTINENT LABS/STUDIES: Cardiac Catheterization [**2179-9-30**]: COMMENTS: 1. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 17 mm Hg and PCWP mean of 15 mm Hg. There was blunting of the x and y descents. There was mild pulmonary arterial hypertension of 36/17 mm Hg. The initial pericardial pressure was measured to be 14 mm Hg. This equalization of pressures is consistent with tamponade physiology. The cardiac index was preserved at 2.4 l/min/m2. 2. Successful pericardiocentesis was performed with removal of 900 ml of serosanguinous fluid. Post-pericardiocentesis, the right sided pressures remained mildly elevated. The pericardial pressure decreased to 5 mm Hg. Echo ([**2179-9-30**]): The left atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a large pericardial effusion. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade. Echo ([**2179-10-1**]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Echo ([**2179-10-2**]): Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a small to moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. The effusion is largest adjacent to the basal to mid inferolateral wall (measures 1.4 cm). Anterior to the right atrium and distal right ventricular free wall, it measures up to 0.8 cm in diameter. Stranding is visualized within the pericardial space c/w organization. There are no echocardiographic signs of tamponade. CT Chest/Abd/Pelvis ([**2179-10-2**]): IMPRESSION: 1. Moderate to large pericardial effusion with pericardial enhancement, a finding that suggests infectious, inflammatory, or neoplastic cause. 2. Small left and tiny right pleural effusions. 3. Marked adrenal hyperplasia. The differential diagnosis would include congenital adrenal hyperplasia, and, in the setting of the associated findings described above, other entities such as tuberculosis, other granulomatous disease, or rare entities such as Erdheim- [**Location (un) **] disease. 4. Several tiny calcified granulomata in the lung bases, consistent with prior granulomatous disease such as tuberculosis. 5. Tiny hepatic lesions, too small to further characterize. 6. Stranding in the subcutaneous fat of the right groin, likely due to prior percutaneous vascular access. 7. Soft tissue attenuation in the anterior mediastinum may represent inflammatory stranding, perhaps secondary to adjacent pericarditis. Residual thymus may also contribute. . . DISCHARGE LABS: [**2179-10-3**] 06:40AM BLOOD WBC-7.5 RBC-4.39* Hgb-13.5* Hct-39.1* MCV-89 MCH-30.8 MCHC-34.6 RDW-12.2 Plt Ct-682* [**2179-10-3**] 06:40AM BLOOD Plt Ct-682* [**2179-10-3**] 06:40AM BLOOD Glucose-90 UreaN-9 Creat-0.9 Na-141 K-4.3 Cl-100 HCO3-28 AnGap-17 [**2179-10-3**] 06:40AM BLOOD Mg-2.1 Brief Hospital Course: Patient is a 39 yo male with a h/o Lyme disease who presents with fevers, chest tightness, abdominal pain, and shortness of breath, and was found to have cardiac tamponade. . # Pericardial Effusion: Patient presented with chest tightness and shortness of breath. CXR demonstrated enlarged cardiac silhouette, and subsequent TTE showed a large pericardial effusion with right atrial collapse. Patient had a pericardialcentesis with 900 cc fluid drained. Fluid was sent for analysis and was found to have 4600 WBC. Gm stain and cultures were all negative. Labs were sent for TB, [**Doctor First Name **], ds-DNA, Lyme, and Babesiosis, which were all negative. Thyroid hormones were also within normal limits. The patient had two repeat ECHOs during this hospitalization, which both showed resolution of the tamponade physiology. The patient was discharged with close outpatient follow-up in the [**Hospital **] clinic. . # Fevers: Patient had persistent fevers since the end of [**Month (only) **]. Serologies for Lyme, Borellia, and Histoplamosis were all negative. Patient's fevers were persistently ~ 102 F prior to admission. During this admission, the patient spiked a fever on day of admission but was afebrile 24 hours prior to discharge. He was discharged with close outpatient follow-up. Medications on Admission: Tylenol prn Oxycodone 10 mg prn for pain in neck and chest Discharge Disposition: Home Discharge Diagnosis: Cardiac tamponade Pericardial effusion Bilateral pleural effusions Lung granuloma Discharge Condition: ambulatory, SpO2 100% on RA Discharge Instructions: You were admitted because you had signs of cardiac tamponade, which means that fluid was building up in the sac around your heart causing compromise of your heart's ability to pump. In the hospital, the doctors placed a [**Name5 (PTitle) 19843**] which emptied much of the fluid around your heart but not all of it. You received serial echocardiograms which demonstrated that a small amount of fluid was still in your heart. In addition, you had a CT scan which showed that some fluid had developed below your lungs, called a pleural effusion. . If you have any worsening of shortness of breath, chest pain, severe lightheadedness, please return to the Emergency Room immediately. Followup Instructions: You should come to the [**Hospital **] clinic on Monday, Tuesday, and Wednesday as instructed to submit sputum samples. At your Monday appointment, you should also have your PPD read. . Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6173**] will see you in [**Hospital **] clinic on Wednesday, [**10-6**]. His office will contact you tomorrow with an appointment time. If you do not receive this phone notification, please call ([**Telephone/Fax (1) 71666**] to schedule this appointment. . You should undergo a Echocardiogram this week to assess for reaccumulation of the fluid around your heart. Please call ([**Telephone/Fax (1) 9410**] on Monday morning to schedule this appointment. . You should wear a paper mask to all of these appointments as instructed by Dr. [**Last Name (STitle) 4427**]. Completed by:[**2179-10-31**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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232, 260

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182,223

17028

Discharge summary

report

Admission Date: [**2186-7-18**] Discharge Date: [**2186-7-19**] Date of Birth: [**2115-5-1**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 71-year-old man with a history of hypertension and hypercholesterolemia who was diagnosed with carotid artery disease in [**2183-1-29**] after an episode of dizziness. He has been followed since by serial ultrasounds, the most recent of which showed a right velocity of 429 cm per second with an IC to CCA ratio of 4.6 and a left-sided velocity of 107 cm per second with a ratio of 1:1. On [**2186-6-21**] a carotid ultrasound showed an 80-99% right ICA occlusion. On [**2186-6-26**] MR of the carotids showed a 95% right ICA lesion with no significant left-sided stenosis. The patient presented for carotid catheterization. A stent was placed in the right internal carotid artery with 20% residual stenosis. The patient was transferred to the coronary care unit for further monitoring. He denied vision changes, paresthesias, chest pain, shortness of breath, dizziness, nausea or vomiting, or pain. He denied any history of claudication, orthopnea, edema, paroxysmal nocturnal dyspnea, lightheadedness, amaurosis fugax. He denied any focal neurological signs. He has had normal bowel habits, no bright red blood per rectum, no melena, no gastroesophageal reflux disease. PAST MEDICAL HISTORY: No history of coronary artery disease, transient ischemic attack, or cerebrovascular accident. He further denied any history of hypertension. He admitted to: 1. Hypercholesterolemia. 2. Peripheral vascular disease. 3. Mastoid surgery. MEDICATIONS AT HOME: 1. Aspirin 325 mg q. day. 2. Plavix 75 mg q. day. 3. Lorazepam 0.5 mg q.a.m. p.r.n. 4. Lipitor 20 mg q.h.s. 5. Vitamin C. 6. Vitamin E. 7. DHEA. FAMILY HISTORY: His father died of heart disease at age 68. SOCIAL HISTORY: The patient is widowed and lives alone. He is a retired electrical engineer. He denied any use of alcohol, denied any use of tobacco, and reports a remote cigar history. He denied any use of illicit drugs. PHYSICAL EXAMINATION: Vital signs were 97.8, heart rate 62, blood pressure 160/80, respiratory rate 18, 99% saturation on room air. He was laying flat with oxygen on nasal cannula at two liters with no apparent distress. HEENT: Anicteric, moist mucous membranes, no jugular venous distension, and a positive right carotid bruit. Cardiovascular: His point of maximal impulse was not palpable. He had a regular rate and rhythm, normal S1 and S2, no murmurs, gallops, or rubs. Radial, dorsalis pedis and posterior tibial pulses were 2+ bilaterally and equal. Lungs: Clear to auscultation anteriorly. Abdomen: Soft, nontender, nondistended, positive bowel sounds, with a questionable left renal bruit. Extremities: Warm and dry with no edema. The right femoral sheath site was without hematoma or bruit. It was clean, dry and intact with minimal oozing. Neurological: Cranial nerves II-XII were intact. Sensation was intact in the upper and lower extremities bilaterally and across the face. Motor was intact in the upper and lower extremities bilaterally and equal. LABORATORY DATA: The patient had no laboratory abnormalities. EKG showed a normal sinus rhythm with a normal axis, good R waves across the precordium. HOSPITAL COURSE: Overall this was a 71-year-old man status post a right internal carotid artery stent for artery disease. He was to continue his aspirin, his Lipitor and his Plavix, to monitor his neurological signs and symptoms every four hours for post procedure transient ischemic attacks and cerebrovascular accidents, to continue Plavix and aspirin for nine months, to maintain a systolic blood pressure during the first week postoperative of 140-170 systolic, to sustain coronary cerebral perfusion. Rhythm was normal sinus. He was monitored on telemetry for bradycardias or vagal symptoms post procedure, but this did not happen. 1. Pump: His ejection fraction was unknown, no clinical evidence for congestive heart failure. Oxygen was weaned. The patient no longer required oxygen for ambulation to maintain saturations in the high 90s. The patient tolerated a regular diet. Fluid and electrolytes were monitored and repleted. 2. Hematology: There was no postprocedure blood loss. His hematocrits were stable throughout his hospitalization. His pulses were strong. The patient had a neurology consultation who found the patient to be neurologically intact, hemodynamically stable. A homocystine level was checked but was pending at the time of discharge. He denied any changes in vision, nausea, vomiting, shortness of breath, or pain during the course of the hospitalization. Telemetry monitoring across the hospitalization showed no ectopy. DISPOSITION: The patient was discharged in stable condition feeling well. FOLLOW-UP PLANS: The patient was instructed to follow up with Dr. [**First Name (STitle) **] in clinic in the next two weeks for blood pressure monitoring as well as to monitor the stent placement. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q. day. 2. Aspirin 325 mg q. day. 3. Lipitor 20 mg q. day. 4. Ativan 0.5 mg q.a.m. p.r.n. 5. Vitamin E. 6. Vitamin C. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 47889**] MEDQUIST36 D: [**2186-7-19**] 13:42 T: [**2186-7-21**] 10:48 JOB#: [**Job Number 47890**]

[ "272.0", "443.9", "433.10" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

1810, 1855

5085, 5501

3336, 4862

1641, 1793

2105, 3318

4880, 5062

164, 1356

1379, 1619

1872, 2082

54,320

160,888

26225

Discharge summary

report

Admission Date: [**2106-12-4**] Discharge Date: [**2106-12-5**] Date of Birth: [**2050-12-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Syncope, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 55 yo male with history of hypertension, hyperlipidemia and daily alcohol consumption of ~3 glasses of wine/night, presents following syncopal episode at the gym this morning. The patient reports that he had a larger than usual amount of wine over [**Holiday 1451**] dinner with friends, although is unable to state exact amount. This morning he woke up and was feeling fine. Took some Viagra. Had 1 glass of water. About 1.5 hours later went to the gym. 30 minutes into the workout he felt dizzy, lightheaded and diaphoretic while doing muscle-bilding exercise. He told his wife he is about to pass out, put his hands down to prevent an impact of his head and passed out on the exercise machine. His wife lowered his to the floor with assistance from other people. He awakened about 30 seconds after passing out and was oriented, although confused how he ended up on the floor. There was no trauma. He reports bowel incontinence, but denies biting his tongue. His wife notes that she saw a few upper extremity jerks, that she felt were more "typical of a vasovagal" than a seizure. The patient states he has 2 loose bowel movements over the past week. Review of systems is otherwise negative. The patient states that he never had prior syncopal episodes, symptoms of alcohol withdrawal or seizures. Denies chest pain, shortness of breath, palpitations. States that he has not had any additional episodes since that time, but does get transiently lightheaded when sits up suddenly in bed. The patient's wife called ambulance and he was brought to the ED. Upon presentation to the ED, initial vitals were T96.7 HR104 BP120/60 RR18 100%. The patient was noted to be very tremulous, but had no ataxia. Blood EtOH of 60. Urine tox negative. In the ED received total of 60 mg IV diazepam over course of 2 hours. Received IV thiamine, folic acid, and multivitamin. Was hydrated with 4L IVF. CEs negative x1. D-dimer negative. Prior to transfer to the ICU vitals were: HR 116, BP 130/71, RR 17, O2Sat 99% 2L. Past Medical History: PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Social History: The patient is a lobbyist. Receintly returned from a trip to [**State 4565**] and [**Country 149**], but did not drink local water in [**Country 149**]. States he drinks 2-3 glasses of wine every night with dinner because he "heard it's good for you", although admits he used to drink more years ago. Quit smoking 5 years ago, used to smoke cigars before then, quit cigarettes 17 years ago. Denies illicit drug use. States he has prescription for Xanax for anxiety, which he used to take for acrophobia when he used to work in a high rise building, but takes it very rarely now. Family History: Father with MI in his 40s, CABG in his late 60s. Mother with dissecting aortic aneurism, passed away in her 70s. Physical Exam: T=98.1 BP=126 BP 147/68 RR=20 O2=97%RA GENERAL: Pleasant, well appearing M in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. Very fine tremor of the tongue. CARDIAC: Regular rhythm, tachycardic to 130s. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. No tremor. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2106-12-4**] 11:35AM WBC-5.8 RBC-4.01* HGB-12.6* HCT-36.4* MCV-91 MCH-31.4 MCHC-34.7 RDW-13.2 [**2106-12-4**] 11:35AM PLT COUNT-404 [**2106-12-4**] 11:35AM NEUTS-67.0 LYMPHS-24.8 MONOS-6.3 EOS-1.3 BASOS-0.4 [**2106-12-4**] 11:35AM ASA-NEG ETHANOL-60* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2106-12-4**] 11:35AM TSH-1.6 [**2106-12-4**] 11:35AM D-DIMER-<150 [**2106-12-4**] 11:35AM CK-MB-2 [**2106-12-4**] 11:35AM cTropnT-<0.01 [**2106-12-4**] 11:35AM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-138 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-19* ANION GAP-21* [**2106-12-4**] 08:13PM CALCIUM-5.5* PHOSPHATE-2.0* MAGNESIUM-1.2* [**2106-12-4**] Chest Xray Heart size, mediastinal and hilar contours are normal and unremarkable. There is no focal consolidation, effusion, or pneumothorax. No overt pulmonary edema. IMPRESSION: No radiographic evidence for pneumonia. Brief Hospital Course: 55 yo male with history of hypertension, hyperlipidemia and daily alcohol consumption of ~3 glasses of wine/night, who presented following syncopal episode at the gym on the morning of admission and was admitted to the intensive care unit. #. Syncope: He had an episode of syncope prior to admission that was most consistent with a combination of orthostatic and vasovagal syncope in the setting of alcohol consumption the night prior to admission, poor oral intake, and the use of Viagra. He was given IVF fluids and monitored on telemetry with no further events and no arrhythmias. He was not orthostatic at discharge. #. Tachycardia: He had tachycardia throughout admission that was thought to be related somewhat to volume depletion and anxiety. PE was ruled out by negative D-dimers. He also reports a history of baseline sinus tachycardia since childhood. #. EtOH withdrawal: He was treated with valium in the ED for possible alcohol withdrawal but this was discontinued after admission and he had no further signs of withdrawal other than tachycardia. #. Hypertension: The patient was normotensive on admission and continued on his outpatient lisinopril. #. Hyperlipidemia: Continued outpatient simvastatin #. Prophylaxis: He was given SC heparin for DVT prophylaxis. #. Code Status: He was full code during this admission. #. Contact: Wife [**Name (NI) 803**] [**Name (NI) **] [**Telephone/Fax (1) 64982**] Medications on Admission: Lisinopril 30mg [**Hospital1 **] Simvastatin 20mg daily Discharge Medications: 1. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Syncope Hypertension Discharge Condition: Good Discharge Instructions: You were admitted because of light headedness. We diagnosed you with benign syncope that may have been caused by dehydration and viagra use. To treat you for this, we gave you intravenous fluids. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. You should avoid viagra for now until you see your primary care doctor. 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: Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment within the next one week.

[ "276.51", "303.90", "401.9", "458.0", "780.2", "E858.3", "300.00", "V17.49", "972.5", "427.89", "272.4", "E849.0", "291.81", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "99.29" ]

icd9pcs

[ [ [] ] ]

6660, 6666

4974, 6401

337, 343

6740, 6746

4054, 4951

7319, 7448

3082, 3197

6507, 6637

6687, 6719

6427, 6484

6770, 7296

3212, 4035

277, 299

371, 2392

2437, 2467

2483, 3066

339

107,660

27347+57536

Discharge summary

report+addendum

Admission Date: [**2188-4-1**] Discharge Date: [**2188-4-18**] Date of Birth: [**2120-7-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ERCP EUS History of Present Illness: This is a 67 year old female, well known to the HPB service with a history of necrotizing gallstone pancreatits c/b pancreatic necrosis/pseudocyst. She also had ARF/ARDS and a prolonged ICU stay. She ultimately went to the OR on [**2187-8-3**] for pseudocyst drainage, but this was not done because the pseudocyst was smaller in size. She had an Ex Lap., IOC, CCY, and Gastrotmy. She recovered from this and has been followed by Alphoso Brown. She presents with 5 days of mid-epgastric pain, N/V x 1 day. She has intermittent loose stools and no report of fever/chills. Past Medical History: 1. HTN 2. Diverticulitis 3. ETOH Abuse 4. GERD 5. Renal Insufficiency 6. Severe Necrotizing Gallstone Pancreatitis 7. Respiratory Failure s/p tracheosotomy [**2187-5-10**] PSH: Open CCY, IOC, Gastrotomy ([**7-14**]) Social History: Used to drink alcohol heavily until [**2174**]. Smoked [**1-12**] cigs/day, quit years ago. Lives in [**Location 2624**] with her daughter and son-in-law. Does not work. Came here from [**First Name8 (NamePattern2) 466**] [**Country 467**] ~ [**2181**]. Family History: NC Physical Exam: VS: 99.2, 98.4, 75, 160/82, 98% RA HEENT: mild scleral icterus, MM dry, no JVD, no bruits CV: Reg S1, S2, no murmur Pulm: decreased BS, R>L, clear Abd: soft, minimally tender Ext: no C/C/E, +2 bilat., warm Rectal: Pertinent Results: CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [**2188-4-3**] 2:59 PM IMPRESSION: Successful CT-guided aspiration of a large subhepatic fluid collection revealing 400 mL of greeenish-brownish nonpurulent fluid. It was sent for various lab tests, which are currently pending. Findings discussed with Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) **] at completion of the examination. . ERCP BILIARY&PANCREAS BY GI UNIT [**2188-4-4**] 8:51 AM Cholangiogram demonstrates a dilated biliary tree. Narrowing is seen in the distal third of the CBD. The pancreatic duct is normal in course and caliber. Final images demonstrate placement of a biliary stent. IMPRESSION: Dilated biliary tree with narrowing in the lower third of the common bile duct. . EUS: A 5 cm X 8 cm cyst was noted in the region of the head of the pancreas. The cyst walls were thin and well-defined. The distance between the gastric wall and the cyst was 3 mm. Moderate amount of debris was noted within the cyst. No intrinsic mass or septations were noted within the cyst. A 4 cm X 8 cm cyst was noted in the region of the pancreas body / tail [corresponding to sub-hepatic fluid collection on CT scan] . The cyst walls were thin and well-defined. The distance between the gastric wall and the cyst was 3 mm. Moderate amount of debris was noted within the cyst. No intrinsic mass or septations were noted within the cyst. Small amout of pancreatic parenchyma was noted in the pancreas body. The pancreatic duct was tortuous and measured 3 mm in diameter. Impression: Two large peri-pancreatic fluid collections with well-defined wall and moderate amount of debis were noted. . CTA ABD W&W/O C & RECONS [**2188-4-8**] 1:15 PM IMPRESSION: 1. Decreased size of large pancreatic pseudocyst replacing the neck, body, and medial tail of the pancreas. Pancreatic parenchyma within the head and uncinate process abnormally enhances but there is normal enhancing pancreas within the tail. 2. Persistent splenic vein occlusion with collateral formation. Portal vein is narrowed at the portal venous confluence to only a few mm, but remains patent. The SMV, IMV, IVC, and renal veins are patent. 3. No pseudoaneurysm evident. Normal arterial vasculature within the abdomen and pelvis. 4. Decreased size slightly of subhepatic fluid collection. 5. Decreased size of intrahepatic bile ducts with appropriate position of extrahepatic bile duct stent. . [**2188-4-9**] 09:30AM BLOOD WBC-12.7*# RBC-3.38* Hgb-8.4* Hct-26.1* MCV-77* MCH-24.9* MCHC-32.3 RDW-15.9* Plt Ct-406 [**2188-4-9**] 09:30AM BLOOD Glucose-151* UreaN-7 Creat-1.0 Na-136 K-3.4 Cl-99 HCO3-29 AnGap-11 [**2188-4-8**] 09:55AM BLOOD ALT-75* AST-19 AlkPhos-292* Amylase-99 TotBili-1.2 [**2188-4-4**] 06:20AM BLOOD ALT-346* AST-206* AlkPhos-639* Amylase-125* TotBili-8.0* [**2188-4-8**] 09:55AM BLOOD Lipase-27 [**2188-4-1**] 12:55AM BLOOD Lipase-673* [**2188-4-9**] 09:30AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7 Brief Hospital Course: She was admitted on [**2188-4-1**]. She was NPO and started on IVF. A CT was obtained on [**2188-4-2**] showed: 1. Intrahepatic bile duct dilatation and common bile duct dilatation. 2. Subhepatic collection, measuring almost 10 cm in diameter. 3. Pancreatic pseudocyst, measuring 10.3 cm x 7.1 cm. 4. Bilateral inguinal hernias. 5. Free fluid in the pelvis. 6. Significant inflammation in the peripancreatic area, consistent with the patient's history of necrotizing pancreatitis with low attenuation areas in pancreas which may represent necrosis. [**4-3**]: CT aspiration: 400cc drawn off. Studies/cytology sent/P. Her abdomen softened and her pain improved somewhat. [**4-4**]: ERCP: stent placed (no drainage of pseudocyst)-no spincterotomy. Her Tbili began to fall from a high of 8.0 to 1.4 on [**2188-4-7**]. On [**4-6**], she was having crampy pain, loose stools, foul odor. She was started back on her Creon, and the diarrhea resolved. [**4-8**]: EUS: Two large peri-pancreatic fluid collections with well-defined wall and moderate amount of debis were noted. She had a baseline CT on [**4-8**] and this showed decreased size of large pancreatic pseudocyst replacing the neck, body, and medial tail of the pancreas. Pancreatic parenchyma within the head and uncinate process abnormally enhances but there is normal enhancing pancreas within the tail. Persistent splenic vein occlusion with collateral formation. Portal vein is narrowed at the portal venous confluence to only a few mm, but remains patent. The SMV, IMV, IVC, and renal veins are patent. No pseudoaneurysm evident. Normal arterial vasculature within the abdomen and pelvis. Decreased size slightly of subhepatic fluid collection. Decreased size of intrahepatic bile ducts with appropriate position of extrahepatic bile duct stent. . She complained of LUQ pain on HD 8 and this seemed to resolve. Overall, she felt better and her LFT's, pancreatic enzymes decreased. She was tolerating a regular diet and her abdomen was softer and mildly tender. She was taking Creon with meals. She will return to the OR next week for drainage of the cyst. Medications on Admission: enalapril, atenolol, protonix, FeSO4, Creon-20, Ca/VitD, MVI Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Eight (8) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 2 weeks. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Abdominal Pain Pancreatic Pseudocysts Discharge Condition: Good Tolerating Diet Abdomen soft, nondistended. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. = = = = = ================================================================ Please resume all regular home medications. . Continue to ambulate several times per day. . Contninue to eat and drink plenty of fluids. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on Thursday, [**2188-4-17**]. Call ([**Telephone/Fax (1) 2363**] to schedule an appointment. You should have nothing to eat or drink 6 hours before surgery. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2188-4-21**] 10:00 Completed by:[**2188-4-9**] Name: [**Known lastname **],[**Known firstname 5139**] Unit No: [**Numeric Identifier 11619**] Admission Date: [**2188-4-1**] Discharge Date: [**2188-4-18**] Date of Birth: [**2120-7-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2083**] Addendum: Prior to her planned discharge, she had emesis on the evening of [**2188-4-9**]. We decided to keep her in-house due to the emesis. Early the next morning, she had more emesis and melena and was found slumped over on the toilet, but still conscious. A Trigger was called. She was hypotensive and tachycardic. She was transferred to the ICU. Her HCT was 20. She received 4 units of PRBC for her active bleed. Her HCT stablilize at 26. She had an acute upper GI bleed with a firm upper abdomen sugestive of a pseudocyst hemorrhage. A CT scan on [**4-10**] revealed of large hematoma within previously seen large pancreatic pseudocyst, with extension of hematoma into the stomach. Possible erosion via thinned lesser curvature wall. The next day on [**4-11**], Celiac trunk angiogram demonstrates irregularity in the splenic artery , but no areas of active extravasation of contrast. She had successful embolization of the splenic artery with multiple coils until stasis was achieved. She toleraed this well and had no drop in HCT. Her diet was advanced slowly and she was able to tolerate regular food by [**2188-4-17**]. Her abdomen was soft and nontender. Vaccines: She received vaccines x 3 after her splenic embolization. She was transferred out to the floor after successful embolization. She then had an episode of hypotension and tachycardia and was again transferred to the SICU for closer monitoring. No new bleeding was identified and her HCT was stable. A follow-up CT on [**4-13**] showed: 1. Interval splenic artery embolization. 2. No significant interval change in the pancreatic pseudocyst and the hematoma. The hematoma and the pseudocyst continues to protrude and impress on the posterior aspect of the stomach. 3. Large amount of free fluid in the abdomen and pelvis with increase in the fluid collection in the left subphrenic space. A small amount of high attenuation dependent material is seen in the left flank and in the pelvis that could represent proteinaceous material versus small amount of blood. No large new hematoma is identified. She was transferred out to the floor after being treated with Lopressor and fluid. Her HCT was again stable. She was started on Cipro/Flagyl and will continue on Cipro for a UTI. She will be discharged and have a repeat CT in 2 weeks. Pertinent Results: [**2188-4-10**] 05:46AM BLOOD WBC-15.2* RBC-2.58* Hgb-6.3* Hct-20.0* MCV-78* MCH-24.4* MCHC-31.4 RDW-16.4* Plt Ct-393 [**2188-4-10**] 09:14AM BLOOD Hct-28.4*# Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**] Completed by:[**2188-4-18**]

[ "577.2", "562.10", "459.0", "V15.82", "401.9", "568.81", "577.1", "530.81", "593.9" ]

icd9cm

[ [ [] ] ]

[ "39.79", "45.13", "51.85", "54.91", "51.87" ]

icd9pcs

[ [ [] ] ]

12109, 12272

4688, 6810

327, 338

7601, 7652

11926, 12086

8829, 11907

1469, 1473

6921, 7490

7540, 7580

6836, 6898

7676, 8806

1488, 1704

273, 289

366, 937

959, 1177

1193, 1453

72,908

176,846

41549

Discharge summary

report

Admission Date: [**2128-1-19**] Discharge Date: [**2128-3-23**] Date of Birth: [**2086-7-18**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: [**2128-1-20**] Cerebral angiogram with coiling [**2128-1-24**] Cerebral angiogram with angioplasty [**2128-1-26**] Cerebral angiogram with verapamil injection [**2128-1-30**] Right Hemicraniectomy [**2128-2-3**] Trach [**2128-2-3**] PEG [**2128-2-5**] Cerebral angiogram with R ICA coiling' [**2128-2-6**] Cerebral angiogram with verapamil injection [**2128-2-9**] CEREBRAL ANGIOGRAM [**2128-2-10**] CEREBRAL ANGIOGRAM WITH VERAPAMIL [**2128-2-11**] CEREBRAL ANGIOGRAM WITH VERAPAMIL [**2128-2-11**] PLACEMENT OF LEFT EXTERNAL VENTRICULAR DRAIN [**2128-2-12**] CEREBRAL ANGIOGRAM WITH VERAPAMIL [**2128-2-13**] CEREBRAL ANGIOGRAM WITH STENT AND COILING OF RIGHT ICA [**2128-2-14**] CEREBRAL ANGIOGRAM WITH VERAPAMIL [**2128-2-23**] Diagnostic angiogram [**2128-2-24**] Angiogram with coiling of right ICA aneurysm [**2128-2-27**] Placement of right VP shunt [**2128-3-2**] Cerebral Angiogram [**2128-3-10**] IVCF placment [**2128-3-16**] diagnostic cerebral angiogram [**2128-3-18**] L VP shunt placement and R cranioplasty History of Present Illness: This ia a 41 year old G4P3 right handed female who was transferred to [**Hospital1 18**] from [**Hospital 27778**] hospital after she developed a frontal headache the day prior. She was at a store with her family and the headache intensified over 15 min to maximal severity and she also developed blurred vision to the point where she could not see anything. She denied nausea, vomiting, abnormal movements, loss of bowel or bladder function. The blurred vision gradually resolved, but she maintained a headache, and was unable to fall asleep secondary to her headache. MRI/MRA imaging was concerning for intracranial hemorrhage with extention into the ventricles and possible visualization of an ACOM aneurysm. Patient estimated that she is 7 weeks pregnant at time of admission. Past Medical History: Asthma Social History: She is married and has three children, ages 8/7/3 Family History: NC Physical Exam: On Admission: T:97.4 BP: 152 /91 HR:60 R18 O2Sats98 RA Gen: WD/WN, comfortable, NAD. HEENT: NCNT Neck: moderately rigid. Abd: Soft, NT, Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3-2.5 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 [**3-25**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger ON DISCHARGE: Prefers her eyes closed and prefers to lay on left side Follows commands on right side to show fingers or wiggle toes Will nod head appropriately to orientation questions about her name, location and family questions about names of her husband and children. Is not orientated to date Motor: Appears full and spontaneous on RUE and RLE. LLE triple flexion. LUE + grasp to command. Pupils are equal bilaterally On Discharge: EO to voice. Pupils are equal and reactive but patient typically refuses. Nonverbal but nods head appropiately to questions. She follows commands with the right side. RUE/RLE spont and purposeful. LUE flexion, has begun to show intermitted spont movement. LLE weak withdrawl to pain. Head incisions are C/D/I with sutures. Bilateral groin sites remain hard but have been improving. In general she is oriented to name / hospital / yr / husbands name / will be able to relaibly tell you she has pain and where when directed / she frowns when in pain or sad. She has been interactive with her children when the visit ie patting her little ones head when he stood on her right side. Pertinent Results: CT HEAD W/O CONTRAST [**2128-1-19**] Bilateral subarachnoid hemorrhage, small foci of intraventricular hemorrhage, MR HEAD W/O CONTRAST [**2128-1-20**] MRA BRAIN: There is an apparent small outpouching versus aneurysm directed posteriorly (series 4- image 91) in the right supraclinoid ICA measuring approximately 1 mm. The right MCA bifurcation has a bulbous appearance, a normal variant. The intracranial vessels are otherwise unremarkable. IMPRESSION: Abnormal signal in the subarachnoid space and in the ventricular system that may represent hemorrhage or pus. Tiny outpouching versus aneurysm directed posteriorly in the right supraclinoid ICA. No other vascular abnormalities are detected. CTA HEAD W&W/O C & RECONS [**2128-1-21**] 1. New region of acute hemorrhage, with both intra- and extra-axial components, immediately adjacent to the right cavernous sinus. This is in close proximity to a focal outpouching of the cavernous segment of the right internal carotid artery.Given the original presentation, and the lack of other ready explanation, this finding must be regarded as suspicious for aneurysmal rupture. There may also be transependymal extension of this hemorrhage into the lateral ventricles. 2. Possible distal right vertebral artery pseudoaneurysm corresponding to a focal outpouching as seen on recent angiography. 3. Decreased extent of subarachnoid hemorrhage overlying the bilateral frontoparietal convexities, with no new focus of subarachnoid blood, other than above. 4. Prominence of the lateral ventricles, bilaterally, not significantly changed. 5. No evidence of subfalcine, uncal or transtentorial herniation CT Head [**2128-1-22**]: IMPRESSION: No significant short-interval changes of the known intraparenchymal and subarachnoid hemorrhage. Persistent bilateral intraventricular hemorrhage in the occipital horns but without developing hydrocephalus. No definite evidence of new foci of intracranial hemorrhage. No midline shift. CTA Head [**2128-1-24**]: IMPRESSION: 1. New right middle cerebral artery infarct involving the temporal lobe as well as basal ganglia region on the right with decrease in size of the flow voids, indicative of vasospasm. 2. Blood products are again seen in the right suprasellar region and adjacent brain along with blood products in the ventricles and sulci from subarachnoid hemorrhage. 3. A new small infarct is identified in the right cerebellum since the previous MRI examination. 4. Other areas of increased signal on diffusion images along the sulci appear to be secondary to subarachnoid blood. 5. Mild ventriculomegaly with the ventricular size slightly decreased from previous MRI examination and stable from CT of [**2128-1-22**]. CT Head [**2128-1-25**]: IMPRESSION: 1. A focus of hemorrhage by the right cavernous sinus is unchanged. 2. Persistent but less conspicuous subarachnoid blood within the right frontal lobe. 3. Continued blood layering within the occipital horns. 4. A small focus of hemorrhage adjacent to the left cavernous sinus is not well visualized on the current exam. Bil Lower Ext Dopplers [**2128-1-26**]: IMPRESSION: No evidence of DVT. CTA Head [**2128-1-28**]: IMPRESSION: 1. Continued evolution of a large right MCA territorial infarction, without evidence of hemorrhagic transformation, midline shift or herniation. 2. Continued retraction of a clot adjacent to the right cavernous sinus, as well as residual subarachnoid hemorrhage and intraventricular hemorrhage. No evidence of new hemorrhage. 3. Diffuse vasospasm of the anterior and posterior circulation, more severe when compared to prior CTA from [**2128-1-21**]. 4. Non-visualization of the previously-noted pseudoaneurysm arising from the V4 segment of the right vetebral artery, which may have thrombosed in the interim. 5. Persistent small outpouching along the lateral aspect of the right cavernous carotid artery, may reflect a tiny cavernous carotid aneurysm. 6. Newly-developed focal outpouching along the medial aspect of the right carotid terminus, which may relate to vasospasm or, alternatively, may reflect a new pseudoaneurysm, post-procedure. CT Head [**2128-1-30**]: IMPRESSION: Interval development of new leftward shift of midline structures, effacement of the suprasellar cistern, and early effacement of the quadrigeminal cisterns, concerning for subfalcine, uncal, and early downward transtentorial herniation. CT Head [**2128-1-30**]: Substantial decrease in the degree of leftward shift of normally midline structures as well as decreased effacement of the quadrigeminal plate cistern (indicating improvement of transtentorial herniation) s/p right hemicraniectomy. Brain parenchyma has decompressed through this right sided defect in the calvaria. Unchanged scattered SAH overlying the right cerebral hemispheric convexity. Small quantity of hemorrhage in the occipital [**Doctor Last Name 534**] of the left lateral ventricle is unchanged. No new areas of intracranial hemorrhage. Diffuse hypodensity in the right MCA and ACA distributions, c/w evolving infarction, is not signficantly changed. [**1-31**] CT Head: IMPRESSION: Minimal increase of mass effect since [**2128-1-30**] with slightly increased effacement of the frontal and temporal [**Doctor Last Name 534**] of the right lateral ventricle and minimally increased midline shift. [**2-2**] Head CTA/P: IMPRESSION: 1. Marked increased transit time and decreased regional cerebral blood volume involving the majority of the right cerebral hemisphere, consistent with infarction. The right basal ganglia appears spared, consistent with maintained arterial flow to these deep nuclei via lenticulostriate arteries, as seen on the CTA portion of the study. 2. Hypodensity in the mid brain is unchanged compared to CT from [**2128-1-31**]. Recommend further evaluation of this finding with MR [**First Name (Titles) **] [**Last Name (Titles) 40806**]y indicated and not contraindicated. 3. Diffuse vasospasm involving the intracranial portion of the right internal carotid artery and its distal branches. Given the attenuation in flow to the majority of the right cerebral hemisphere as seen on CTA, progression of the vasospasm compared to [**2128-1-28**] is likely. 4. Small outpouchings from the cavernous portion of the right ICA and right carotid terminus are not significantly changed. LENIS [**2128-2-4**]: No DVT to bil lower extremities Head CT [**2128-2-5**]: IMPRESSION: 1. Evolving right MCA and ACA territory infarcts, with mild increase in the diffuse swelling of the right cerebral hemisphere, with associated increase in the transtentorial herniation compared to the prior study of [**2128-1-31**]. No evidence of new hemorrhage. 2. Stable right frontal SAH. Mild decrease in the intraventricular hemorrhage. No hydrocephalus. Head CT [**2128-2-6**] IMPRESSION: 1. Evolving right MCA/ACA infarct, with stable right hemispheric swelling and transcranial herniation since the prior study. No evidence of hemorrhage within the infarct. 2. Stable right frontoparietal SAH and left occipital intraventricular hemorrhage. No evidence of hydrocephalus. CTA HEAD [**2128-2-7**] No evidence of new hemorrhage. Vasospasm is improved since the most recent CTA of [**2-2**], but appears worse than on the catheter angiogram of [**2-6**]. Continued herniation of right hemisphere through the craniectomy defect. Evolving right hemisphere infarction. Head CT [**2128-2-11**]: Status post right hemicraniectomy with a 2 mm increase in size of the diameter of the lateral ventricles. No new hemorrhage noted. Head CT [**2128-2-11**]: Proper placement of EVD catheter. Head CT [**2128-2-12**]: Improved; decreased swelling, decreased ventricular size. Lenies [**2-14**]: IMPRESSION: 1. No evidence of DVT in left lower extremity veins. 2. A 4.7 x 1.9 x 3.1 cm anechoic collection, within the left medial thigh, likely represents a seroma, less likely abscess. CT HEAD [**2-14**]: IMPRESSION: No new hemorrhage identified. Ventricular size has slightly decreased. Diffuse right cerebral abnormalities are again noted. Post-coiling changes are seen. Bil Femoral Ultrasound [**2128-2-16**]: IMPRESSION: Little interval change to tubular fluid collection within the medial left groin for which differential includes old hematoma or seroma. Interval development of a small probable hematoma immediately anterior to the right common femoral artery and vein in the right inguinal region measuring approximately 3 cm. No findings of pseudoaneurysm or AV fistula bilaterally. [**2-16**] Xray Hips: FINDINGS: AP view of the pelvis and two views of each hip. No fracture identified in either hip. No osteonecrosis. No degenerative changes. [**2-19**] CT Head with Angiogram - 1. Interval development of marked hydrocephalus and intraventricular hemorrhage compared to [**2128-2-14**]. Dr. [**Last Name (STitle) **] discussed this with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 90370**] via telephone on [**2128-2-19**]. 2. Continued evolution of large cerebral infarct, with overlying hyperdensity in a cortical/gyral pattern. This hyperdensity could represent laminar necrosis or subarachnoid hemorrhage. 3. Apparent narrowing of right M1 segment at the distal aspect of the stent was not seen on the [**2128-2-14**] angiogram. However, this finding may be secondary to artifact from the stent. Vasospasm is otherwise simlar to the [**2128-2-14**] angiogram. 4. Right carotid aneurysm and right A1 segment obscured by streak artifact from coil pack. CXR [**2128-2-24**] As compared to the previous radiograph, there is no relevant change. Minimal retrocardiac atelectasis. Normal size of the cardiac silhouette. No focal parenchymal opacity suggesting pneumonia. Normal lung volumes. No pulmonary edema. No pneumonia Cerebral Angiogram [**2128-2-24**] Successful embolization of the known residual supraclinoid / paraopthalmic aneurysm involving the right internal carotid artery. The aneurysm is well coiled. CT head [**2128-2-24**] 1. Similar extent of intraventricular and subarachnoid hemorrhage. 2. Stable ventriculostomy catheter with stable degree of hydrocephalus, predominantly of components of the right lateral ventricle. 3. Similar degree of transcranial herniation. CXR [**2128-2-28**] Minor left lower lobe atelectasis. Satisfactory appearance of medical devices. CT head [**2128-2-28**] 1. Interval conversion of left ventricular drain to a ventriculoperitoneal shunt, no evidence of hemorrhage along the catheter tract. 2. Stable ventricular size, with relative prominence of the right lateral ventricle. No interval progression of ventricular dilatation. 3. Extensive right-sided parenchymal edema, though degree of transcranial herniation through a large craniotomy defect is slightly decreased from prior study. 4. Decreased conspicuity of subarachnoid and intraventricular blood products, with no new focus of hemorrhage identified. [**2128-2-29**] Bil LE Dopplers 1. No deep vein thrombosis noted in the bilateral lower extremities. 2. Bilateral groin fluid collection, similar in appearance though decreased in size compared to [**2128-1-20**] study and likely represent resolving hematomas or seromas from prior instrumentation. [**2128-3-2**] Cerebral Angiogram: Minimal filling at the base of the R ICA aneurysm [**2128-3-7**] CT ABD FINDINGS: CT ABDOMEN: There is subtotal atelectasis of the left lower lobe with some residual aerated lung at the posterior medial left lung base. No pleural or pericardial effusion. The liver, spleen, adrenal glands, and pancreas are normal in appearance. The kidneys enhance and secrete contrast symmetrically. There is a subcentimeter hypoattenuating lesion in the lower pole of the left kidney which is too small to accurately characterize. There is a ventriculostomy catheter which terminates in the right pelvis. There is no collection adjacent to the catheter tip. There is a G-tube in the stomach. The abdominal aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. Bowel loops are normal caliber. A normal appendix is seen. There is no upper abdominal ascites. CT PELVIS: There is a Foley catheter in a decompressed bladder. There is a small amount of air within the bladder likely related to catheterization. There is no pelvic ascites. There are multiple, soft tissue nodular densities in the anterior abdominal wall and a small amount of gas in the anterior abdominal wall inferiorly on the right. This is all likely related to subcutaneous injections. There is soft tissue ossfication involving the musculature posterior to the left hip, particularly the obturator internus, externus and pyriformis. There are stellate shaped areas of calcification in the bilateral groin anterior to the femoral vessels. There are no lytic nor blastic bone lesions. IMPRESSION: 1. No evidence of acute intra-abdominal pathology. 2. Calcification involving the musculature posterior to left hip may be related to heterotopic ossification from brain injury. 3. Ossification/calcification anterior the femoral vessels likely related to prior line placement and subsequent hematomas seen on Vascular U/S [**2128-2-16**]. [**2128-3-8**] ABD US The liveR is normal in echogenicity with no focal lesions present. The portal vein is patent with hepatopetal flow. The common bile duct measures 2 mm and is normal. The gallbladder shows no evidence of cholelithiasis or cholecystitis. IMPRESSION: No cholelithiasis or secondary findings of acute cholecystitis. [**2128-3-9**] ECHO Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). [**2128-3-9**] DOPPLERS IMPRESSION: New right-sided common femoral and superficial femoral vein thrombus since prior US. Findings are consistent with an above-knee DVT. [**2128-3-10**] CT BRAIN FINDINGS: A left ventriculostomy catheter with frontal approach is noted terminating in the left lateral ventricle, unchanged. In comparison to [**2128-2-28**] exam, there is notable increase in size of the ventricles, concerning for faulty catheter drainage. There is no evidence of acute intracranial hemorrhage, or shift of normally midline structures. The right cerebral hemisphere demonstrates edema and continues to herniate through the craniectomy site, unchanged from prior exam. The [**Doctor Last Name 352**]-white matter differentiation of the left hemisphere appears preserved. The basal cisterns are patent. Right ethmoid opacification is again noted. The remainder of paranasal sinuses and mastoid air cells appear well aerated. IMPRESSION: In comparison to [**2128-2-28**] exam, there is progressive enlargement of ventricles, concerning for impaired catheter drainage. A heterogeneous appearance, edema and herniation of the right hemisphere is unchanged from prior exam. No evidence of intracranial hemorrhage. Head CT [**2128-3-16**]: IMPRESSION: No interval change. Head CT [**2128-3-17**]: IMPRESSION: Interval right cranioplasty, with no evidence of acute intracranial hemorrhage. Head CT [**2128-3-18**]:Post right cranioplasty changes with left ventriculostomy shunt in unchanged position. Ventricles are stable in size. No evidence of acute intracranial hemorrhage. Head CT [**2128-3-19**]: Stable Brief Hospital Course: This is a 41 year old female who was 11 weeks pregnant with history of HTN who presented with headache. Head CT revealed SAH. She was admitted to neurosurgery and an OB consult was done. On [**1-20**], patient was taken to angio where a R vertebral artery dissection was was found. The artery was coiled and sacrificed and patient was placed on heparin drip. On [**1-21**], patient was more lethargic and emergent CTA was done. She was found to have a new R ICH and heparin drip was discontinued. On [**1-22**], patient's exam was improved, more alert, but reported headache overnight. TCDs were done which showed moderate vasospasam L MCA and mild vasospasm on bilateral ACAs. A repeat head CT was done which showed no change from previous scan. On [**1-23**],fetal ultrasound: Single gestational sac which by size corresponds with a 5 week pregnancy without yolk sac or fetal pole or heart beat is identified within this sac. Human Chorionic Gonadotropin-level 0200-[**Numeric Identifier 90371**] at 1700-[**Numeric Identifier 90372**]. The patient experienced worsening headache. On exam she was awake to voice, oriented x to person, place and time, moves all extremities to command with full motor strength. There was left asal labial fold flattening and slight left pronator was noted. On [**1-24**], The patient was noted by nursing to have an acute desaturation from 95% to 85% after taking pills with liquid due to decreased mental status. A chest Xray was performed which was consistent with worsening atelectasis within the left lower and upper lobes. MR [**First Name (Titles) **] [**Last Name (Titles) **] protocol per neurology, MRI showed R MCA infarct involving temp lobe and BG, also small R cerebellar infarct. The patient was electively intubated and taken to neuroradiology for an Angiogram with angioplasty to Right ICA and Right MCA. Verapamil to all other arteries. [**1-25**]: A head CT was performed which was consisted with a focus of hemorrhage by the right cavernous sinus which was unchanged. There was persistent but less conspicuous subarachnoid blood within the right frontal lobe. There was continued blood layering within the occipital horns. A small focus of hemorrhage adjacent to the left cavernous sinus is not well visualized on the current exam. The patient was febrile overnight, there was concern for chorioamniotis vs septic abortion. OBGYN felt there was no need for d&c at this time with plans for a ultrasound on [**1-26**]. The patientcontinued to be intubated due to poor respiratory status. [**1-26**] The patient contnues to be intubated on a vasopressor to keep a goal systolic blood pressure greater than 160, mini BAL sent and showed no growth, Transvaginal ultrasound was performed which was consistent with no retained products. Transcranial doppler with evidence of spasm on left. Angio was completed and Verapamil was injected throughout. [**1-27**] her exam remained stable. On [**1-28**] her IV fluids were decreased as patient was 4L positive, she recieved albumin x2, CTA head was obtained which was stable but vasospasm was still noted and significant. She was transfused with one unit PRBC for a low HCT. On [**1-29**] she remained stable during the day, TCD improved. Overnight the patient became hypertensive and on [**1-30**] [**Name6 (MD) 21336**] morning RN noted patients pupils to be irregular and the Nsurg was called. On exam patient was no longer following commands on the R side and pupils were asymmetric but appeared to react. A STAT head CT was done which showed worsening R MCA infarct with new ACA infarct, new midline shift, and herniation. Upon arrival to the ICU after CT, her R pupil remained larger and reactive, but left pupil was nonreactive, no spont R sided movement, attempted to localize on RUE, LUE extends, BLE withdrew. Mannitol 100gm was given emergently and NA 23%. She was taken emergently to the OR for a right sided hemicraniectomy. A subgaleal drain was placed. Patient returned to the ICU where her exam remained unchanged except L pupil was 2mm and reactive. A post-op CT was stable. Her SBP was kept 180-200, no mannitol was continued as vasospasm was still a concern. On [**1-31**] she remained neurologically stable. Drain output was minimal therefore it was removed. A head CT was performed which revealed minimal increase in MLS and mass effect but no intervention was indicated at this time with stable exam and risk of vasospasm. On [**2-1**], patient's exam remained unchanged, her groin sites were softer to touch and no increase in sizes of hematoma. On [**2-2**], she was noted to have a downward gaze and was febrile. EEG was initiated to r/o seizures and Keppra was increased. On [**2-3**], she remained febrile, TCD showed critical vasospasm on the R/L MCA and SBP was kept 180-200. Her trach and PEG were placed. On [**2-4**] she remained stable. On [**2-5**] she underwent a cerebral angiogram that showed an enlargement of the R ICA aneurysm, she was then coiled but not fully. She returned to the ICU with a sheath in place. Blood pressure parameters were liberalized to 140-160, IVF were decreased, and Nicardipine was started. On [**2-6**], she returned to angio to re-assess vasospasm which appeared improved, she received verapamil intra-arterially. Her exam remained stable. Also on [**2-6**] she was trasnfused with 2 units of PRBC's to maintain a hematocrit of 30. On [**2-7**] her TCD's showed increased velocities and a repeat CTA of the head showed improvement in the vasospasm. On [**2-8**] the staples were removed from her drain site, her BP goal was changed to 120-180 systolic, and she was febrile to 103. On [**2-9**], she was taken to angio to re-evaluate. The angio showed the R side had improved but the left side had mild to moderate vasospasm. At that time, her SBP was kept at 180-200, and her angio sheath remained for a repeat angio on [**2-10**]. On [**2-10**], she returned to angio which showed mild to moderate spasm to the left and she received Verapamil to bil ICAs. She also received a transfusion of one unit for a HCT of 28. Her sputum culture grew MRSA and she was started on Vancomycin. On [**2-11**], a Head CT showed an increase in her ventricles and a Left sided EVD was placed at bedside. Her SBP was relaxed to 120-140 with Nicardipine. Vancomycin was discontinued and Ancef was started for the drain. She returned to angiogram which showed moderate to severe spasm and received Verapamil to the left. Her EVD was dropped to 5 cm. Her SBP was allowed to return to 170-190. Nimodipine was discontinued. On [**2-12**], her exam changed- asymmetric pupils and sluggish R sided movement. A head CT was done which showed improvement. Her EVD was kept at 5 cm. She returned to angiogram and received additional verapamil (5mg to the R ICA, 10mg to L ICA), it was also noted that the R ICA aneurysm appeared larger. Post-angio, her blood pressure was liberalized to 140-160. Patient was taken to the Angio suite on [**2-13**] for stent assisted coiling of her right ICA aneurysm. In late [**Month (only) 958**] it was noticed that the patient's left lower extremity ROM is limited most likely due to a seroma in the left groin. A bilateral femoral ultrasound was done there was no psuedo aneurysm and normal arterial and venous flow was noted. An orthopedic consult was obtained for contracture of her left hip. No surgical intervention indicated. She developed MRSA in her sputum was treated with Vancomycin for propholaxis for the EVD and MRSA in her sputum. Ms [**Known lastname 90373**] EVD an attempt was made to wean her EVD. Her EVD was raised to 10 but then went back to 5 after oozing from her EVD site. During the evening, she continued to ooze and a additional stitch was placed. On [**2-17**], her exam & HCT remained stable and her EVD was raised to 10. On [**2-18**] her HCT was stable at 28. Her exam was also stable so the EVD was raised to 15. On [**2-19**] she continued to tolerated the weaning of the EVD so it was raised to 20. A repeat CT on this day showed that the patient had developed hydrocephalus; again the EVD was dropped for better drainage, we plan to put in a perminant Vertricular peritoneal shunt. Patient drained was moved on 10cmH20 and remained stable. She remained neurologically stable. On [**2-23**] she underwent another diagnositic angiogram that showed continued enlargement of Right ICA aneurysm, it was coiled. A repeat CT also showed a new IVH, her SBP parameters were lowered to 160. On [**2-24**] she underwent an angiogram which showed enlargement of the existing aneurysm which required more coils. On [**2-27**] she underwent a VPS with a programable valve set at 0.5. A follow up CT showed She will undergo a head CT [**2-28**] to evaluate her ventricular size was stable. Neurologically she slowly improvd with the more eye opening answering yes/no questions appropriatly and moving the right side with excellent strenght. She requires mechancal ventilation so a vented rehab is being seeked. On [**2128-2-29**] Screening LE Dopplers showed no DVT. On [**3-3**] she underwent an angiogram without intervention. This showed minimal filling at base of aneurysm. Her post-procedure Hct droped to 20. She was transfused with 2 units of PRBCS and her Hct raised to 28. Lovenox was initiated instead of Heparin for DVT prophylaxis with less abdominal injections. She was intermittently hypopneic with unclear etiology, requiring a ventilation rate. She had a BAL. Tube feeds were restarted. Her neurologic status remained relatively unchanged, she required light stimulus for EO and LUE movement at times. [**3-4**]: Her hematocrit was stable at 27.3. She remained on CPAP through the night. On [**3-5**], patient was febrile overnight 101. Vancomycin was started for 4+ gram positive cocci and yeast found in bronch specimen. In the morning, exam remained unchanged, she had minimal eye opening, followed commands on R side and moves purposefully, wiggles toes on LLE and no movement of LUE. From 4/16-4/17she remained stable but continued spiking temperatures. On [**3-8**], she continued to spike. CSF and UA was sent. Shunt was tapped and CSF was sent. Results demonstrated GPC in clusters. Pt left VP shunt was then externalized for presumed meningitis. ID was consulted prior and recommended broad spectrum abx / meropenem was initiated. Vancomycin 1.5g was continued concurrently. She was taken to OR on [**3-9**] and underwent L EVD placement and removal of VP shunt. A CT brain was stable. Fever workup incuding echo (TTE) was negative. Her lower extremity doppler study was positive for a DVT. An IVCF was placed on [**2128-3-10**]. CSF was sent again on [**3-11**]. Her exam remained stable [**Date range (1) 90374**]. On [**3-12**] her serum WBC was 3.5 down from 6.1, her Tmax was 101.5 at 08:00. She underwent a clamping trial of the EVD and ICP's remained stable. She underwent diagnostic cerebral angiogram on [**2128-3-16**] which was stable and no intervention was done. On [**3-17**], she was planned for a cranioplasty on the right side, but her crani site appeared [**Hospital1 2824**] so she underwent a R cranioplasty and L VP shunt. Her shunt was programmed at 0.5 and a subdural drain was placed. Post-op head CT was stable with expected post-op changes. She had a speech and swallow evaluation and was cleared for PMV. On [**3-18**] AM a head CT was done to reassess ventricular size which were stable and her shunt was kept at 0.5. On [**3-19**], she was uncomfortable and complaining of stomach discomfort. ACS was asked to assess and everything appeared fine. Her HCT was 25.1 and was repeated in the afternoon it was 27. It was also noted that she had no menstrual cycle for two months and OB/GYN was consulted. A HCG was sent which was less than 5. On [**3-22**], medicine was consulted for optimal hypertensive management. They recommended starting a second [**Doctor Last Name 360**] - Lisinopril to her regimen of Metoprolol 50mg TID. Vancomycin was d/c'd as she had completed her course. On [**3-23**], pt was cleared and had a bed at [**Hospital3 **] Medications on Admission: ProAir Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Ondansetron 4 mg IV Q8H:PRN nausea 3. HydrALAzine 10 mg IV Q6H:PRN SBP>160 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 8. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for bronchospasm. 10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**11-23**] Tablets PO Q6H (every 6 hours) as needed for headache. 11. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-23**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 15. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes . 16. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 17. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q2HR PRN () as needed for pain. 19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash on back. 20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 21. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: SUBARACHNOID HEMORRHAGE BILATERAL VERTEBRAL ARTERY DISSECTION RIGHT VERTEBRAL ARTERY ANEURYSM RIGHT ICA ANEURYSM SPONTANEOUS ABORTION STREPTOCOCCUS PNEUMONIAE / pneumonia ACUTE RESPIRATORY FAILURE RIGHT MCA INFARCT LEFT HEMIPLEGIA CEREBRAL ARTERY VASOSPASM / SEVERE POST-OPERATIVE FEVER ANEMIA REQUIRING TRANSFUSION RIGHT ACA INFARCT CEREBRAL EDEMA SEVERE INTRACRANIAL HYPERTENSION MRSA infection (Sputum) OBSTRUCTIVE HYDROCEPHALUS BILATERAL FEMORAL ARETERY PSEUDOANEURYSMS LEFT GROIN/FEMORAL REGION SEROMA TRANSIENT TRANSAMINITIS CNS INFECTION/MENINGITIS DEEP VEIN THROMBOSIS / RIGHT LOWER EXTREMEITY AMENORRHEA HYPERTENSION Discharge Condition: Mental Status: Will answer yes/no question appropriately by shaking head Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. Followup Instructions: Follow-Up Appointment Instructions Have your sutures removed on [**3-31**], you may have those removed at our office please call [**Telephone/Fax (1) 4296**] for an appointment or you may have them removed at your rehab facility ??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a MRI/MRA ([**Doctor Last Name **] Protocol) at that time. PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN FOR YOUR BLOOD PRESSURE AND GENERAL CARE. Completed by:[**2128-3-23**]

[ "320.9", "437.3", "342.92", "442.3", "434.91", "997.2", "453.40", "E879.8", "634.91", "642.03", "482.42", "V48.6", "443.24", "348.89", "481", "331.4", "599.0", "998.12", "348.4", "430", "447.8", "996.63", "E878.1", "674.03" ]

icd9cm

[ [ [] ] ]

[ "02.34", "39.75", "99.29", "02.39", "01.25", "38.7", "39.50", "43.11", "96.72", "00.41", "02.04", "02.43", "31.1" ]

icd9pcs

[ [ [] ] ]

34614, 34685

20486, 32619

315, 1342

35355, 35355

4622, 9734

36096, 36663

2270, 2275

32677, 34591

34706, 35334

32645, 32654

35571, 36073

2290, 2290

3921, 4603

267, 277

1370, 2155

2737, 3483

9743, 20463

2304, 2484

35370, 35547

2177, 2186

2202, 2254

50,815

139,249

39365

Discharge summary

report

Admission Date: [**2175-8-10**] Discharge Date: [**2175-8-18**] Date of Birth: [**2097-12-9**] Sex: F Service: ORTHOPAEDICS Allergies: Aspirin Attending:[**Doctor Last Name 1350**] Chief Complaint: Lumbar spinal stenosis Major Surgical or Invasive Procedure: Posterior lumbar decompression and fusion History of Present Illness: [**Known firstname 1743**] [**Known lastname **] is a 77-year-old female who presented with a debilitating syndrome of progressive back and radiating leg pain as well as weakness, provoked by standing and walking. Over time, she progressively lost ability to walk as a result of this syndrome. She was found to have severe spinal stenosis with neurogenic claudication. Her syndrome was refractory to prolonged and multimodal course of conservative care. Due to the severity of symptoms, in concert with the refractory nature of the syndrome despite conservative care, she did elect to undergo surgical treatment. Past Medical History: see admit H&P Social History: NC Family History: NC Physical Exam: see admission H&P Pertinent Results: [**2175-8-10**] 08:32PM HCT-25.5* [**2175-8-10**] 04:34PM TYPE-ART PO2-205* PCO2-44 PH-7.41 TOTAL CO2-29 BASE XS-3 INTUBATED-INTUBATED [**2175-8-10**] 04:34PM GLUCOSE-109* LACTATE-0.9 NA+-135 K+-3.3* CL--101 [**2175-8-10**] 04:34PM HGB-9.3* calcHCT-28 O2 SAT-98 [**2175-8-10**] 04:34PM freeCa-1.07* [**2175-8-10**] 01:36PM TYPE-ART PO2-177* PCO2-41 PH-7.45 TOTAL CO2-29 BASE XS-4 INTUBATED-NOT INTUBA [**2175-8-10**] 01:36PM GLUCOSE-104 LACTATE-1.0 NA+-134* K+-3.4* [**2175-8-10**] 01:36PM HGB-9.6* calcHCT-29 [**2175-8-10**] 01:36PM freeCa-1.11* Brief Hospital Course: Pt underwent the above mentioned procedure. She tolerated this well and was transferred to the ICU post-operatively given significant blood loss as well as for her significant pulmonary history. ICU noted development of hospital-acquired pneumonia and treated appropriately with IV antibiotics. She otherwise progressed well in the unit. She responded well to treatment, and was transferred to the floor from the ICU. Vanco/Zosyn were utilized to cover the pneumonia. Pain was adequately controlled with IV followed by PO meds. Drain was discontinued when output was minimal, incision maintained excellent appearance throughout hospitalization. PT worked with the patient. She had difficulty progressing secondary to multiple medical comorbidities and low reserve. Once patient was stable from the standpoint of her pain control, and with good control of her comorbidities, she was deemed stable for transfer to rehab. Medications on Admission: see admit H&P Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q6hr () as needed for wheezing. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for prn fever T> 100.9. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-10**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP > 140. 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 grams IV Intravenous Q8H (every 8 hours) for 8 days. 16. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 12H (Every 12 Hours): 750 mg IV Q12H. continue for 8 days Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Lumbar spinal 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. Daily dressing change until dry for 24 hours, then leave open to air. 3. Continue PT exercises, ambulate 4. no lifting > 10 lbs Physical Therapy: Disc unloader brace to be worn when out of bed. Ambulate as tolerated. Please assist with mobility and balance Treatments Frequency: Change posterior dressing daily until dry for 24 hours, then may leave open to air. [**Month (only) 116**] shower. No baths Followup Instructions: 1. Return to clinic 10-14 days after discharge (Dr. [**Last Name (STitle) 1007**] Completed by:[**2175-8-17**]

[ "401.9", "737.39", "493.20", "486", "288.60", "338.18", "E878.1", "733.00", "553.3", "997.39", "530.81", "244.9", "V10.11", "V10.3", "724.02", "507.0" ]

icd9cm

[ [ [] ] ]

[ "77.78", "81.08", "81.63", "38.93", "84.52" ]

icd9pcs

[ [ [] ] ]

4348, 4420

1703, 2633

295, 339

4487, 4487

1114, 1680

5133, 5246

1057, 1061

2697, 4325

4441, 4466

2659, 2674

4670, 4832

1076, 1095

4850, 4962

4984, 5110

233, 257

367, 984

4502, 4646

1006, 1021

1037, 1041

28,206

124,455

11857

Discharge summary

report

Admission Date: [**2197-5-29**] Discharge Date: [**2197-6-19**] Date of Birth: [**2132-10-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: [**6-8**] Venogram [**6-9**] Venogram with attempted catheter clearance [**6-14**] EGD with balloon dilataion of pylorus History of Present Illness: 64M s/p minimally invasive esophagectomy for stabe III CA [**98**] days prior to admission, now with respiratory distress. Per report patient sent from rehab with signs of labored breathing, tachypnea, decreased 02 sats and episodes of bilious emesis. Was in ED preparing for urgent intubation. No report of fevers or chills. Past Medical History: 1. Esophageal Cancer Patient was initially diagnosed in [**2197-1-4**] at which time he developed problems swallowing with solid food getting stuck in his mid-chest. EGD on [**2197-1-4**] demonstrated a 3cm malignant, nodular mass at the GE junction with biopsy consistent with adenocarcinoma, extending beneath squamous epithelium. Endoscopic ultrasound was performed on [**2197-1-16**] with staging consistent with T3N1. He is being treated with 5FU and radiation. He had his first dose of 5-FU on [**2197-2-25**] which he tolerated well. Given his renal insufficiency he is not a candidate for cisplatin therapy, however his primary oncologist is considering adding a second [**Doctor Last Name 360**] depending on how he responds to 5-FU 2. Anemia 3. Asthma 4. Hypertension 5. Hypothyroidism 6. Gout, chronic smoldering, polyarticular 7. Chronic Renal Insufficiency - baseline cr 1.4 8. Clostridium difficile colitis and treated with PO vanco 9. Strongyloides infection, dx in [**2194**] with eosinophilia and anemia s/p Ivermectin therapy 10. [**5-19**] s/p minimally invasive esophagectomy Social History: Comes from [**Location 1188**] house rehab center Home: Pt is from [**Male First Name (un) 1056**] originally, immigrated here > 12 years ago. Lives alone. Not able to read. Spanish-speaking alone. Separated from wife and has 4 children who do not live locally. Occupation: previously employed in farm work EtOH: previously used to binge drink but quit drinking Drugs: Denies Tobacco: quit 15-20 years ago Family History: No hx of CAD, CVA, DM, Cancer. Physical Exam: On admission: 99.3, 120, 160/100, 35, 85RA uncomfotable, distressed Alert but difficult to assess orientation [**1-21**] distress NCAT, neck staples and incisions c/d/i bilious emesis on clothes RRR no murmurs Lungs with coarse breath sounds bilaterally, tachypneic Abdomen soft nontender J tube in place On discharge: 99.5, 99, 112/65, 18, 96RA NAD A&0x3 RRR no murmurs Lungs clear with mild crackles RLL - chronic discoloration changes over sternum and back consistent with post radiation changes Abdomen soft and nontender - J tube without erythema incisions in excellent condition no peripheral edema Pertinent Results: [**2197-5-29**] 08:30PM BLOOD WBC-15.8*# RBC-3.44* Hgb-10.5* Hct-32.2* MCV-94 MCH-30.6 MCHC-32.6 RDW-16.0* Plt Ct-236 [**2197-5-30**] 02:06AM BLOOD WBC-21.3* RBC-3.18* Hgb-9.9* Hct-30.7* MCV-97 MCH-31.0 MCHC-32.1 RDW-16.1* Plt Ct-210 [**2197-5-31**] 01:46AM BLOOD WBC-19.3* RBC-2.62* Hgb-8.0* Hct-25.3* MCV-97 MCH-30.5 MCHC-31.6 RDW-16.3* Plt Ct-199 [**2197-6-7**] 05:50AM BLOOD WBC-7.2 RBC-3.38* Hgb-10.1* Hct-32.8* MCV-97 MCH-29.7 MCHC-30.7* RDW-16.9* Plt Ct-303 [**2197-6-8**] 10:30AM BLOOD WBC-8.7 RBC-3.12* Hgb-9.5* Hct-29.7* MCV-95 MCH-30.4 MCHC-32.0 RDW-16.7* Plt Ct-316 [**2197-6-9**] 05:25AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.5* Hct-28.8* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.5* Plt Ct-290 [**2197-5-29**] 08:30PM BLOOD Neuts-82* Bands-12* Lymphs-5* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2197-5-29**] 08:30PM BLOOD PT-13.3 PTT-29.9 INR(PT)-1.1 [**2197-5-29**] 08:30PM BLOOD Glucose-198* UreaN-33* Creat-1.8* Na-136 K-5.1 Cl-102 HCO3-21* AnGap-18 [**2197-5-30**] 02:06AM BLOOD Glucose-152* UreaN-29* Creat-1.6* Na-139 K-4.5 Cl-111* HCO3-19* AnGap-14 [**2197-6-7**] 05:50AM BLOOD Glucose-136* UreaN-26* Creat-1.5* Na-135 K-5.1 Cl-103 HCO3-20* AnGap-17 [**2197-6-9**] 05:25AM BLOOD Glucose-142* UreaN-24* Creat-1.5* Na-133 K-4.2 Cl-103 HCO3-18* AnGap-16 [**2197-5-29**] 08:30PM BLOOD ALT-23 AST-17 CK(CPK)-31* AlkPhos-334* TotBili-0.5 [**2197-5-29**] 08:30PM BLOOD cTropnT-<0.01 [**2197-5-30**] 02:06AM BLOOD CK-MB-3 cTropnT-0.01 [**2197-5-29**] 08:30PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0 [**2197-5-30**] 02:06AM BLOOD Calcium-7.1* Phos-2.7# Mg-1.6 [**2197-6-9**] 05:25AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9 [**2197-6-1**] 05:43AM BLOOD Vanco-38.4* [**2197-6-1**] 10:22AM BLOOD Vanco-32.7* [**2197-6-5**] 06:00AM BLOOD Vanco-16.8 [**2197-5-29**] 08:53PM BLOOD Lactate-2.2* [**2197-6-1**] 03:57PM BLOOD Glucose-91 K-4.3 [**2197-5-30**] 02:16AM BLOOD freeCa-1.09* [**2197-6-1**] 03:57PM BLOOD freeCa-1.11* EKG [**5-29**] - Sinus tachycardia. Non-specific inferolateral ST-T wave changes. Compared to the previous tracing of [**2197-5-22**] atrial flutter is absent. Sinus tachycardia is present. ST-T wave changes are slightly more pronounced. CXR [**5-29**] - IMPRESSION: Post-surgical appearance with findings in the lower right hemithorax raising the possibility of herniated bowel loops and/or other intra-abdominal contents. There is no definite consolidation. CT torso [**5-30**] RUL and RLL consolidations, and airspace opacity consistent with pneumonia, possibly related to aspiration. Some adjacent atelectasis. Gastric conduit intact. ETT and NGT in appropriate position. Minimal inflammatory change in upper abomen likely represent postsurgical change. mediastinal lymphadenopathy. persistent left SVC. J-tube in good position. no acute intraabdominal process. [**6-2**] CXR FINDINGS: There is slight worsening to a right lower lobe consolidation. Consolidation within the right upper lobe remains stable. Right subclavian central venous catheter is unchanged with tip in the mid SVC. There is a small left pleural effusion. The cardiomediastinal silhouette is stable. No pneumothorax. [**6-5**] Video Swallow: FINDINGS: There is slight worsening to a right lower lobe consolidation. Consolidation within the right upper lobe remains stable. Right subclavian central venous catheter is unchanged with tip in the mid SVC. There is a small left pleural effusion. The cardiomediastinal silhouette is stable. No pneumothorax. 6/16 Esophagus: IMPRESSION: Limited evaluation of the esophagus and gastric conduit shows no evidence of leak or obstruction. [**6-7**] CXR: As compared to the previous radiograph, there is an improvement. The right-sided central access line is in unchanged position, the right-sided opacities and the left-sided pleural effusion have almost completely disappeared. In the right lung, only a perihilar and a basal area of atelectasis subsist. [**6-9**] Venogram and catheter stripping IMPRESSION: 1. Unsuccessful attempt of fibrin sheath stripping via transfemoral approach. 2. Unsuccessful attempt of accessing the Port-A-Cath with a 0.018 Glidewire. 3. SVC venogram demonstrates tip of the catheter adheres to the vessel wall with presence of tight fibrin sheath. [**6-13**] ECG Sinus tachycardia. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2197-5-29**] no diagnostic change. [**6-13**] CXR (portable AP) IMPRESSION: 1. Negative examination for new aspiration. 2. Residual atelectasis and/or pneumonia, the sequale of prior aspiration in the right lower lung region with adjacent small right pleural effusion. [**6-13**] chest CT IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multifocal pulmonary opacities, most concentrated in the right upper lobe, but also involving both lower lobes, likely representing aspiration or multifocal pneumonia. Mild right lower lobe atelectasis. 3. Status post esophagectomy with debris in the intrathoracic stomach. [**6-13**] blood cultures - coagulase negative staphylococcus [**6-13**] sputum cultures - Gram negative rods [**6-14**] CXR (portable AP) FINDINGS: In comparison with the study of [**6-13**], the right pleural effusion and atelectatic change appear to have decreased. The left hemidiaphragm is now well seen. The left costophrenic angle is sharp. The appearance is consistent with some improvement, though much of this may merely reflect the upright technique. Right subclavian catheter remains in place. [**6-15**] EGD with pyloric balloon dilatation Impression: The high up esophagogastric anastomosis was noted. No stricturing noted at the anastomotosis. The puloric opening was narrow causing some resistance to passage of the EGD scope into the duodenum. Normal duodenum A 15mm CRE balloon was introduced for dilation and the diameter was progressively increased to 18 FR successfully in the pylorus. Pyloric dilatation allowed free passage of endoscope into the duodenum. Brief Hospital Course: Patient was admitted to ICU , intubated and treated with IV vanco/zosyn. His white count trended down over the next few days and he remained febrile until post op day 4. He was weaned to extubate on HD 4 and successfully extubated. He continued on iv abx and had a swallow study done on HD 5. He was to remain NPO and they recommended that a barium swallow be repeated. His tube feeds were increased to goal and were eventually cycled overnight. On HD 7 he had a video swallow and barium swallow that showed no esophageal leak and that patient would be okay to eat soft solids as long as he sat upright while eating. These recommendations were implemented. The CVL team recommended Venogram for his port a cath that was not drawing back. This was done which showed fibrin sheath. An attempt to clear the catheter was made but the catheter tip was imbedded in the wall of the vessel. His port was deaccessed. The remainder of his course consisted of increasing his po intake and planning for rehabilitation. On HD 10 he had explosive diarrhea and c.diff was negative. It eventually resolved. He had a hypertensive episode requiring transfer to the TSICU on HD 25. He returned to the floor on HD 26. He experienced bouts of emesis throughout his hospitalization, for which a balloon dilation of the pylorus was performed on HD 26. He was able to ambulate on his own but he has significant difficulty caring for his medical needs such as starting and stopping his tube feeds. On discharge he was in good condition tolerating the tube feeds and frequent soft solid diet, having bowel movements, urinating, and ambulation without difficulty. Medications on Admission: tylenol, levothyrixine, albuterol, atrovent, amiodarone, oxycodone/acet, metoprolol, senna, famotidine, lipirtor, singulair, Jevity tube feeds, SQH, colace, Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 2. Montelukast 5 mg Tablet, Chewable [**Month/Year (2) **]: Two (2) Tablet, Chewable PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) for 2 weeks. 5. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation Q4H (every 4 hours). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation Q4H (every 4 hours). 8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 10. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours). 12. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 13. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Two (2) PO Q6H (every 6 hours) as needed. 14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 15. Levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q48H (every 48 hours) for 1 days: Continue until [**2197-6-23**] for a total of 1 week of therapy. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aspiration pneumonia Right port a cath malfunction Pyloric obstruction Discharge Condition: Hemodynamically Stable, Tolerating PO intake, Pain Well Controlled Discharge Instructions: Call or come back if you experience increasing fevers, chills, nausea, vomiting, shortness of breath, chest pain or any other concerns. You should make sure you are upright for at least one hour after eating and should only eat when upright. You can have a liquid and soft solid diet. Cycle your tube feeds overnight and stop them when you are taking in sufficient amounts of food orally. You should eat six small meals a day. Take pain medications only as needed. Resume your home medications. Take amiodarone for a total of 2 weeks then stop on [**2197-6-26**]. Your Port a cath should not be accessed Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call ([**Telephone/Fax (1) 1483**] to set up an appointment. Completed by:[**2197-6-19**]

[ "507.0", "458.9", "V45.89", "272.0", "427.31", "E879.8", "244.9", "151.0", "537.0", "274.0", "403.90", "585.9", "493.20", "285.9", "787.91", "996.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "96.04", "96.6", "42.92", "97.01", "38.93", "96.57", "87.44", "88.51" ]

icd9pcs

[ [ [] ] ]

12594, 12664

9012, 10667

336, 459

12779, 12848

3052, 8989

13506, 13673

2378, 2410

10874, 12571

12685, 12758

10693, 10851

12872, 13483

2425, 2425

2745, 3033

276, 298

487, 816

2439, 2731

838, 1938

1954, 2362

58,843

104,135

47798

Discharge summary

report

Admission Date: [**2170-3-23**] Discharge Date: [**2170-4-21**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 9598**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 85 yo woman with h/o lymphoma who presents s/p fall at home. The patient has reportedly experienced a low grade fever and increased fatigue over the past three days and unsteadiness on her feet. Last night, she attempted to sit on the toilet and only recalls coming to lying on back with her head resting on a pipe. She pressed the emergency button and EMS arrived on scene. The event was unwitnessed, she does not recall feeling light headed, having any chest pain or palpitations or blurry vision,hitting her head, any seizure activity, aura or post ictal state or loss of bowel or bladder control. She does have prior history of falls, most recent five years ago.On one occaision she had suffered a SAH following a mechanical fall. She is unable to give clear hx regarding her other falls but does state that she had fallen on a hot day. She has a hx of EBV driven B and T cell proliferation-probably angio-immunoblastic lymphoma and is s/p 6 cycles CHOP completed [**10-16**] currently in remission. She had presented with LAD in neck in [**2165**] with CT showing multiple lymph nodes and biopsy cervical lymph node showing an atypical lymphoproliferative disorder, highly suggestive of evolving T-cell lymphoma. Subsequent inguinal biopsy in [**5-16**] was interpreted as either EBV expressing large B cell NHL or angio-immunoblastic lymphoma with an EBV expressing malignant B cell clone. She underwent 6 cycles of R-chop completed in [**10-16**]. PET/CT on [**2169-11-14**] showed no evidence of disease. In the ED, the patient's VS were T 99.3, BP 105/35, P 91, O2 96% on RA. She had a CT Head and Neck, which did not show any evidence of ICH or fracture. She had a CXR, which was negative for PNA, CHF, with trace fluid in R fissure, no pleural effusion. She was initially placed in ED Obs, where she was seen by PT and found to be orthostatic (SBP 140 to 80s). She received 1L IVF. She was admitted to medicine for further workup and evaluation. On floor, patient had a low grade temp to 99.4 and rigoring. Past Medical History: PAST MEDICAL HISTORY: Notable for status post cholecystectomy, status post subarachnoid hemorrhage [**4-/2167**] with no residua, status post appendectomy, hypertension Gerd Hypothyroidism Lymphoma Social History: The patient lives in a retirement community and continues to be active in all facets of her life. Family History: Non-contributory Physical Exam: On admission: VS - Temp 99.4 HR: 91 BP: 127/70 RR: 18 02 SAT: 100% RA GENERAL -comfortable, pleasant, shivering. HEENT - mucous membranes dry, OPC, unable to visualize tympanic membranes [**1-9**] wax, no ear pain with exam, no erythema, swelling externally. NECK - neck veins flat, no carotid bruit, no LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, II/VI holosystolic murmur heard best at apex. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-11**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait exam deferred. SKIN: 1cm erythematous plaque left lower lip. Pertinent Results: Admission Labs [**2170-3-23**] 09:10AM BLOOD WBC-8.3 RBC-3.19* Hgb-9.8* Hct-29.0* MCV-91 MCH-30.8 MCHC-33.8 RDW-16.0* Plt Ct-138* [**2170-3-23**] 09:10AM BLOOD Neuts-80.2* Lymphs-6.9* Monos-4.3 Eos-8.4* Baso-0.3 [**2170-3-23**] 09:10AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-133 K-4.5 Cl-103 HCO3-23 AnGap-12 [**2170-3-23**] 09:20PM BLOOD CK(CPK)-24* [**2170-3-23**] 09:10AM BLOOD cTropnT-<0.01 Other Labs [**2170-3-24**] 06:30AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 [**2170-3-27**] 09:00AM BLOOD FDP-0-10 [**2170-3-27**] 09:00AM BLOOD Fibrino-283# [**2170-3-30**] 01:00PM BLOOD Ret Aut-1.8 [**2170-4-3**] 06:00AM BLOOD VitB12-462 Folate-18.6 [**2170-3-30**] 01:00PM BLOOD Hapto-109 [**2170-3-27**] 09:00AM BLOOD D-Dimer-1013* [**2170-3-27**] 09:00AM BLOOD Hapto-159 [**2170-3-24**] 06:30AM BLOOD TSH-2.6 [**2170-3-24**] 06:30AM BLOOD Cortsol-37.7* [**2170-3-30**] 08:00AM BLOOD HIV Ab-NEGATIVE [**2170-4-6**] 07:19PM BLOOD Vanco-13.7 CXR ([**3-23**]) - IMPRESSION: Apparent enlargement of the left atrium for which clinical correlation is advised. Mild interstitial coarsening which could be related to interstitial disease or may be exaggerated due to technique. CT Head ([**3-23**]) - IMPRESSION: 1. No acute intracranial process. No displaced fracture. 2. Stable age-related involutional change, small vessel ischemic disease. 3. Mild paranasal sinus disease. CT C-Spine ([**3-23**]) - IMPRESSION: 1. No acute fracture within the cervical spine. 2. Mild multilevel degenerative disease. Stable minimal C7 on T1 anterolisthesis. MRI Head ([**3-25**]) - CONCLUSION: No evidence of intracranial lymphoma. Two small foci of old hemorrhage in the right frontal and temporal lobes. CT C/A/P ([**3-25**]) - IMPRESSION: 1. Numerous new mediastinal, hilar, axillary, retroperitoneal, intraabdominal, mesenteric, pelvic, and inguinal enlarged abnormal lymph nodes are consistent with recurrent lymphoma. Mildly increased size of the spleen. 2. Wall thickening with surrounding fat stranding of the ascending colon, hepatic flexure, and proximal transverse colon, consistent with colitis. Etiologies include infectious, inflammatory, and ischemic. Clinical correlation is recommended. 3. Small bilateral pleural effusions with adjacent atelectasis. Small intra-abdominal and pelvic ascites, new since prior exam. [**Month/Year (2) **] ([**3-27**]) - The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2169-7-7**], the mitral regurgitation may be somewhat reduced. Bone Marrow Bx ([**3-28**]) - SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: - HYPERCELLULAR MARROW WITH ATYPICAL T-CELL DOMINANT LYMPHOID AGGREGATES, SUSPICIOUS FOR BONE MARROW INVOLVEMENT BY T-CELL LYMPHOPROLIFERATIVE PROCESS (SEE NOTE) Bone Marrow Bx Cytogenetics ([**3-28**]) - INTERPRETATION: No clonal cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. [**4-1**] CT Head: No acute intracranial process as clinically questioned. If there is concern for lymphoma, an MRI of the brain may be obtained for further characterization. [**2170-4-4**] CXR: 1. Worsening moderate pulmonary edema. 2. Increased pleural effusions, large on the right and small on the left. [**2170-4-5**] ECG: Atrial fibrillation with a controlled ventricular response. Left axis deviation. Non-specific ST-T wave changes. Compared to the previous tracing the rate is slower. [**2170-4-9**] CXR: In comparison with the study of [**4-7**], the cardiomediastinal contours are unchanged. Bilateral pleural effusions persist. Indistinctness of pulmonary vessels. This suggests some underlying elevation of pulmonary venous pressure. Retrocardiac opacification is consistent with left basilar atelectasis. Monitoring and support devices remain in place. [**2170-4-11**] RUE Ultrasound: No evidence of DVT Brief Hospital Course: This is an 85 year old female with hx HTN, lymphoma s/p R-CHOP, SAH in setting of mechanical fall, admitted following unwittnessed non-mechanical fall and found to have recurrent lymphoma. #. Syncope: Pt presented s/p fall with loss of consciousness. 0f note she was orthostatic in ER and has had prior episodes which sound vasovagal in nature and it is likely that her vasovagal syncope and orthostasis was secondary to hypovolemia. Patient noted to have moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] '[**67**]. Pt had mild peripheral edema, with MR [**First Name (Titles) 21782**] [**Last Name (Titles) 34106**] to poor forward flow and syncope, however repeat [**Last Name (Titles) 113**] showed no concerning features to suggest this. Pt has also had low grade fevers, rigors and fatigue for several days, suggesting possible infection although exam non focal without elevated white count Her urine cultures showed staph UTI. She received IVF, tylenol and demerol as needed. #. Lymphoma: She has a history of EBV driven B and T cell proliferation-probably angio-immunoblastic lymphoma and is s/p 6 cycles R-CHOP concluding [**10-16**] with PET in [**11-15**] showing no evidence active disease. Her presentation was discussed with her hematologist/oncologist who concluded that her rigors, fevers and fatigue was also strongly suggestive of B sypmtoms due to lymphoma recurrence. Patient also had cervical, inguinal, and axillary lymphadenopathy. She was transferred to the OMED service for further evaluation. A bone marrow biopsy was performed which showed lymphoma recurrence. Originally there were plans to start her on Rituxan, Doxil, and Velcade. However, she developed altered mental status and severe hyponatremia and chemotherapy was ultimately deferred due to her poor functional status. #. Thrombocytopenia: Patient noted to have platelets trending down. Initial concern was HIT as patient had a pre-test probability that was intermediate based on her 4T score. She was empirically started on argatroban. A HIT antibody was sent with a mildly positive result (Optic Density of 0.44) This was repeated and was negative. Given the high negative predictive value of this test, it was concluded that the patient did not have HIT. Her argatroban was discontinued. A bone marrow biopsy showed involvement of lymphoma in her bone marrow and it was ultimately felt that she had bone marrow suppression and thrombocytopenia from lymphoma. #. Atrial Fibrillation: New onset during this hospitalization with rates in the 140s. Patient was started on metoprolol tartrate and uptitrated as patient could tolerate. During her ICU stay hypotension was limiting use of metoprolol, therefore she was loaded with amiodarone. She was monitored on telemetry and was noted to be in and out of atrial fibrillation. Patient remained asymptomatic. CHADS2 score at least 2. She was continued on ASA 81 mg but was not further anticoagulated due to thrombocytopenia. Her dose of amiodarone should be tapered to 200mg po daily after discharge (should switch to this dose on [**4-23**]) #. Hyponatremia: While on the oncology service, the patient developed mental status changes with associated hyponatremia. Her sodium trended down, and renal was consulted. She was started on fluid restriction and given lasix because she was felt to be volume overloaded; however, her sodium continued to trend down and she became more somnolent and confused. She was transferred to the ICU for hypertonic saline administration. Her sodium improved with hypertonic saline. Ultimately, her hypertonic saline was stopped and she was started on lasix, NaCL tabs, tubefeeds, and 1L fluid restriction per renal recommendations. She had hypotension, however, and was therefore unable to tolerate the lasix. She was given some saline boluses with improvement in her sodium. Urine sodium decreased, suggesting improvement of her underlying SIADH. SIADH may be [**1-9**] oncologic process or respiratory infection. She was then weaned off salt tabs and her sodium remained stable on only a 1L fluid restriction. #. Delirium: Onset of delirium occurred with hyponatremia. Her delirium improved with hypertonic saline administration in the ICU but she remained mild delirious, felt to be due to resolving ICU delirium, UTI effect, bronchitis effect, or hyponatremia effect. #. Bronchitis: While in the ICU she developed a cough. Sputum cultures failed to reveal a bacteria and she remained afebrile. She was empirically started and completed on a 7 day course of levofloxacin. Her cough improved. #. HTN: She remained normotensive however given concern for infection and potential to decompensate to septic physiology, her diovan was initially held. While in the ICU, after being started on [**Hospital1 **] lasix, the patient had some problems with hypotension. For this, she was given NS boluses with improvment in BP. She remained normotensive after discontinuation of all BP medications. #. Anemia: She had a normocytic anemia likely secondary to disease progression in her marrow and anemia of chronic disease. Hct was trended daily and remained stable and stools were guaiac negative. She did get intermittent blood transfusions during her stay. #. Hypothyroid: Continued home levothyroxine dosage. TSH 2.6 on [**3-24**]. #. UTIs: Initially found to have a Klebsiella UTI, for which she completed a 5 day course of ciprofloxacin. She was later found to have an MRSA UTI, for which she completed a 7 day course of vancomycin. Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN fever Aspirin 81 mg PO/NG DAILY Calcium Carbonate 500 mg PO/NG TID Ciprofloxacin HCl 500 mg PO/NG Q12H Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **] Levothyroxine Sodium 100 mcg PO/NG DAILY Multivitamins 1 TAB PO/NG DAILY Oxybutynin 5 mg PO BID Pantoprazole 40 mg PO Q24H Vitamin D 400 UNIT PO/NG DAILY Diovan 160 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Continue 200mg po bid until [**4-22**], then change to 200mg po daily. 7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 9. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Last Name (un) 100913**] House Discharge Diagnosis: Primary Diagnosis: Non-Hodgkin's Lymphoma Secondary Diagnoses: Hyponatremia Altered Mental Status due to Urinary Tract Infection Urinary Tract Infection Bronchitis Hypothyroidism Hypertension Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital because you had fallen and we needed to evaluate why you fell. You were also spiking fevers and were found to have recurrence of your lymphoma. You were transferred to the oncology service where you were going to receive chemotherapy. However, you developed altered mental status and low sodium. You were transferred to the ICU temporarily due to your low sodium level. You were given IV fluids with extra sodium and your sodium improved. Your mental status has also slowly improved. You were seen by Dr. [**Last Name (STitle) **] while you were in the hospital and it was decided not to give you any chemotherapy. You are being discharged back to the facility where you came from with hospice. The following changes were made to your medications: ADDED amiodarone 200mg by mouth twice daily through [**4-22**]. On [**4-23**], you should start taking amiodarone 200mg by mouth daily. Followup Instructions: You have the following appointments scheduled: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2170-6-25**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], 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 Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] will also be involved in your care while you are at your facility with hospice. [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]

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Discharge summary

report

Admission Date: [**2182-4-18**] Discharge Date: [**2182-6-2**] Date of Birth: [**2113-7-15**] Sex: M Service: MEDICINE Allergies: Versed / Gluten Attending:[**First Name3 (LF) 2297**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation and Mechanical Ventilation Blood transfusions Chemotherapy Basiliximab History of Present Illness: 68 yo M with a h/o lymphoma s/p auto-BMT in [**2176**], Afib (off anticoagulation) and PVD who presents with subacute dyspnea on exertion and generalized weakness. History is provided by patient's wife/hcp. [**Name (NI) **] was last in his USOH 6 weeks ago when he developed dyspnea on exertion and a dry cough. Symptoms were short lived and only occurred while climbing stairs. Patient ignored symptoms for several weeks, and finally saw his PCP [**Last Name (NamePattern4) **] [**2182-3-25**]. Patient was started on moxifloxacin for presumed pneumonia, but chest xray and cultures (unclear if blood or sputum) were negative, so antibiotics were stopped after 4 days. Symptoms persisted so he presented to the [**Hospital3 2783**] ED and was admitted from [**3-28**] through [**4-2**]. Patient was noted to be anemic and was transfused multiple units PRBCs. Upper endoscopy was pursued which was negative. A colonoscopy was performed several years ago and was normal. Patient was also thrombocytopenic, but unclear to what degree. During this admission blood cultures, CT torso, bone marrow biopsy and bone scan were all unremarkable, and patient was discharged without a definitive diagnosis. During this admission patient developed an acute maculopapular rash which was later biopsied by dermatology after discharge and was reportedly consistent with allergy. He had a PET scan on [**4-15**] which was negative except for increased bilateral adrenal uptake. Patient's outpatient oncologist pursued TTE today to rule out SBE, which was negative for vegetations but worrisome for Afib with RVR to the 130s. Patient's PCP was [**Name (NI) 653**], who advised that he present to the [**Hospital1 18**]. . In the ED, patient triggered on arrival for BP 71/47.Improved with fluids to systolics in the mid 80s, and per report this is not far from the patient's baseline BP. Intial VS were 92, 80/53, 17, 96% RA, then 100% on 2L and then 96% 4L. Labs revealed an AGMA, Cr of 1.5, thrombocytopenia to 47 and anemia to Hct 27 from baseline in the 30s. EKG showed afib with a RBBB. CXR was initially unremarkable. UA was normal and blood cultures were sent. CTA was negative for PE. Patient was guaiac positive on exam with brown stool, and had an NG lavage which was negative. Decision was made to transfuse blood and platelets. Patient tolerated platelets well but while getting blood transfusion developed rigors, tachypnea and afib with RVR to the 160s. Rectal temerpature was 101.6. Transfusion was stopped, and repeat CXR showed mild pulmonary edema. Patient received Solumedrol 125 mg IVx1, Tylenol 1 g po x1, Benadryl 50 mg IVx1, and Demerol 12.5 mg IVx1. Saturation was maintained in the 90s prior to this on 4L, but after transfusion reaction patient became mottled and a sat was hard to obtain. ABG on 100% NRB was 7.26/29/59/14, so intubation was pursued. Patient received etomidate 20 mg and succinylcholine 120 mg. Patient was given vancomycin and zosyn. Periperhal neo was started and on transfer VS were 117, 83/50, 18, 100% on TV 470 RR 22 PEEP 5 FiO2 100%. Patient presents to the MICU on versed for sedation. . On arrival to the ICU, patient in intubated and sedated. Because of a documented allergy to versed, this drip is stopped and propafol is started. . Review of systems: limited due to patient being intubated and sedated. he appears comfortable. Past Medical History: 1. T cell lymphoma (EATCL): similar to a very aggressive form of NHL, diagnosed in [**2175-7-20**] at [**Hospital3 **] after patient presented with RLQ abd pain and found to have perforated small bowel from infiltrative lesion. 2. Atrial Fibrillation: rate controlled, off anticoagulation since [**11-22**] 3. Hyperlipidiemia 4. Hypertension 5. Coronary artery disease 6. Peripheral vascular disease s/p an iliac artery stent for claudication 7. Benign bladder tumor 8. h/o colonic polyps: [**1-21**] villi glandular polyp; [**2-22**] tubular adenoma 9. Celiac spru diagnosed [**8-22**] Social History: married to [**Doctor First Name 2155**] x 24 years they live in [**Location (un) 246**] with their 14 yo daughter [**Name (NI) **] and a pet cat. originally from [**Location (un) 1459**] retired since [**2169**] after working for 30 years at Ratheon as a computer programming manager. His father is deceased and his mother at 82 lives independently in her own apt upstairs from one of her daughters. Mr [**Name13 (STitle) 57280**] is the oldest child and has 2 sisters and one brother with good relationships with all of them. He reports that the entire family has been very supportive and that his wife, who accompanies him to all of his appts, is very involved and helpful. Both he and his wife have carefully ready all the BMT materials and found more on their own. Their daughter is aware that her father has cancer but they have not explained the details of BMT. She is described as very bright and they plan to allow her to visit during his admission. Mr [**Name13 (STitle) 57280**] is Catholic and describes his faith and church community as being very important. He would like to see a priest during his admission. No tobacco use in 14 years. Prior 35 year ppd use. Rare etoh use. Family History: Mother is 82 alive with CHF, Father died of CHF at 79. Two sisters and one brother who are alive and well. Paternal aunt with a similar intestinal perforation details unknown. Physical Exam: Admission Exam: Vitals: T: 103.3 BP: 97/62 P: 99 TV 470 RR 22 PEEP 5 FiO2 100% General: Intubated, sedated Skin: generalized maculopapular rash on UEs and torso HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular, 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, 1+ LE edema, 2+ pulses, no clubbing, cyanosis On Transfer to BMT: Vitals: 96.2 118/64 68 18 98RA General: NAD, pleasant and cooperative Skin: mild remaints of maculopapular rash on left side of abdomen HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ LE edema, 2+ pulses, no clubbing, cyanosis Neuro: A & O x 3, CN II-XII intact, no asterixis Pertinent Results: Admission Labs: [**2182-4-18**] 02:34PM PT-15.9* PTT-27.1 INR(PT)-1.4* [**2182-4-18**] 02:34PM PLT SMR-VERY LOW PLT COUNT-47*# [**2182-4-18**] 02:34PM NEUTS-78.7* LYMPHS-16.5* MONOS-3.5 EOS-0.7 BASOS-0.6 [**2182-4-18**] 02:34PM WBC-5.6 RBC-2.80*# HGB-9.5*# HCT-27.3*# MCV-98 MCH-33.8* MCHC-34.6 RDW-18.7* [**2182-4-18**] 02:34PM DIGOXIN-0.8* [**2182-4-18**] 02:34PM HAPTOGLOB-123 [**2182-4-18**] 02:34PM cTropnT-<0.01 [**2182-4-18**] 02:34PM LD(LDH)-416* [**2182-4-18**] 02:34PM estGFR-Using this [**2182-4-18**] 02:34PM GLUCOSE-125* UREA N-40* CREAT-1.5* SODIUM-130* POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-18* ANION GAP-17 [**2182-4-18**] 02:38PM LACTATE-4.0* K+-5.1 [**2182-4-18**] 02:57PM K+-4.7 [**2182-4-18**] 04:12PM URINE MUCOUS-FEW [**2182-4-18**] 04:12PM URINE HYALINE-8* [**2182-4-18**] 04:12PM URINE RBC-0 WBC-0 BACTERIA-NONE [**Month/Day/Year **]-NONE EPI-0 [**2182-4-18**] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [**2182-4-18**] 04:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 . Other Labs: [**2182-4-21**] 05:22AM BLOOD proBNP-3020* [**2182-4-23**] 04:11AM BLOOD ALT-51* AST-38 LD(LDH)-269* AlkPhos-59 TotBili-4.1* DirBili-2.3* IndBili-1.8 [**2182-4-19**] 04:07AM BLOOD ALT-143* AST-127* LD(LDH)-527* CK(CPK)-159 AlkPhos-83 TotBili-2.3* [**2182-4-18**] 11:18PM BLOOD calTIBC-218* Ferritn-[**Numeric Identifier 55741**]* TRF-168* [**2182-4-20**] 08:12AM BLOOD Triglyc-205* [**2182-4-18**] 02:34PM BLOOD Hapto-123 [**2182-4-18**] 07:00PM BLOOD Hapto-70 [**2182-4-21**] 06:25PM BLOOD Hapto-<5* [**2182-4-18**] 11:18PM BLOOD TSH-2.0 [**2182-4-18**] 11:18PM BLOOD Cortsol-134.8* [**2182-4-21**] 05:22AM BLOOD Cyclspr-338 [**2182-4-22**] 05:30AM BLOOD Cyclspr-482* [**2182-4-23**] 04:11AM BLOOD Cyclspr-401* . Micro: [**2182-4-19**] 04:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2182-4-21**] 05:22AM BLOOD HIV Ab-NEGATIVE [**2182-4-19**] 04:07AM BLOOD HCV Ab-NEGATIVE [**2182-4-19**] 09:53AM BLOOD PARVOVIRUS B19 ANTIBODIES: IgG pos / IgM neg [**2182-4-22**] 05:18AM BLOOD VOIDED SPECIMEN - CORVAC-PND [**2182-4-23**] 04:11AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND - CMV VL ([**4-23**]): pending and [**4-18**] negative - C diff ([**4-20**]): neg - Sputum ([**4-20**]): resp flora - Influenza DFA ([**4-19**]): neg - EBV serology ([**4-19**] and [**4-20**]): IgM pos / IgG neg - Legionella UAg: neg - Urine Cx: neg - Blood Cx ([**4-18**]): pending . CTA CHEST [**2182-4-18**]: 1. No pulmonary embolism. 2. Bowing of the interventricular septum to the left, raising a question of pulmonary hypertension and correlation with ECHO could be performed. 3. Distended gallbladder. If there are RUQ symptoms, an ultrasound is recommended for further evaluation. Liver/GB U/S ([**2182-4-19**]): CONCLUSION: 1. Moderately distended gallbladder with sludge, but no specific son[**Name (NI) 493**] findings of acute cholecystitis. While this diagnosis cannot be excluded, the clinical presentation does not seem indicative of cholecystitis. 2. Small right pleural effusion also noted. Bone Marrow Pathology: - HYPERCELLULAR MARROW (50% FOR AGE WITH ERYTHROID DOMINANT TRILINEAGE HEMATOPOIESIS. - MORPHOLOGICAL FEATURES OF INVOLVEMENT BY LYMPHOMA ARE NOT SEEN. Cardiac ECHO ([**2182-4-22**]): The left atrium is mildly dilated. A patent foramen ovale is present. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: Assessment and Plan: 68 yo M with a h/o lymphoma s/p auto-BMT in [**2176**], Afib (off anticoagulation) and PVD who was admitted for subacute dyspnea on exertion and generalized weakness, hypotension and acute hypoxic respiratory failure, and found to have diagnosis of HLH, expired during this admission after being transferred to ICU. [**Hospital Unit Name 153**] course: Patient was transferred to [**Hospital Unit Name 153**] for a second time after worsening respiratory distress on the floor, with CXR consistent with ARDS. He was intubated on arrival to ICU. He was also found to be hypotensive, likely [**2-20**] shock. Broad antibiotic coverage was started with linezolid/meropenem/vancomycin, as well as voriconazole (for presumed aspergillus) and acyclovir (for herpetic appearing lesions) and he was started on pressors. Skin lesions on buttocks were biopsied by dermatology service and found to be growing [**Last Name (LF) 23087**], [**First Name3 (LF) **] fungal coverage was changed to micafungin, bronch was done and showed no e/o PCP but patient was started on prophylactic dose of bactrim daily. ID team was consulting, as well as BMT. Patient continued to be hypotensive and was supported with fluids, albumin and IVF, and HLH was treated agressively with high dose IV steroids, as well as Alemtuzumab. ICU course was also complicated by acute renal failure, which improved with IVF so likely pre-renal. He also was noted to have afib with RVR and was started on a diltiazem drip when BP tolerated, however he was often hypotensive. He was also on a lasix gtt for fluid overload given frequent IVF boluses and signficant anasarca, along with pressors for improved diuresis, however BP was often low as above. In addition, he had significant transaminitis. Initially thought to be [**2-20**] medication effect as he was on voriconazole, however even after stopping remained elevated, RUQ u/s showed no portal vein thrombosis, most likely elevation in liver enzymes due to HLH. Patient was treated aggressively until family decided to focus on comfort measures. Patient expired on [**2182-6-2**], autopsy was declined. # Hypotension: Concern for sepsis given that patient met SIRS criteria with fever, tachypnea and tachycardia, but no obvious source. Initially on broad spectrum Abx for HCAP given recent admission although Vanco/Cipro peeled back after a couple days when less likely PNA. Supported with fluids and initially with pressors. Parvovirus was IgM positive but IgG negative. BP slowly improved over the next few days with these therapies and pt was stable on at home blood pressures at time of discharge to floor. On the floor, BP remained stable, however was hypotensive after transfer to ICU, see course above. # Hypoxic respiratory failure: Pt was intubated twice during admission. It appears there is somewhat of a chronologic association with platelet/blood transfusion, and differential was TRALI, CHF, pneumonia. Pt initialy started on Vanco/Cipro which was D/ced when sputum grew respiratory flora. Respiratory failure improved fairly quickly and was extubated. ECHO was unremarkable. On the floor, oxygen saturation remained in high 90s initially, however he was transferred to ICU again for respiratory distress, CXR was consistent with ARDS, for which he was intubated again, see ICU course above. # [**Last Name (un) **]/AGMA: patient presented with [**Last Name (un) **], which improved with fluid resusication, indicating some extent of pre-renal state which was supported by FeNa<1%. patient also has ABG with metabolic acidosi with appropriate respiratory compensation prior to intubation. Likely AGMA from lactate. Renal failure quickly improved with Cr back to baseline but bumped up again to 1.5 a few days later thought to be due to contrast load from imaging in ED. This second Cr bump resolved over the next couple of days and Cr returned to baseline, however ICU course was complicated by renal failure, likely pre-renal, improved with IVF # Afib: Rate controlled after intubation although had been in RVR. Pt was continued on home digoxin with levels in appropriate level. However, he developed episodes of ventricular tachycardia captured on telemetry. He was lightheaded during one episode but for the most part remained asymptomatic and hemodynamically stable. Cardiology was consulted and felt that VT could be an early sign of digoxin toxicity. Digoxin was discontinued and metoprolol was uptitrated. However, pt continued to have A fib with RVR and occasionaly with abherancy (went in and out of RBBB). His metoprolol was uptitrated to 75 TID and his digoxin was added back. He was also started on Diltiazem 30 four times a day. After transfer to the ICU for respiratory failure, he was placed on a diltiazem drip when BP tolerated for frequent episodes of RVR, see above for details. # HLH: Repeated BM aspirate had findings consistent with HLH. Received Etoposide starting on [**3-10**], [**4-27**], [**5-1**], [**5-4**]. Also started on steroids and then cyclosporine. Pt was Parvovirus IgM positive. Etoposide dosing was initially limited by hyperbilirubinemia. Etoposide was given at half dose initially. When bilirubin normalized, he received full dose etoposide q3-4 days. Cyclosporine was discontinued on [**2182-5-12**] since pt's ferritin levels were elevated and his smear showed histiocytes with engulfed RBC. On [**5-17**] and [**5-18**] he was started on basiliximab, and later in ICU received Alemtuzumab as well as high dose steroids. # Edema: Pt developed significant LE edema and scrotal swelling, likely [**2-20**] aggressive IV hydration. His baseline weight prior to admission was 140s and his weight was as high as 200s. He was diuresed with lasix gtt while in the ICU as pressures tolerated, however he was often hypotensive and unable to tolerate. # Transaminitis: Pt had rising LFTs and elevated bilirubin. RUQ U/S was unrevealing. Liver consult was initiated and felt that the elevation in liver enzymes were secondary to either shock liver from pt's initial hypotensive state or from his HLH. Chemotherapy was initiated (etoposide dose was initially reduced when bilirubin was high) and liver enzymes normalized subsequently. Liver enzymes started to trend upwards again when voriconazole was started for presumed aspergillosis infection, and after voriconazole was stopped they continued to uptrend, repeat RUQ u/s showed no portal vein thrombosis. Most likely cause was HLH. #Calcium/PTH: Pt with hyperparathyroidism and low calcium, likely [**2-20**] poor vit D absorption in pt with celiac disease as well as steroids. He was given vit D 50,000 every other day for 3 doses and then continued once a week for goal 7 weeks. Medications on Admission: # metoprolol tartrate 50 mg Qam and 25 mg Qpm # digoxin 125 mcg daily # simvastatin 40 mg Tab Oral # Tylenol PM Extra Strength Discharge Medications: N/A, expired Discharge Disposition: Expired Discharge Diagnosis: Hemophagocytic lymphohistiocytosis (HLH) Afib with RVR Respiratory failure Septic shock ARDS Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2182-6-4**]

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icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "38.91", "96.09", "96.6", "86.11", "96.71", "38.93", "00.14", "96.72", "99.25" ]

icd9pcs

[ [ [] ] ]

18077, 18086

11119, 17863

283, 366

18222, 18232

6992, 6992

18288, 18325

5597, 5774

18040, 18054

18107, 18201

17889, 18017

18256, 18265

5789, 6973

3684, 3761

236, 245

394, 3665

7008, 8110

3783, 4371

4387, 5581

8122, 11096

14,180

162,841

29049

Discharge summary

report

Admission Date: [**2190-11-9**] Discharge Date: [**2190-11-15**] Service: MEDICINE Allergies: Penicillins / Codeine / Tape Attending:[**First Name3 (LF) 44522**] Chief Complaint: Direct admission for kidney biopsy. Major Surgical or Invasive Procedure: Central venous line placement Bone marrow biopsy Past Medical History: 1. DM2 ([**8-/2186**]): Diet controlled 2. HTN 3. CAD - MI ([**2182**] and [**1-/2187**]) - S/p stent placement ([**1-/2187**]) for bradycardia to 30bpm - Echo ([**2189**]): EF 65%; mild LVH 6. Gout 7. S/p appendectomy 8. Colonoscopy ([**2186**]): Normal. Denies h/o PUD/GERD. 9. Right cataract 10. Thrombocytopenia of unclear etiology 11. Renal failure of unclear etiology Social History: SOCIAL HISTORY: 1. Tobacco: Patient quit smoking 40 years ago. 2. Alcohol: None. 3. Employment: Retired. 4. Marital status: Widowed, has a large family, most of who live in the [**Hospital1 1562**] area. She currently is living in [**Hospital1 1562**], spending six months in [**Hospital1 1562**] and six months in [**State 108**] Family History: No history of anemia, renal disease, cancers, rheumatologic disease or autoimmune disease. No family history of kidney disease, diabetes or hypertension. Physical Exam: VITAL SIGNS: 97.8 74 136/76 24 94%RA GENERAL: A well-developed, well-nourished, younger than stated age appearing, female in no apparent distress. HEENT: TMs are intact, and the oropharynx is clear. Fundi grade I hypertensive changes bilaterally, surgical pupil right. NECK: Supple with no thyroidomegaly, adenopathy, masses or carotid bruits. LUNGS: Clear to auscultation and percussion bilaterally. HEART: Normal sinus rhythm with no significant murmurs, rubs, ectopy, or gallop rhythms. ABDOMEN: No hepatosplenomegaly or masses. Bowel sounds are normal. No tenderness to palpation. BACK: No CVA tenderness. EXTREMITIES: Peripheral pulses are intact and equal. Patient had some inflammation and erythema of the left first metatarsal and was tender to touch. NEUROLOGIC: Cranial nerves II-XII intact. Normal reflexes. Normal muscle strength and sensation in the upper and lower extremities. Sensation intact. No asterixis. Pertinent Results: [**2190-11-9**] 03:15PM PT-14.5* PTT-25.3 INR(PT)-1.3* [**2190-11-9**] 03:15PM PLT SMR-VERY LOW PLT COUNT-30* [**2190-11-9**] 03:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2190-11-9**] 03:15PM NEUTS-68 BANDS-5 LYMPHS-11* MONOS-9 EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 [**2190-11-9**] 03:15PM WBC-12.5* RBC-2.92* HGB-9.3* HCT-27.3* MCV-94 MCH-31.7 MCHC-33.9 RDW-19.7* [**2190-11-9**] 03:15PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-1.4* [**2190-11-9**] 03:15PM estGFR-Using this [**2190-11-9**] 03:15PM GLUCOSE-178* UREA N-53* CREAT-5.6* SODIUM-143 POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-14* ANION GAP-20 [**2190-11-9**] 09:57PM PLT COUNT-105*# . VQ scan: Low probability for pulmonary embolus. . CT OF THE CHEST: Again seen is a left-sided pacemaker with leads in unchanged positions. There is a trace pericardial fluid. Extensive coronary artery atherosclerotic calcifications are seen. The thoracic aorta also demonstrates atherosclerotic calcifications. There is no aneurysmal dilation. The airways are patent to the segmental level. Again seen in the lungs are multiple bilateral pulmonary nodules (series 2, 12, 14, 17, 18, 38). These look stable since the prior study. The increased reticulation in the lung bases is again appreciated, unchanged. There is no pleural effusion or pneumothorax. . CT OF THE ABDOMEN: On this non-contrast study, the liver, adrenal glands, spleen, pancreas appear unremarkable. There is no hydronephrosis. There is a small region of hypodensity in the left kidney (series 2, image 70 and 301b, image 31), which is of simple fluid attenuation. Atherosclerotic change of the abdominal aorta is again seen. The loops of bowel are of normal caliber and do not demonstrate surrounding inflammatory change or wall thickening to suggest colitis. No free intraperitoneal air is seen. There is no ascites. . CT OF THE PELVIS: The bladder, uterus, adnexa, and rectum appear unremarkable. There is a small amount of free fluid in the pelvis. No pathologic pelvic or inguinal lymphadenopathy is seen. There is extensive stranding of the superficial subcutaneous fat of the right and left flank as well as in other dependent locations. . OSSEOUS STRUCTURES: Extensive degenerative changes of the spine are again seen. No concerning lytic or sclerotic lesions are seen, but the bones have an overall mottled appearance. Brief Hospital Course: The patient was initially admitted to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] for kidney biopsy. She spiked on the day of admission and cultures were sent off, which were negative to date. Hematology and neprhology were following the patient. A bone marrow biopsy was performed yesterday. TTP again was ruled out by smear. [**Doctor First Name **] was negative 2x. Antiphospholipid-syndrome was considered as well. During the course of her hospitalization the pt's renal failure was worsening, however a renal biopsy was deferred due to her fever on admission. Since admission however she has been afebrile. She was treated for a UTI with Ciprofloxacin. The etiology of her thrombocytopenia and ARF remained unclear. Extensive workup for vasculititis and multiple myeloma, TTP/HUS, HIV were negative. Other workup is pending. On HD 4, the patient had an episode of dizziness and nausea. She was found to have hypotension to the 70s. Lactate was elevated to 7.2. She responded well to fluids. A CT of the abdomen did not show any etiology of suspected sepsis or any evidence of ischemic bowel. Cardiogenic sources of her hypotension were felt to be of low probability. The patient was also found to be in low grade DIC. Given suspicion for microthrombi in the context of possible antiphospholipid syndrome Heparin drip was started. The patients pressure stabilized over the next day, however her [**Hospital 69979**] clinic status did not improve. She had one episode of atrial fibrillation. The patient expressed her wish to discontinue all medications and transition to hospice, which was arranged with the family and palliative care. She went into atrial fibrillation with rapid ventricular rate in the 150-70's prior to planned ambulance transport. Her SBP was borderline in the 70-100 range. Upon talking with the family about the likelihood of her dying in transport home; the family still felt very strongly about attempting the trip home. The team decided with the family to attempt 5mg IV diltiazem which resulted in decreased HR to 120 with SBP as low as 68; she was given approx 1L NS which increased her SBP to 100. Monitors were turned off and she was transferred in ambulance home. Medications on Admission: MEDICATIONS ON ADMISSION: 1. Metoprolol 25 mg daily. 2. Protonix 40 mg daily. 3. Lipitor 10 mg daily. 4. Colchicine Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 5-30mg PO Q1h prn as needed for pain. Disp:*30 ml* Refills:*0* 2. Ativan 1 mg Tablet Sig: 0.5-2mg Tablets PO Q2h prn: may be given under the tongue. Disp:*30 Tablet(s)* Refills:*0* 3. Levsin 0.125 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for Secretions. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Thrombocytopenia of unclear etiology Acute renal failure of unclear etiology Presumed sepsis of unclear etiology ------ Diabetes type 2 Discharge Condition: Serious, discharge to hospice Discharge Instructions: You will have hospice services at home to help you and your family. You are given morphine under the tongue for pain and respiratory distress. Lorazepam you can use for anxiety and also nausea. Levsin can be used to dry out your airway if you have a lot of secretions. Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "41.31", "38.93", "99.05", "99.07" ]

icd9pcs

[ [ [] ] ]

7424, 7475

4662, 6879

274, 325

7655, 7687

2201, 4639

8006, 8014

1086, 1241

7045, 7401

7496, 7634

6931, 7022

7711, 7983

1256, 2182

199, 236

347, 722

754, 1070

11,109

120,510

10349

Discharge summary

report

Admission Date: [**2124-3-30**] Discharge Date: [**2124-4-6**] Date of Birth: [**2054-5-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25342**] Chief Complaint: s/p MVC ? epidural from OSH; transfer to [**Hospital1 18**] for further w/u Major Surgical or Invasive Procedure: ERCP intubation History of Present Illness: 69 yo male trasferred from OSH 6 days ago s/p MVC at 30 mph. No external injuries upon presentation, concern for epidural hematoma per OSH. Intubated for psobbile combativeness, thus pt was paralyzed and could not be examined on admission. Reportedly struck parked car then went off the road and struck tree. Unclear if LOC and etiology, perhaps TIA vs syncopal episode given carotid US revealing stenosis. Past Medical History: 1. Colon cancer s/p resection c/b liver mets 2. CVA 6 yrs ago 3. melanoma x 2, back and left chest wall, resected 4. CAD 5. Parkinson's disease, diagnosed 8 yrs ago 6. HTN Social History: Social: married with 3 children, 3+EtOH, no tobacco Family History: 1. F-- colon ca in 70's, died of CVA 2. M--? bowel cancer with liver mets at 56, died at 80's (needs clarifciation) 3. sibs-- one with prostate cancer Physical Exam: Admisson: 99.8 90 [**Telephone/Fax (3) 34345**]% intubated General: paralyzed HENT: right 4 mm left 3 mm, reactive, bilaterally blood in mouth, small laceration on left upper lip Neck: trachea midline Chest: CTAB, RRR Abd: soft, ?tender, ND; midline incsion; FAST neg Pelvis: stable Rectal: decreased tone; guaiac neg Ext: no deformity @+ DP/PT bilat Back: ?tenderness, no deformity Transfer: Temp 96.9 BP 148/62 Pulse 64 Resp 18-20 O2 sat 98% RA FS 111-119 Gen - Alert, no acute distress, o x 3 HEENT - PERRL, extraocular motions intact, scleral icterus, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds, healing midline scar, no HSM, neg [**Doctor Last Name 515**] Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**1-22**] intact, moves all extremities, no asterixis Skin - jaundiced Pertinent Results: EKG: NSR 70, no ST seg elevation [**3-30**] Head CT: No sign of intracranial hemorrhage. Old infarctions. MRI is recommended to better assess the cerebellum and brainstem. Sinusitis. [**3-30**] MRI Head and C Spine: 1. There is no evidence of hemorrhage. 2. Two large disc protrusions at C5-6 and C6-7. At the level of C5-C6, the protrusion is large and is causing cord compression, as described above. [**3-31**] echo: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The aortic valve leaflets (3) are mildly thickened. 3. The mitral valve leaflets are mildly thickened. [**4-1**] RUQ US: Diffuse intrahepatic biliary ductal dilatation, without focal lesion found. Findings are concerning for obstructing mass in the porta hepatis. CT is recommended for further evaluation. Normal- appearing gallbladder and common bile duct. [**4-1**] CT abd: 1) Three hypodense lesions in the liver involving segment VIII and VI. The mass largest mass in segment VIII infiltrates the porta hepatis and leads to intrahepatic biliary ductal dilatation. While these lesions likely represent metastases from the patient's known colon cancer, the appearance of the mass in the porta hepatis is somewhat atypical and cholangiocarcinoma is included in the differential diagnosis. 2) Status post wedge resection in segment II with postsurgical seroma or a resolving hematoma. 3) A subcentimeter hypodense lesion in the spleen likely represents a small cyst. [**4-3**] ERCP: The common bile duct was normal without filling defects. There was a stricture in the hilum. The right intrahepatic duct was cannulated and there was evidence of post obstructive dilation A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm by 10f uncovered metal stent biliary stent was placed successfully across the stricture terminating in the right main hepatic duct. [**4-4**] Carotid studies: complete/right ICA occlusion; 60-70% left ICA stenosis [**4-4**] CT abd: IMPRESSION: 1) Multiple hepatic metastases, with the largest lesion in segments 8 and 1 exerting mass effect on the right and left main bile ducts, resulting in intrahepatic biliary ductal dilatation. 2) Status post common bile duct stent placement. 3) Small lymph nodes in the porta hepatis without mass effect on the common bile duct. 4) Postsurgical seroma or resolving hematoma adjacent to the area of wedge resection in the left lateral hepatic segment, unchanged since [**2124-4-1**]. 5) Accessory right hepatic artery, probably arising from the aorta between the celiac trunk and the superior mesenteric artery. CT Chest: IMPRESSION: 1) Flattened-shaped consolidation with air bronchogram in left upper lobe, corresponding to the lesion noted on chest x-ray which has been decreasing in size, probably representing resolving pneumonia; however, in this patient with colon cancer, please confirm resolution by followup chest CT. 2) Multiple noncalcified pulmonary nodules as described above, measuring less than 5 mm in diameter. In this patient with colon cancer, please follow up in 3 months. 3) Multiple calcified pleural plaques, probably due to prior asbestos exposure. 4) Coronary artery calcification. 5) Limited evaluation of the abdomen demonstrates liver metastasis, dilated biliary duct, CBD stent, decreased ascites, and cystic structure in the mid abdomen described as seroma. For the detailed evaluation of the abdomen, please refer to the official report of the abdominal CT performed 2 days ago. Brief Hospital Course: Trauma serivice course: Pt was extubated successfully on HD 3 and sent to the floor. Head CT did not show epidural bleed as indicated for transfer to the [**Hospital1 **]. Initial stay was complicated by post extubation confusion, most likely secondary to benzodiazepines (O x1). CT cspine with MRI showed C5-C7 disk herniation without cord compression or focal neurological deficits. Pt completely asymptomatic on exam without cervical midline tenderness. On [**4-2**], LFTs noted to be elevated, pt jaundiced. RUQ U/s showed intrahepatic biliary dilatation. LFTs notable for TB peaked at 15.9, DB 8. GIU consulted for ERCP. C-collar taken off for ERCP with stent placement, which showed a mass (1of 3) compressing the porta in segment 8, likely a metastasis from a primary colon CA. Post ERCP course complicated by pancreatitis by labratory numbers, however, pt was never symptomatic clinically, and lab values improved significantly within a 24 hour period. Patient also had hypertension on the floor while on home [**Month/Year (2) 4982**]. [**Month/Year (2) **] were titrated to keep pressures within range for good IC perfusion knowing results of Carotid ultrasound. On [**4-2**], noted to be oriented x 2-3 [**Name8 (MD) **] RN notes. MS noted to improve on HD #5. Pt had some post procedure ERCP confusion requirign 1:1 sitter. Team thought this was likely related to versed received during ERCP. He was followed by HB surgery for possible surgical intervention, however given his extensive disease, he is not a surgical candidiate. Heme/onc saw the pt and helped to arrange f/u. A request for transfer to medicine was made for "delta MS," however pt o x 3 this morning on trasnfer. His labs were notable for LFTs which are trending down post ERCP with no abd pain. The pt has no complaints this morning on transfer. Daughter at bedside and feels he is at his baseline. Transferred to medicine for mgmt of his post ERCP elevated amylase, lipase. 1. Elevated amylase/lipase: Asx and non-revealing abd exam. Enzymes are currently trending down. Likely related to peri-ERCP irritation. No evidence of acute pancreatitis at this time. His repeat check of LFTs int he am showed improvement in his LFTs. He was placed on a clear diet day of trasnfer and tolerated a full diet the next morning. * 2. Delta MS: Currently oriented and appears at baseline. Likely prior delta MS [**First Name (Titles) **] [**Last Name (Titles) 4085**] related in the setting of receiving benzos. Afebrile with no WBC. Will check UA/cx today as well. On MRI head, no evidence of mets. UA and urine cx were unrevealing to date for infection. As for his mental status, he was oriented x 3 untilt he evening of trasnfer when he became mildly confused and the following morning was only oriented x 1. A few hours later on re-examaniation, he was oritend x 3 and at his baseline. There was no other explanation for this as pt was afebrile, had not recieved any [**Last Name (Titles) 4085**] which could affect his MS. After a long conversation and assurance of the family that this was sundowning, the pt was discharge. * 3. s/p MVA: currently pain free. F/u with Dr [**Last Name (STitle) 363**] * 4. HTN: Given stenosis would like to maintain SBP 120-140's. titratedBP meds for this effect. * 5. Colon cancer: Post obstructive mets causing acute presentation over last few days as well as jaundice. App heme/onc consult. Pt's family decided that they would like pt s chemo care at [**Hospital1 **] and this was arranged with Dr [**Last Name (STitle) 150**]. A repeat CXR per onc for better eval of superior opacity on [**4-1**] CXR was done which showed some improvement, a chest CT was done which showed some [**Month (only) **] in the size of the nodule but reccomended a 3 month follow up chest CT to look for progression. * 6. [**Last Name (un) 3562**] disease: cont carbidopa-levodopa. Follwed by Dr [**Last Name (STitle) **]. * 7. PPx: Famotidine, heparin sq * 8. Full code. This should be readdressed w/ pt and family as outpt. * 9. Comm: with wife, pt, and family [**Last Name (STitle) **] on Admission: Meds at home: toprol xl 50 mg [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg qd, fosinopril 30 mg [**Hospital1 **], zocor 20 mg qd, carbidopa/levodopa 25-250 mg [**Hospital1 **] * Meds on transfer: tylenol, [**Hospital1 **], famotidine, cabridopa-levodopa, folic acid, heparin sq, insulin sc, lisinopril, toprol xl, simvastatin, tamsulosin, thaimine Discharge [**Hospital1 **]: 1. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2* 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary: 1. Motor vehicle accident 2. Obstructive jaundice 3. Delta MS [**First Name (Titles) 767**] [**Last Name (Titles) 4982**] 4. Lung nodule Secondary: 1. Parkinson's disease 2. Colon cancer Discharge Condition: Afebrile, pain free, mental status at baseline. Discharge Instructions: If you have chest pain, shortness of breath, fevers/chills, dizziness or fainting, please call your PCP or come to the ED. 1. Take [**Last Name (Titles) 4982**] as directed 2. Attend all follow up appointments PLEASE HAVE A FOLLOW UP CHEST CT PERFORMED in 3 MONTHS TIME. Followup Instructions: Ortho: Dr [**Last Name (STitle) 363**]. [**2124-4-27**] 1:45 pm. [**Hospital Ward Name 23**] [**Location (un) **]. [**Telephone/Fax (1) **]. Neurology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 1942**] Date/Time:[**2124-5-4**] 8:30 Heme/onc: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2124-4-27**] 4:30 PCP: [**Name10 (NameIs) **] [**Last Name (STitle) 34346**] on [**2124-4-13**] 9:30 am to f/u from this admission.

[ "722.0", "197.7", "292.81", "V10.05", "V10.82", "518.89", "E812.0", "577.0", "401.9", "332.0", "E939.4", "576.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "51.85", "51.87" ]

icd9pcs

[ [ [] ] ]

11566, 11641

6041, 10125

391, 408

11881, 11930

2393, 2438

12251, 12937

1126, 1278

11662, 11860

11954, 12228

1293, 2374

276, 353

436, 845

2447, 6018

10139, 10326

867, 1041

1057, 1110

10344, 11543

64,994

175,825

41992

Discharge summary

report

Admission Date: [**2193-9-5**] Discharge Date: [**2193-9-23**] Date of Birth: [**2120-11-2**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2193-9-9**] Total aortic arch replacement(28mm Gelweave graft),Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] tissue), Coronary artery bypass graftx 2 (LIMA-LAD,SVG-PDA), Endoscopic harvesting of the long saphenous vein. [**2193-9-8**] - Dental extractions of teeth #4, 7, 10, 12, 14, 29 and 30. [**2193-9-6**] - left heart catheterization, coronary angiogram History of Present Illness: 72 year old female with no past medical history presented [**9-4**] to OSH with shortness of breath. She states she went about her usual routine, and was walking to start doing laundry, when her legs felt "rubbery," she became more short of breath, and she presented to [**Hospital3 3583**] emergency room. She notes she remembers little after the ride to the OSH ED. In the ED, she was found to have respiratory distress, CXR with pulmonary edema, and she was intubated and transferred to the CCU. Initial troponin was 0.16, which trended to 1.79 peak. Her initial EKG showed nonspecific ST-T wave changes, with new ST depressions in V3-V5 while in the ICU. No ST elevations. Overnight, the patient had hypotension (thought to be in setting of getting propofol) requiring dopamine. Initially covered with broad spectrum abx for presumed pna, later stopped. She had a TTE showing 30% EF with moderate Ao insufficiency, small pericardial effusion, aneurysmal sounding of apex and akinesis of anterior wall and adjacent septum. On [**9-5**], she was weaned of dobutamine, extubated, transferred to [**Hospital1 18**] for further workup. She is now being referred to cardiac surgery for revascularization and repair of ascending aorta aneurysm/ +/-AVR. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - s/p 4 pregnancies with 3 vaginal deliveries and 1 emergent c-section and subsequent hysterectomy Social History: married, lives with her husband. Former nurse [**First Name (Titles) **] [**Last Name (Titles) 3325**]. -Tobacco history: 30 pack-year smoking history, [**1-27**] PPD. -ETOH: denies -Illicit drugs: denies Family History: Mother alive at 96, has pacemaker for syncope, pt is unsure of diagnosis. No family history of early MI, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: Adm PE: VS: T=99.4BP=139/70HR=88RR=14O2 sat= 100% 2L GENERAL: WDWN F 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 no JVD. CARDIAC: Forceful PMI. RR, normal S1, S2. Early systolic murmur at LLSB. 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. Decreased air movement b/l. 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: Imaging: [**9-5**] CXR: Large lung volumes suggest obstructive airways disease. Heart is moderately enlarged. Thoracic aorta is generally large, minimal diameter in the aortic arch 6 cm. No pneumonia. Possible mild residual interstitial edema best appreciated at the right lung base. Pleural effusion minimal on the right, if any. No pneumothorax. Right jugular line ends in the mid SVC. [**9-6**] TTE: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. LV systolic function appears moderately-to-severely depressed secondary to severe hypokinesis/akinesis of the inferior and posterior walls; the apex also appears hypokinetic (no thrombus seen). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The abdominal aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([**1-27**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**9-6**] Cath: 1. Selective coronary angiography of this left dominant system revealed a two vessel disease. The LMCA had no angiographically-apparent flow-limiting stenosis. The LAD had a mid 70% stenosis. The LCX was samll with no hemodynamically significant lesions. The RCA was diffusely disease with fresh appearing occlussion of the mid vessel and collateral supply from septal branches of the LCA robustly filling the distal RCA and PLA branches. 2. Limited resting hemodynamics revealed a normal systolic pressure at the aorta (139/59 mmHg). 3. Supravalvular aortography revealed an ascending arch aneurysm of 6.2 cm2 with at least 2+ aortic regurgitation. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Ascending aortic aneurysm. [**9-6**] CTA: 1. Aortic aneurysm of the ascending aorta as noted, with 3D measurements as noted; greatest dimension 5.8 x 5.4 cm. Mild noncalcified plaque in the descending thoracic aorta. 2. Atherosclerotic changes also noted at the bilateral internal iliac arteries, and the left common femoral artery. 3. Possible nonocclusive thrombus of the right internal jugular vein. It is also possible that this represents a mixing artifact from inflow of small veins into the right internal jugular artery, but this would be unusual. 4. Left adrenal nodule measuring 12 mm, which may represent an adenoma. 5. Nonspecific mild thickening of the tracheal wall in the subglottic region as noted. It should be noted that if previously intubated, this may represent a stenotic change, although other etiologies cannot be excluded. Please compare with prior imaging if available. If not, direct visualization by bronchoscopy may be indicated to ensure no underlying pathology. Intra-op TEE [**2193-9-9**] Conclusions PREBYPASS: Moderate Aortic insufficiency with severely dilated LV. Severely dilated ascending aorta with aorta measuring 5.5-5.8 cm just distal to ST ridge. The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Right ventricular chamber size and free wall motion are normal. The ascending aorta is severely dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Moderate (2+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. TV and PV appear normal. There is no pericardial effusion. Dilated LV but preserved LV systolic function with LV FAC >60%. No segmental wall motion abnormalities. POSTBYPASS: The patient is on an epinephrine infusion. There is a well-seated, well-functioning bioprosthetic valve in the aortic position. No aortic regurgitation is seen. There is no aortic stenosis. Mean gradient across the aortic valve is < 10 mmHg. The ascending aorta now measures 3.0 cm in diameter. There is no dissection flap seen in the aortic arch or descending thoracic aorta. Biventricular function is unchanged. No segmental wall motion abnormalities. Mitral regurgitation is unchanged. Discharge labs: Brief Hospital Course: On [**2193-9-8**], she underwent extraction of 7 teeth. On [**2193-9-9**], She was taken to the operating room where she underwent coronary artery bypass grafting to two vessels, and aortic valve replacement and an ascending aorta and total arch replacement. Please see operative note for details. Overall the patient tolerated the procedure well. She was transferred to ICU intubated on Epi and Neo. She was extubated on POD #1 and found to alert and oriented and breathing comfortably. The Epi was weaned off her 1st night post-op, but she remained on Neo 24hrs longer due to continued hypotension. She required 1 unit of blood to optomize her hemodynamics. Her batablockade was delayed due to borderline hypotension. She had significant nausea in immediate post-op period and required several antiemetics. She was transferred to floor on POD #3. Chest tubes remained in 2nd to continued drainage. Her pacing wires were removed without difficulty. She had a PICC line placed IN IR that was pulled back to a midline. On POD#4 she had two hours of rapid a-fib and was started on IV amiodarone. She converted to SB and medications were adjusted. She continued to have brief episodes of rapid a-fib and was started on Coumadin. Unable to increase betablocker significanlty due to SB baseline. Lisinopril and norvasc were added for hypertension. She has had persistent nausea that had limited her po intake activity and prolonged her hospital stay. She has required several antiemetics. Her LFTS, amylase and Lipase have been negative, she has moved her bowels, medications were minimized and her nausea resolved eventually. She developed an elevated WBC in POD #7, urine and CXR were unremarkable. Her left upper extremity midline was discontinued and tip culture was negative. Her WBC remained elevated but she was afebrile and her white count is slowly trending down. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD # 14 the patient was ambulating freely, the wound was healing and pain was minimal The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: None Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary artery disease aortic insufficiency s/p coronary artery bypass grafts x2, ascending/arch replacement Hypertension ascending Aortic aneurysm Discharge Condition: Alert and oriented x3, nonfocal Deconditioned, Ambulating with assistance 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 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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2193-10-14**] at 1:30pm Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2193-10-15**] at 9:00 am Please call to schedule appointments with: Primary Care Dr. [**Last Name (STitle) 87157**] [**Name (STitle) 17996**] ([**Telephone/Fax (1) 6699**]in [**4-30**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2193-9-23**]

[ "521.09", "424.1", "410.71", "787.02", "427.31", "E878.2", "401.9", "305.1", "414.01", "441.2", "997.1" ]

icd9cm

[ [ [] ] ]

[ "38.97", "23.09", "35.21", "39.61", "36.11", "88.42", "36.15", "38.45", "88.56" ]

icd9pcs

[ [ [] ] ]

10339, 10398

8094, 10284

296, 702

10591, 10831

3608, 5676

11804, 12519

2536, 2713

10419, 10570

10310, 10316

5693, 8053

10855, 11781

8071, 8071

2728, 3589

2092, 2165

237, 258

730, 1982

2196, 2297

2004, 2072

2313, 2520

26,895

125,598

33462

Discharge summary

report

Admission Date: [**2185-4-6**] Discharge Date: [**2185-5-25**] Date of Birth: [**2109-9-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: Fever, AMS, biliary obstruction Major Surgical or Invasive Procedure: ERCP [**2185-4-6**]: Biliary stent placed ERCP [**2185-1-11**] for blocked stent History of Present Illness: 75F with h/o amyloidosis, c/b ESRD on HD, with recent NSTEMI [**3-5**] admitted after ERCP for cholangitis. Pt currently cannot give a reliable history as she is still sedated after ERCP. Per the chart, pt admitted to OSH with abdominal pain and mental status changes. She reportedly had worsening abdominal pain, episodic SOB, had a few episodes of diarrhea. Was generally feeling weak and lethargic. Son states that she was saying things that didn't make sense. At OSH, had fever to 100.2, was confused and delirious. LFTs with obstructive pattern, RUQ u/s with intrahepatic biliary dilatation -> overall, concern for biliary sepsis. Also noted to have thrombocytopenia, labs c/w DIC. Transferred here for ERCP for definitive therapy. . Recently hospitalized in [**Hospital 8641**] Hospital [**3-5**], with NSTEMI, acute pulmonary edema, needed emergent dialysis. On ASA/Plavix. [**Name (NI) 1094**] husband died last week, son also recently had MI (though pt is not aware of this - family has not told her yet in context of her delirium). Past Medical History: amyloidosis CAD, s/p NSTEMI [**3-5**] ESRD [**1-29**] amyloidosis on HD - HD MWF at [**Location (un) 32944**] Dialysis Center, Dr. [**Last Name (STitle) **] is nephrologist; last HD [**4-5**] HTN CHF - ?EF not known - sounds in setting of NSTEMI by OSH records Social History: Retired. Denies tobacco, EtOH, or IVDU. Family History: FH: noncontributory Physical Exam: VS: 97.4 120/75 61 18 94% RA Gen: sedated, able to answer questions and follow commands; oriented to person, year, birthday HEENT: PERRL, eyes rolling when open lids; OP with blood lining teeth, was bleeding more actively before, now less; sm blood R nare; MM dry CV: RRR, nl S1/S2, 2/6 systolic murmur RUSB Chest: R tunneled HD catheter Pulm: clear anteriorly Abd: soft, NT/ND, + BS Ext: no [**Location (un) **], thickened coarse skin on LE; L AVF with +thrill/bruit Pertinent Results: [**2185-4-7**] 12:52AM BLOOD WBC-10.4 RBC-2.80* Hgb-9.1* Hct-26.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-18.8* Plt Ct-96* [**2185-4-7**] 12:52AM BLOOD Neuts-83.6* Lymphs-11.7* Monos-3.6 Eos-0.6 Baso-0.4 [**2185-4-7**] 12:52AM BLOOD Plt Ct-96* [**2185-4-7**] 01:50AM BLOOD Fibrino-873* D-Dimer-2708* [**2185-4-7**] 12:52AM BLOOD Glucose-122* UreaN-63* Creat-6.9* Na-137 K-5.9* Cl-96 HCO3-22 AnGap-25* [**2185-4-7**] 12:52AM BLOOD ALT-94* AST-34 LD(LDH)-202 AlkPhos-419* Amylase-198* TotBili-2.7* [**2185-4-7**] 12:52AM BLOOD Lipase-207* [**2185-4-7**] 12:52AM BLOOD Albumin-2.5* Calcium-7.8* Phos-7.4* Mg-2.7* [**2185-4-7**] 01:50AM BLOOD Hapto-403* LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2185-5-17**] 3:40 PM LIVER OR GALLBLADDER US (SINGL Reason: eval for interval change in size or new lesions [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with known liver lesion. REASON FOR THIS EXAMINATION: eval for interval change in size or new lesions 75-year-old woman with known liver lesions. Assess for interval change in size or new lesions. LIVER ULTRASOUND: Comparison is made to prior examination of [**2185-4-22**]. In the left lobe of the liver, there is a 12.1 x 6.1 x 4.0 cm multiloculated mass which has changed its appearance significantly from the prior examination, whereas previously it appeared overall quite heterogeneous with small areas of hypoechogenicity. There now appear to be large fluid components in this mass. The remainder of the liver is unremarkable. There is ascites surrounding the liver. The gallbladder is collapsed. The common bile duct is normal at 2 mm. There are small lymph nodes around the celiac axis measuring 0.7 cm in short axis. The pancreas appears unremarkable. IMPRESSION: 1. Large mass in the left lobe of the liver. The appearance has changed significantly from the prior examination of [**2185-4-22**] and the mass now contains large loculated fluid components. This may represent tumor necrosis. 2. No new lesions are identified. 3. Ascites surrounding the liver. ========== [**2185-5-20**] 9:03 am BLOOD CULTURE Source: Line-Dialysis 2 OF 2. Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2185-5-21**]): REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2185-5-21**] AT 0400. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2185-5-21**]): GRAM NEGATIVE ROD(S). =========== Brief Hospital Course: [**Date range (1) 77612**] The patient's initial MICU course was complicated by acute GI bleeding, bacteremia, fungemia, and dialysis access complications. In this complicated setting, she also had a NSTEMI which was medically treated, and also was noted to have a liver mass. Due to a significant bleeding diatheses, a biopsy could not be performed until the patient was stabilized. She gradually improved and was transferred to the floor for futher evaluation. [**2093-5-6**] Her bleeding diatheses was managed with improving nutrition as directed by nutrition consult, and high dose vitamin K SQ for three days. Her respiratory status decompensated, with increasing oxygen requirement, thought to be due to profound hypotension with even modest ultrafiltration on hemodialysis despite aggressive sodium modelling and dialysis protocol optimization. Once her coagulation profile improved, her pleural effusion was tapped to optimize her respiratory status, and approximately one liter was removed. The fluid was sent for cytology and culture. The patient was also significantly deconditioned and in significant pain and often declined physical therapy; her medical regimen was adjusted to include fentanyl transdermal patch for better basal pain control in an effort to increase adherence to a PT regimen. [**2102-5-14**] The patient was taken off of daptomycin and fluconazole after receiving over 14 days of treatment for both the bacteremia and fungemia. The patient still had diffuse anasarca with limited fluid removal during HD secondary to symptomatic hypotension. A repeat liver US was obtained which showed a rapid progression in size of the previously seen lesion. A family meeting was held and it was decided to pursue a liver biopsy to help determine if further aggressive care would be beneficial in terms of life prolongation. Serial cultures were obtained after stopping the prior dapto and fluconazole. On [**5-20**] the patient grew out GNR. She was started on zosyn and cipro for empiric coverage. [**2105-5-23**] The patient preliminary liver biopsy results demonstrate amyloidosis and further discussions with the patient's health care proxy, her son, indicated a desire to moves towards hospice care. Her central venous catheters were removed, her antibiotics were discontinued, and her dialysis was stopped. She was then transferred to a skilled nursing facility with hospice care. Medications on Admission: plavix 75mg daily asa 81mg daily zosyn 2.25g q8 protonix 40mg daily atenolol 100mg daily amlodipine 10mg daily PhosLo 667mg tid risperdal 0.5mg [**Hospital1 **] oxycodone 5mg tid prn dulcolax 10mg prn Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO q1 hour as needed. 2. Acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every four (4) hours. Discharge Disposition: Extended Care Discharge Diagnosis: 1. Cholangitis 2. Amyloidosis 3. Acute blood loss anemia 4. End stage renal disease with secondary hyperparathyroidism and related anemia with fistula and catheter acess complications 5. [**Female First Name (un) 564**] fungemia 6. Vancomycin resistant enterococcal septicemia 7. Cholelithiasis 8. Thrombocytopenia 9. Atrial fibrillation 10. Non-ST elevation myocardial infarction 11. Pleural effusions, recurrent 12. Gram negative rod septicemia Discharge Condition: Guarded, comfort care only Discharge Instructions: You are being discharged to hospice care. Followup Instructions: Hospice

[ "E878.8", "790.7", "583.81", "588.81", "277.39", "286.6", "511.9", "427.31", "458.21", "112.89", "403.91", "410.71", "578.9", "998.11", "574.51", "428.23", "576.1", "410.72", "428.0", "996.62", "573.8", "585.6", "996.73", "E879.1" ]

icd9cm

[ [ [] ] ]

[ "51.88", "50.11", "51.14", "51.87", "39.50", "97.05", "00.42", "44.43", "00.40", "51.85", "34.91", "51.10", "39.95", "86.05" ]

icd9pcs

[ [ [] ] ]

7767, 7782

4907, 7323

345, 428

8273, 8302

2402, 3199

8392, 8403

1871, 1893

7575, 7744

3236, 3279

7803, 8252

7349, 7552

8326, 8369

1908, 2383

4559, 4884

274, 307

3308, 4515

456, 1511

1533, 1796

1812, 1855

23,045

112,245

18997+18998

Discharge summary

report+report

Admission Date: [**2190-7-4**] Discharge Date: [**2190-7-13**] Date of Birth: [**2134-1-24**] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: 56-year-old gentleman with a history of myelodysplastic syndrome which has progressed to acute myelogenous leukemia complicated by pancytopenia, absolute neutropenia, and chronic infection involving his lungs (presumptively fungal). The patient was admitted to day with a cough which then progressed to dyspnea and fever. The patient denied any other acute complaints. In the Emergency Department, he was noted to be tachycardic and febrile to 102. He received intravenous fluids, cefepime, and vancomycin and was transferred to the Intensive Care Unit for further evaluation. PAST MEDICAL HISTORY: Myelodysplastic syndrome diagnosed in [**2189-6-21**] which progressed to acute myelogenous leukemia; poor prognosis - cytogenetic was 5q negative and mono filmy 7. Acute myelogenous leukemia diagnosed in [**2189-8-21**]; status post induction with 7+3 which was completed on [**2189-10-21**] with overall poor response complicated by chronic fungal pneumonitis - question Aspergillosis. Negative bronchoalveolar lavage in [**2190-1-21**] and in [**2190-1-21**] for Pneumocystis carinii pneumonia and neuro fungi. [**2190-1-21**] - right palate lesion consistent with chloramine pathology. Hypertension. Type 2 diabetes. Gastroesophageal reflux disease. History of partial small bowel obstruction. History of small-bowel bleed. History of alloimmunization to platelets. Coronary artery disease. History of diabetes insipidus; status post lithium. Chronic hyponatremia felt to be secondary to lithium. Depression. MEDICATIONS ON ADMISSION: 1. Glucotrol 20 mg by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. [**Doctor First Name **] 60 mg by mouth twice per day. 4. Lopressor 12.5 mg by mouth once per day. 5. Voriconazole 200 mg by mouth twice per day. 6. Caspofungin 50 mg by mouth once per day. 7. Risperidone. 8. Levofloxacin. ALLERGIES: METFORMIN . PHYSICAL EXAMINATION ON PRESENTATION: Temperature maximum was 102.7 degrees Fahrenheit, his blood pressure was 107/55, his heart rate was 93, his respiratory rate was 30, and his oxygen saturation was 100 percent on room air. Generally, a tired ill-appearing diaphoretic male. Head, eyes, ears, nose, and throat examination revealed the oropharynx was dry, poor dentition, white plaque on tongue, with a bruise over right eye and over bridge of nose. Cardiac examination revealed a regular rate. First heart sounds and second heart sounds. No murmurs. Pulmonary examination revealed decreased breath sounds at the bases. No rales or rhonchi. Abdominal examination was benign. Extremity examination revealed the extremities were warm and dry. Right Port-A-Cath with granulation tissue and foul smelling. Neurologic examination revealed affect was flat. Alert and oriented times three. In no apparent distress. Speech was fluent. Cranial nerves were intact. RADIOLOGY: A chest x-ray revealed no focal pneumonia, persistent right-sided effusion. A computed tomography angiogram of the chest revealed no pulmonary emboli, right pleural effusion, multiple nodular densities throughout parenchyma. PERTINENT LABORATORY VALUES ON ADMISSION: White blood cell count was 0.8. His hematocrit was 30.2. Chemistry profile was notable for a blood urea nitrogen of 32, creatinine of 1.4, platelets of 15, D-dimer was 4832, lactate was 2.5, and INR was 1.4. SUMMARY OF HOSPITAL COURSE: 1. ACUTE MYELOGENOUS LEUKEMIA: The patient's treatment has been limited by persistent infection involving old line infections and pulmonary issues. The patient had been on Synercid two weeks prior to admission for persistent line infection and a known history of vancomycin-resistant enterococcus. The [**Hospital 228**] hospital course was notable for an increased level of blasts in circulation. As high as 37 percent blasts were noted on complete blood count from [**2190-7-13**]. The patient was persistently febrile and was treated broadly for his known pulmonary infection as well as other possible sources. The patient was maintained on transfusion parameter scales. He did not have any evidence of disseminated intravascular coagulopathy or tumor lysis during this hospitalization. 1. HISTORY OF VANCOMYCIN-RESISTANT ENTEROCOCCUS STATUS POST LINE REMOVAL: The patient has a history of old line site infection with granulation tissue. Dr. [**Last Name (STitle) **] from Surgery evaluated the site and felt that the line site was not infected, and most likely his fevers were attributed to his known pulmonary infection. The Surgery Service debrided the patient's wound at bedside using silver nitrate. 1. CHRONIC INFECTIOUS PNEUMONITIS: A Pulmonary consultation was obtained. The patient had a bronchoscopy without any evidence of a fungal or Pneumocystis carinii pneumonia or bacterial pneumonia. A video-assisted thoracic surgery was considered versus computed tomography-guided biopsy. The decision regarding this was pending at the time of discharge. However, the patient was persistently febrile despite negative bronchoalveolar lavage. A repeat chest computer tomography revealed slightly worsening bilateral infiltrates, pulmonary edema, and stable left-sided pleural effusion. The patient did not have an oxygen requirement during his hospitalization, and his breathing was stable. He had a nonproductive cough. 1. CORONARY ARTERY DISEASE: The patient was maintained on metoprolol. He had no active issues during his hospital course. 1. TYPE 2 DIABETES: The patient was maintained on twice per day fingerstick glucose checks and a regular insulin sliding scale. 1. INFECTIOUS DISEASE: An Infectious Disease consultation was obtained to assist in the management of the patient's pneumonitis. The patient was treated with Synercid in light of his known history of vancomycin-resistant enterococcus. He was also treated with imipenem after intermittently being on Zosyn. The thought was that imipenem would give no Cardia coverage. However, despite broad coverage for gram-positive and gram-negative rods as well as fungal organisms with both caspofungin and voriconazole, the patient remained febrile. 1. PSYCHIATRY: The patient has a history of depression. The patient is on lithium as an outpatient. He was maintained on this. His lithium level on admission was within normal limits. He was also maintained on Risperdal at bedtime. 1. HYPONATREMIA: There was no evidence of hyponatremia during his hospital course. 1. MYOPATHY: The patient developed right hip flexor weakness on [**7-10**]. A magnetic resonance imaging of his lumbosacral spine revealed a L4-L5 disc herniation as well as a right inferior ramus fracture. It was unclear whether or not this was a new or old fracture. Plain films may help in determining this. The patient was able to ambulate. The Orthopaedic Service was consulted to evaluate the fracture. There was no evidence of cord compression on his magnetic resonance imaging. The Orthopaedic Service felt that the patient was able to weight bear as tolerated with the assistance of physical therapy. The patient denied any hip pain or pelvic pain, and overall right hip flexor strength was [**3-26**]. NOTE: Discharge followup, medications, and Addendum to this Discharge Summary to follow. Dr.[**Last Name (STitle) **],[**First Name3 (LF) 51907**] [**MD Number(4) 51908**] Dictated By:[**Last Name (NamePattern1) 12866**] MEDQUIST36 D: [**2190-7-13**] 14:51:30 T: [**2190-7-15**] 11:42:34 Job#: [**Job Number 51909**] Admission Date: [**2190-7-4**] Discharge Date: [**2190-7-23**] Date of Birth: [**2134-1-24**] Sex: M Service: EXPIRED: [**2190-7-23**]. PRESENT ILLNESS: The patient was a 56 year old gentleman with acute myelogenous leukemia, who was transferred to the intensive care unit after developing respiratory distress. In the intensive care unit he received treatment for pulmonary hemorrhage. The patient had been transferred from the hematology/oncology service, where he was undergoing treatment for AML that had been refractory to several chemotherapies, and he had persistent blast pancytopenia and diffuse pulmonary process, possibly infection, and had been noted to require increased oxygen demand and developed dyspnea and tachypnea with a new left lower lobe opacity on chest x-ray. Chest CT from [**7-16**] had shown multiple "defined pulmonary nodules slightly improved". The differential was considered to be aspergillosis versus no cardia versus septic emboli versus PCP [**Name Initial (PRE) 1064**]. The patient had been stable on the floor prior to transfer to the intensive care unit. In the intensive care unit it was noted that the patient was in respiratory distress. His hematocrit was noted to have dropped from 25 to 18. PHYSICAL EXAMINATION: Physical exam at admission to the ICU: Vitals: Temperature 103.8. Blood pressure 85/47. Heart rate 110. Respiratory rate 40. Oxygen 96% on 100% non-rebreather mask. In general the patient was diaphoretic and tachypneic, anxious, using accessory muscles to breathe. HEENT: PERRL, anicteric. Oropharynx dry. Neck supple without JVD. Cardiovascular hyperdynamic precordia. Normal S1 and S2. Question of flow murmur. No rubs or gallops. Lungs decreased breath sounds and coarse rales in the bilateral lower lobes. No wheezing. Abdomen soft and nontender, nondistended. Extremities without clubbing or cyanosis. Extremities with 1+ bilateral pitting edema. No calf edema. Neurologic: The patient alert, scared, moving all extremities, anxious. Skin with diffuse petechiae. LABORATORY DATA: Hematocrit 24.7 on admission, decreased to 18 in the setting of chest x-ray showing new prominent alveolar left lower lobe opacity. ECG sinus tachycardia, rate 150's, normal axis, slightly peaked T-waves in V3 to V5. Upsloping ST depressions in V3 to V5, possibly related. HOSPITAL COURSE: For hypotension and anemia, the patient received 3 liters of normal saline boluses for hydration, 1 unit of platelets, vitamin K, Amicar for thrombocytopenia, 2 units packed red blood cells and oxygenation on 100% non- rebreather facemask. He was given morphine for comfort. Subsequently the patient reported feeling much better and was mildly sedated without pain, breathing comfortably after this care was delivered. Consultations including infectious disease, hematology, oncology and palliative care were continued. Given the gravity of the situation, the patient and his family decided to pursue comfort measures only, considering that his leukemia was not treatable, nor was the pulmonary hemorrhage with low platelets with platelets at the level of 5, down from 10. The patient was presumed to have had an episode of acute respiratory distress with sudden onset requiring transfer to the intensive care unit, likely due to pulmonary hemorrhage secondary to thrombocytopenia with platelets less than 10. For the respiratory distress, the patient was continued on broad spectrum antibiotic coverage, including Caspofungin, Voriconazole, Acyclovir, Dalfopristin and Imipenem. In the event that the respiratory distress was related to underlying pulmonary infection, oxygen supplementation with a non-rebreather mask maintained oxygen saturation over 90%. He received a blood transfusion and platelet transfusion for anemia and thrombocytopenia. Also Amicar was started for thrombocytopenia that was severe with a platelet level of 5. IV fluid boluses were given for hypotension. The patient had end stage AML refractory to chemotherapy and several platelet transfusions. A family meeting with palliative care and ICU team led to pursuit of comfort measures in light of futility of additional treatment, unable to maintain adequate levels of thrombocytes and blood cells with continuing pulmonary hemorrhage. The patient expired at 3:00 p.m. on [**2190-7-23**]. He was noted to be unresponsive and found to be breathless, pulseless and without heart tones, blood pressure or corneal reflexes. The patient's family and private physician were notified. They refused anatomic gifts and autopsy. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Myelodysplastic syndrome. 2. Acute myelogenous leukemia. 3. Coronary artery disease. 4. Gastrointestinal bleeding. 5. Diabetes. 6. Depression with memia. 7. Possible fungal pneumonitis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7775**] Dictated By:[**Last Name (NamePattern1) 51910**] MEDQUIST36 D: [**2191-7-13**] 12:41:09 T: [**2191-7-13**] 13:33:14 Job#: [**Job Number 51911**]

[ "733.19", "996.69", "511.9", "288.0", "054.79", "205.00", "117.3", "253.5", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.28", "86.28", "99.04", "33.24", "93.90" ]

icd9pcs

[ [ [] ] ]

12463, 12928

1720, 3293

10181, 12378

3547, 9078

9101, 10163

162, 744

3308, 3519

767, 1694

12403, 12442

3,678

163,776

50553

Discharge summary

report

Admission Date: [**2136-7-20**] Discharge Date: [**2136-7-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 81 y/o M w/COPD on home O2, dCHF, Myelodysplasia w/excess blasts, recently admitted to [**Hospital1 18**] for hypoxia from [**Date range (1) 24350**]. Per d/c summary, pt initially went to [**Hospital6 20592**] for leg pain. At that time he was found to be in ARF w/elevated CK, and had "evidence of CHF and COPD flare" as well as pancytopenia with 15% blasts. Here he was initially in the [**Hospital Unit Name 153**] for hypoxia (93% on RA) and concern for blast crisis. He did well, tolerated fluid resuscitation, and did not require intubation. He was seen by Heme-Onc, who felt he did not have AML but had Myelodysplasia with excess blasts. His renal failure resolved with hydration (0.8 on d/c, from 2.1). Per the family's request, he was transferred back to [**Location (un) **] on [**7-4**], and was discharged to home from there on [**7-5**]. He finished a course of antibiotics on [**7-6**]. He was discharged home on 2 liters oxygen although he had not been on this prior. He was doing well post-d/c per his daughter, but over the past few days has been more lethargic, decreased po intake, increasing shortness of breath. He was febrile to 102 last pm. His mental status remained at baseline (alert, oriented, interactive) with the exception of one episode of confusion last pm which resolved within minutes. He has no dysuria but per the daughter has had diarrhea and urinary/fecal incontinence over the past 3-4 weeks with inability to tell when he is stooling or urinating. He had no focal weakness, nausea, vomiting, abdominal pain, cough, or other symptoms. At the OSH ED, he was tachypneic in 40s with o2 sat 80s, and was placed on bipap. He was transferred here for further w/u. In our ED, he was febrile to 101.9, hypotensive to the 70s/50s, with o2 sat 99% on bipap. Has had 20 cc UOP. Past Medical History: 1. COPD 2. HTN 3. CHF (MUGA [**6-24**] with LVEF 61%; TTE [**6-24**] w/"depressed" systolic fxn but diff to assess, TTE on [**3-22**] was EF 50%, inferobasilar HK, mild MR) 4. CAD s/p CABG x2 ([**2112**], [**2133**]) 5. h/o prostate Ca, s/p TURP 6. Hyperparathyroidism 7. Pancytopenia (baseline Hct during prior hosp low-mid 30s, platelets 40s-50s, WBC 2) 8. Myelodysplasia w/excess blasts (dx last hospitaliz) 9. colonic perforation [**2134**] s/p sigmoid resection (at [**Location (un) **]) 10. carotid artery stenosis s/p CEA in [**2130**] Social History: Lives at home with his wife. Smoked [**1-22**] ppd for 60 yrs, quit 6 yrs ago. Family History: Fam Hx: identical twin brother died [**2-25**] from leukemia Physical Exam: PE: P: 76 BP: 104/78 R: 24 100% on bipap Gen: uncomfortable male, not in acute distress, with bipap mask in place HEENT: NC, AT, perrl, anicteric, conjunctivae noninjected. Neck: supple, JVD difficult to assess but appears flat. Lungs: good air movement throughout, no wheezes, rhonchi, or crackles, no dullness to percussion CV: RRR, no m/r/g Abd: soft, nt/nd, +bs. Rectal: large external hemorrhoid, decreased rectal tone. Ext: no clubbing, cyanosis, or edema Skin: no rash Neuro: perrl, eomi, tongue midline, strength 5/5 x4, decreased rectal tone as above. Pertinent Results: [**2136-7-20**] 08:50PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.022 [**2136-7-20**] 08:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR [**2136-7-20**] 08:50PM URINE RBC-[**3-24**]* WBC-[**3-24**] BACTERIA-MOD YEAST-NONE EPI-[**3-24**] [**2136-7-20**] 08:50PM URINE MUCOUS-FEW [**2136-7-20**] 07:45PM LACTATE-2.1* [**2136-7-20**] 07:20PM GLUCOSE-161* UREA N-30* CREAT-1.3* SODIUM-133 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-15 [**2136-7-20**] 07:20PM ALT(SGPT)-50* AST(SGOT)-61* LD(LDH)-1174* CK(CPK)-48 ALK PHOS-99 TOT BILI-0.5 [**2136-7-20**] 07:20PM cTropnT-0.03* [**2136-7-20**] 07:20PM CK-MB-NotDone proBNP-9466* [**2136-7-20**] 07:20PM CALCIUM-8.6 PHOSPHATE-2.6* MAGNESIUM-1.5* [**2136-7-20**] 07:20PM HAPTOGLOB-375* [**2136-7-20**] 07:20PM CORTISOL-376.5* [**2136-7-20**] 07:20PM WBC-2.4* RBC-2.41*# HGB-7.6*# HCT-21.6*# MCV-90 MCH-31.4 MCHC-35.0 RDW-16.1* [**2136-7-20**] 07:20PM NEUTS-55 BANDS-5 LYMPHS-27 MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-11* NUC RBCS-14* [**2136-7-20**] 07:20PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-2+ SCHISTOCY-OCCASIONAL TEARDROP-2+ BITE-OCCASIONAL [**2136-7-20**] 07:20PM PLT SMR-VERY LOW PLT COUNT-40* [**2136-7-20**] 07:20PM PT-15.1* PTT-26.0 INR(PT)-1.5 . [**7-24**] MR L spine FINDINGS: There is a transitional vertebra between the lumbar spine and the sacrum. For the purposes of this dictation, the most inferior disk will be referred to as S1/2, and the transitional vertebra will be referred to as partially lumbarized S1. Bone marrow signal is diffusely abnormal, consistent with diffuse bone infiltration by tumor. There is a suggestion of cortical destruction in the posterior inferior endplate of L3, posterior superior endplate of L4, posterior inferior endplate of L5, and posterior superior endplate of S1. Mild compression deformities are seen in all of the visualized vertebrae from T12 through S1, likely secondary to pathologic fractures. There is no bone marrow edema on the STIR images to suggest that these fractures are acute. The conus terminates at L1. No compression of the conus is noted. At L3/4, there is a disc bulge and a more focal right paracentral herniation, which displaces the nerve roots medially and posteriorly. In addition, there is a shallow, small epidural mass extending from the posterior vertebral body into the right neural foramen, which may represent epidural tumor or a mottled osteophyte- CT could provide differentiation between the two etiologies. There is only mild associated narrowing of the right neural foramen. At L4/5, there is facet spondylosis and a disc bulge with mild associated central stenosis and lateral recess narrowing bilaterally. At L5/S1, there is a disc bulge and facet spondylosis with mild central stenosis and bilateral lateral recess narrowing. Lenticular epidural structures are noted extending from L3 through L5 posterior to the vertebral bodies and anterior to the thecal sac, with high signal on T1- and T2-weighted images. These likely represent epidural fat, and less likely distended epidural veins. This appearance is not consistent with epidural tumor. The following preliminary report was given by Dr. [**Last Name (STitle) **] to a resident caring for the patient at 12:30 a.m. on [**2136-7-25**]: Abnormal signal in vertebral bodies. Disc herniation impinging on the thecal sac on the right at L3/4. No spinal cord compression. The final report was discussed with Dr. [**Last Name (STitle) 9570**] at 1:45 p.m. on [**2136-7-25**]. IMPRESSION: 1. Diffuse bone marrow infiltration by tumor, with probable cortex destruction at multiple levels. Probable epidural extension of tumor into the right L3/4 neural foramen with mild foramen narrowing. 2. Small right paracentral disc herniation at L3/4, which displaces the nerve roots. 3. Mild central stenosis and lateral recess narrowing at L4/5 and L5/S1. Brief Hospital Course: A/P: 1. Hypotension: Patient was likely hypotensive from dehydration secondary to diarrhea. Once he was fluid resucitated his BP returned to [**Location 213**]. He was then normotensive for the remainder of the admission. Cortisol stim test was normal. Anti HTN meds were held. 2. Fever/Diarrhea: [**Month (only) 116**] be related in that patient has c.diff from recent Abx course and profound diarrhea. C diff was neg x 2 but patient was treated with empiric flagyl. Sent home to complete a 14 day course. Rectal tube placed in MICU. By the third day the diarrhea had resolved (either spontaneously or due to the flagyl). He had no diarrhea for the rest of the admission. 3. Urinary and bowel incontinence: Patint was incontinent of urine and feces during the admission. By report of his family the urine is baseline for the patient since his radical prostatectomy. The stool was likely due to the diarrhea. However it was noted that the patient had poor rectal tone. There were no other neurological findings. An MRI was negative for nerve impingement or cord compression. 4. Myelodysplasia:h/o MDS with xs blasts. Patient evaluated by Heme/Onc. Transfused to Hct > 28. Patient will have Heme Onc Follow up in [**Location (un) **] with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **]. 5. Prostate Cancer - patient with negative PSA. However MRI did demonstrate tumor spread. Will follow up with Dr. [**Last Name (STitle) **] as an outpatient. 6. ARF: Resolved to normal with fluids. Cr 0.6 at discharge. Code status: DNI Medications on Admission: 1. Protonix 40 po daily 2. Trazodone 50 qhs prn 3. Ipratropium 4. Colace 5. Isosorbide mononitrate SR 120 mg daily 6. Fluticasone 2 puffs [**Hospital1 **] 7. Albuterol 8. Metoprolol 75 mg po bid 9. Lisinopril 10 daily 10. ?Prednisone Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Disp:*24 Tablet(s)* Refills:*0* 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:*8 Tablet(s)* Refills:*0* 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 nebulizers* Refills:*2* 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q3-4H () as needed. Disp:*QS 1 month treatment* Refills:*6* 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). Disp:*120 treatments* Refills:*2* 8. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 9. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Disp:*qs 1 month Tablet(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Location (un) 976**] VNA Inc Discharge Diagnosis: Primary: Hypotension . Secondary: COPD CHF diastolic CAD h/o prostate cancer urinary incontinance myelodysplasia with excess blasts Discharge Condition: On Oxygen 2L (baseline at home)Eating WellWalking with walkerHemodynamically stable Discharge Instructions: Please take all medications and make all follow-up as indicated in the discharge paperwork. If you have any chest pain, shortness of breath, abdominal pain please call your doctor or go to a hospital. Also monitor you bowel movements. If you are not having BM x 3-5 days or develop abdominal pain/swelling seek medical attention. Note that we stopped all of your Blood Pressure Medicines (Imdur, Metoprolol, Lisinopril) Please don't take these until you see your primary care provider. Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 105253**] in 1 week [**Telephone/Fax (1) 27541**]. He will need to set you up with appropriate follow up for your pulmonary disease. You will also need follow up for you myelodysplasia by a hematologist/oncologist. Call Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 89520**] and set up an appointment in [**1-22**] weeks.

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icd9cm

[ [ [] ] ]

[ "96.09" ]

icd9pcs

[ [ [] ] ]

10550, 10612

7503, 9081

274, 281

10788, 10873

3462, 7480

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2803, 2865

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66,508

131,118

49026

Discharge summary

report

Admission Date: [**2165-2-25**] Discharge Date: [**2165-7-6**] Date of Birth: [**2104-3-7**] Sex: M Service: MEDICINE Allergies: Penicillins / Morphine / Dilaudid-Hp / Meropenem Attending:[**First Name3 (LF) 3984**] Chief Complaint: elective admission for reduced intensity conditioning with clofarabine, ATG, TLI, and allogenic SCT Major Surgical or Invasive Procedure: autologous stem cell transplant Intubation Bronchoscopy Hemodialysis History of Present Illness: Mr. [**Known lastname 9241**] is a 60 yo M with multiple myeloma Doxil/Decadron/Revlimid C2D22 presenting for elective admission for reduced intensity conditioning with clofarabine, ATG, TLI, and allogenic SCT. Please see Heme/Onc and Rad/Onc notes in OMR for more details. In brief, since [**2160**], the patient has recurrent, relapsing multiple myeloma refractory to treatment with Velcade, Revlimid, Doxil, and auto-SCT. Followed by Dr. [**Last Name (STitle) **], and it was decided he would undergo experimental protocol with reduced intensity conditioning with clofarabine, ATG, TLI (to reduce the GVD effect) and allogenic SCT for the graft-vs-tumor effect. He has been cleared by ID and cardiology to undergo his auto-SCT. Should receive prophylactive ivermectin the day of admission. Was seen by radiation oncology before admission, will be receiving 800 cGy of radiation (10 doses of 80 cGy), with goal being suppression rather than myeloablation. He has completely tapered his trazodone and is currently on Neurontin 600 mg PO BID. . On ROS, patient admits to chronic fatigue and states his mood is 'so-so', but says the Cymbalta has helped with his mood. Denies HI/SI. Denies fevers, chills, worsened shortness of breath, chest pain, lower extremity swelling or DVT with Revlimid. Past Medical History: - Multiple Myeloma dx [**2160**] s/p 5 cycles Velcade [**2160**] s/p auto-BMT in [**2160**] c/b post BMT PNA s/p dendritic cell vaccine [**2163**] s/p 5 cycles Velcade beginning [**1-/2164**] Doxil/Decadron/Revlimid (C2 started on [**2165-2-4**]) - HTN - Type II Diabetes - Depression with hospitalization in [**8-/2164**] (see OMR discharge summary for full details) - Peripheral Neuropathy - Pulmonary HTN - Dyslipidemia - Sleep Apnea - Glaucoma - Varicella Zoster, [**2164-5-15**] with Post-herpetic neuralgia. - Prostatectomy in [**2153**] for early Prostate CA - totally edentulous Social History: Lives with wife, daughter and 88 yr old mother in law in [**Name (NI) 18825**] MA; his mother-in-law has some form of dementia. He was born and raised in MA; lived in southern NH for 3 years and moved back. He is retired from the automotive repair industry. Their daughter is 23, and has autistic. They have Day-Care health aides who come and help weekly--all through VNAs. They also have 2 dogs and 1 cat (their daughter cares for the cat and litter box). They do not have a pool or outdoor hot-tub. His travel history is very benign. He travelled to [**State 5111**], [**State 3908**], and [**State 5170**] many, many years ago, and has not travelled outside of MA in the past 5 years. He was never in the military. Denies current tobacco use (stopped smoking cigars 24 years ago); social EtOH. marijuana use as a teenager, none currently. Family History: Father with alcoholism. Mother with anxiety and depression, and two siblings with anxiety and depression. Physical Exam: Physical Exam on admission VS: 97.3 136/70 20 100 95% on RA GA: obese, pleasant M sitting in bed, AOx3, NAD HEENT: PERRLA. MMM, no mucositis or open ulcers. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Lines: L subclavian present, nt to palpation. R port-a-cath nt to palpation. Pulm: CTAB no crackles or wheezes Abd: obese, soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Neuro/Psych: mood 'so-so', denies SI/HI. moving all extremities appropriately. decreased sensation in stocking/glove distribution. Pertinent Results: On Admission 139 103 13 AGap=13 ----------------- 4.1 27 0.9 . Ca: 9.4 Mg: 1.8 P: 2.8 . ALT: 24 AP: 70 Tbili: 0.5 AST: 19 LDH: 155 Dbili: 0.1 UricA:5.9 . MCV = 96 1.9>12.0<125 ------------ 33.6 . N:48.0 L:22.3 M:7.5 E:20.9 Bas:1.3 . Gran-Ct: 920 . PT: 13.1 PTT: 24.2 INR: 1.1 . [**Hospital Unit Name 153**] course: [**6-18**]- Blood Culture, Routine (Final [**2165-6-30**]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . SENSITIVE TO Daptomycin (2.0 MCG/ML). VANCOMYCIN SENSITIVITY CONFIRMED BY REPEAT TESTING. . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Blood Culture, Routine (Final [**2165-6-22**]): ENTEROCOCCUS FAECIUM. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 278-6956W ([**2165-6-20**]). ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. PSEUDOMONAS AERUGINOSA. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier **], [**2165-6-21**]. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R 2 S CEFTAZIDIME----------- R 4 S CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R 1 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S =>16 R PIPERACILLIN---------- =>128 R 16 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R URINE CULTURE (Final [**2165-6-22**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R RESPIRATORY CULTURE (Final [**2165-6-22**]): OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. MODERATE GROWTH. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R 2 S CEFTAZIDIME----------- R 4 S CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R 1 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S =>16 R PIPERACILLIN---------- =>128 R 16 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R FUNGAL CULTURE (Final [**2165-7-4**]): NO FUNGUS ISOLATED. Brief Hospital Course: *Initial BMT Course* The patient has had a recurrent, relapsing multiple myeloma refractory to treatment with Velcade, Revlimid, Doxil, and auto-SCT. It was decided he would undergo experimental protocol with reduced intensity conditioning with clofarabine, ATG, TLI (to reduce the GVD effect) and allogenic SCT for the graft-vs-tumor effect. He received 800 cGy of radiation (10 doses of 80 cGy), with goal being suppression rather than myeloablation. Day 0 of his transplant was [**2165-3-8**]. . His conditioning course was complicated by fevers, hyponatremia, and hyperglycemia. Regarding his fevers, this was thought most likely related to the ATG; however cultures at that time revealed ESBL E.coli urinary tract infection. He was started on vancomycin and aztreonam. Regarding his hyponatremia, this was thought most likely SIADH related to pain. He then received his stem cell infusion on [**2165-3-8**]. His stem cell infusion was complicated by fevers to 102. This was thought most likely related to his ATG and stem cell infusion. Subsequently, pt was noted to have altered mental status with increased somnolence. He underwent an LP on [**2165-3-15**] which was not suggestive of an infection. Pt was transferred to the ICU for the first time on [**2165-3-16**] for hypoxia and AMS. . *[**Hospital Unit Name 153**] Course by problem ([**Date range (1) 102903**])* # ARDS/intubation: this was attributed to both Paraflu PNA type 3 (diagnosed with a bronch, all other cultures negative), and ESBL sepsis (see below). Pt was intubated for approximately 3 weeks. Oxygenation had normalized after the first week, but pt was repeatedly unable to tolerate efforts to wean becoming aither apneic or agitated. Ultimately, trach was placed and pt was weaned first to PSV and soon after to trach mask. . # ESBL E coli bacteremia: Same organism involved in UTI described above. Pt initially received gentamycin, then underwent desensitization to meropenem (h/o anaphylaxis to PCN and trach) and completed a course of more than 14 days with subsequent negative blood cultures. . # Persistent fevers & Coag negative Staph line infxns: Despite negative surveillance blood cultures since [**3-16**], patient experienced persistent fevers. His Port-o-cath was removed on [**3-25**] and cultured out CoNS, and pt completed 1 week of vancomycin after the line pull. His HD line was also pulled [**4-7**] - NGTD; currently has a temporary line in place for HD (tunnelled line being delayed due to repeated positive catheter tip cultures). Pt continued to be febrile, thus his midline was pulled on [**4-8**], and it again showed CoNS. Vancomycin was restarted. ENT was consulted on [**4-5**] and felt that there were no evidence of sinus infection on exam despite some opacification seen on head CT. Pt was also on micafungin for positive B-glucan (127 on [**4-2**]), which was initially thought to be a false positive result (since there were several possible reasons for it such as CVVH and IVIG). However the repeat levels were initially higher and then trended down. Galactomannam was negative. Ultimately, there was no evidence of a fungal infection, but pt remained on micafungin for prohphylaxis. . # ARDS: thought to be due to bacteremia (see above), parainfluenza type 3 pneumonia and possibly PE (see below). Pt was intubated, placed on ARDSnet protocol, and slowly weaned off the ventilator. Weaning process was complicated by AMS, agitation and apnea. Pt received a dose of IVIg for hypoglobulinemia. Subsequently patient was trached. Initially pt required pressure support ventilation at night to support respiration however he was able to be weaned to 35 % trach mask. . # Possibility of pulmonary embolism: Pt was noted to be tachycardic on ventilator with development of new A fib. CTA of chest was not obtainable due to acute renal failure (see below) and VQ scan was deemed to be non-diagnostic given pt's pulm infections and anarsarca. LENIs of lower extremeities were negative. An echocardiogram was done which showed a hypokinetic R ventricle, felt to be suggestive PE. Pt was started on anticoagulation with heparin gtt x 2 weeks which was subsequently stopped when pt developed an iliopsoas hematoma. Pt is currently off of all anticoagulation given the bleed and limited findings to support diagnosis of PE. # Iliopsoas hematoma: developed spontaneously in setting of systemic anticoagulation for ?PE as above. Pt was initially noted to have an acute drop in Hct (6 points in 24 hours), was CT-scanned, which showed a new fluid collection in left iliacus muscle. The size of the hematoma had doubled in size by the next day. Pt required 4 units of pRBCs, last of these being on [**4-9**]. His Hct has been relatively stable since then. Subsequent scans have shown interval decrease. . # ARF: Thought to be multifactorial: Bacteremia, contrast dye pt received for a CT scan, supratherapeutic cyclosporine, gentamycin and acyclovir (acyclovir crystals seen in urine). Brief period of hypotension (never required pressor support, however) when intubated. Renal U/S showed no hydronephrosis. Pt was started on CVVH initially for maximum diuresis, which was then switched to HD when blood pressure tolerated. Monitoring digoxin and cyclosporin levels closely in setting of HD. Renal consult has been following the patient. . # New atrial fibrillation: Noted for the first time in the ICU. Rate controlled with Lopressor/ Digoxin was restarted with daily digoxin levels in setting of HD. Pt will need anticoagulation to reduce risk of stroke in the future. (Not started in the hospital due to iliopsoas hematoma, see above) . # Altered Mental Status: Pt has a history of depression with one inpt psych hospitalization. Pt's mental status has been very slow to improve and was the primary factor contributing to difficulty weaning from the vent requiring trach. He winces to pain everywhere on his body--this hyperasthesia was initially attributed to cymbalta withdrwal but persisted for over two months since cessation of cymbalta. Psych and neuro have been following the patient, per both teams, his current mental status is attributable to a profound delirium secondary to his multiple ongoing medical problems; they recommend haldol for agitation. MRI and LP were unremarkable. EEG was c/w a "toxic-metabolic state." . # MM: Day 0 of SCT=[**2165-3-8**]. BMT team followed patient in the ICU for management of CellCept and cyclosporin dosing. . *BMT course by problem ([**4-11**] to present)* # FEVERS/ ESBL "colonization" / ESBL PNA:Pt remained on trach upon return from the [**Hospital Unit Name 153**]. Levofloxacin was started on [**4-7**] for concern about increased trach secretions. As part of an infectious work-up for low-grade fevers after transfer CT of torso was done [**4-13**], it showed increased patchy opacities in bilateral posterior lung bases, bronchospcopy was pursued. BAL revealed gram negative rods and pt was restarted on aztreonam (given PCN allergy). Fevers soon resolved and respiratory status was stable. GNRs speciated as ESBL resistant to aztreonam. Given pt's improvement on aztreonam, it was thought that another pathogen had been targeted and ESBL was acting as colonizer; atreonam was continued past a two week course. Pt was afebrile, with stable resp status, and without leukocytosis for almost two weeks despite not receiving any Abx to target the ESBL. He then became febrile again, CT showed worsening confluence of opacities, and BAL showed ESBL. He was briefly transferred to the [**Hospital Unit Name 153**] for 48hrs (not because of any clinical decline) to receive meropenem desensitatization. . # Altered Mental Status: Neuro and psych teams which had been following in the [**Hospital Unit Name 153**] continued to follow on the floor as his mental staus failed to improve. Soon after trach placement, pt was able to follow verbal commands with actions in all 4 extremities. Once passy-muir valve was in place, it became clear that he was throughly confused. Neuro work-up was repeated with a second set of MRI and LP, both of which were unremarkable. Per Neuro, this was still c/w delirium. Psych agreed with ths diagnosis and continued to recommend holdin his outpt antidepressants and continuing to manage agitation with haldol. Neurology eventually recommended a third set of MRI/LP but this was not pursued as it was felt to be low yield given no change in his clinical status. Given the lack of progress in his mental status, cyclosporin was discontinued on day+55 (but soon restarted at a lower dose) to determine if this could be contributing to his AMS. During the last week of [**Month (only) **], Mr.[**Known lastname 102904**] mental state gradually improved as he was weaned of cyclosporin and by the first week in [**Month (only) 205**] we was alert, oriented, and conversant. It is now believed that much of his AMS can be attributed to cyclosporine neurotoxicity. He has at times been somewhat confused and on [**5-22**], was confused and hypersomnolent without a known cause. However, as of [**5-24**], he is alert, oriented, and communicative. . # ARF: Around day #60, Pt's renal function improved and pt was no longer requiring HD. Creatinine improved to 1.6, by first week of [**Month (only) **], however on [**5-22**] creatinine began rising again to 2.7 on [**5-24**]. Renal was consulted again, and ARF was believed to be due to prerenal azotemia progressing to ATN, likely caused by elevated uric acid levels and use of acyclovir in setting of volume depletion from copious diarrhea. Dose of acyclovir was adjusted and allopurinol started on [**5-24**]. . # AFIB/RVR: Mgt with metoprolol and digoxin continued. No anticoagulation given bleed as above. . # UE DVT: LENIS of the upper extremities were ordered as the pt developed UE edema out of proportion to the lower extremity edema which was resolving with HD. This reveal a right brachial DVT in the brachial vein through which a PICC was not running (but perhaps through which prior picc lines had been). Given his bleed hx, we did not anticaoagulate and were reassured by a repeat scan two days laters which showed significant interval decrease in the clot. Etiology of UE edema unknown. . # DIARRHEA: Upon return from [**Hospital Unit Name 153**] (second time for Meropenem desensitization), pt developed significant amounts of diahrrea. CDIFF and stools cultures (including cultures for atypical organisms) were repeatedly negative. Flex sig was done with biopsies negative for both GVH and CMV. There was some concern for melena, but stool was dark green and guiaic positive but not black; pRBC requirement during this episode was 2 packs over 48hrs. Given decreased relative sensitivity of flex sig, colonoscopy was pursued which was negative, but endoscopy showed two large oozing necrotic duodenal ulcers. . # MM s/p ALLO: At the two month mark, free kappa/lamba were sent to assess response of myeloma to the Allo, this showed elevated kappa chains. A bone marrow bx was obtained in early [**Month (only) 205**] which showed 7% plasma cells. . #? PE: On [**5-22**] again Pt was ruled out for PE, after he became tachycardic, tachypneic, and had an ABG that showed respiratory alkalosis. A CXR and V/Q scan were obtained which were ruled low liklihood for PE, and Mr. W was ruled out. . #Duodenitis: Even with althered mental status Pt was frequently gesturing towards stomach when asked if he was having pain, and grimicing upon palpation of abdomen. Pt was r/o for pancreatitis and C.DiffX3. An endoscopy was performed which showed two large necrotic chronic duodenal ulcers. Biopsies were obtained and negative for CMV, HSV. Pantoprozole IV was started which brought relief to Pt's pain after two days, and as of [**5-24**] abdominal exam much improved and patient is no longer complaining of abdominal pain. . #Rash Around [**5-19**], Pt noted to have [**Doctor Last Name **] erythematous macular rash on trunk and extremities. After rash seemed to be worsening, dermatology was consulted and punch biopsies obtained, for concern of drug reaction or GVHD. Preliminary read of the biopies favored drug reaction. Ciprofloxacin was d/c and rash still present but resolving as of Jult 10. . #Hearing Loss Pt noted to have increased hearing loss bilaterally since admission to the hospital, etiology unclear but believed may be in part secondary to gentamicin toxicity. On [**5-24**], ears were irrigated with normal saline and a large amount of wax was removed. Pt reports his hearing improved significantly after this treatment, but still w/ hearing deficits. Pt is scheduled for outpt audiology exam on Tuesday [**5-28**], for evaluation of hearing loss. . #Sacral Ulcer Pt has stage III decubitus ulcer on sacrum. Plastic surgery was consulted for wound debridement on [**5-22**] and is following the patient. Plastic is following Pt but wound site is very tender and creates significant discomfort for pt... [**Date range (3) 102905**] # Afib: Currently in afib with RVR. Increased diltiazem 60 mg qid to 90 mg QID with little effect. Unclear reasons why the patient remains in the arrhythmia. It might be related to anxiety. TSH normal on [**2165-5-25**]. Off anticoagulation given history iliopsoas hematoma. - Continue AV nodal blockade with diltiazem 90 mg QID. - Start metoprolol 25 mg PO q8hr. Will cover with metoprolol IV and increase metoprolol dose if needed. - If the patient has anxiety, give low dose of ativan. - Tachycardia might be related to low volume [**12-17**] diarrhea, so continue IVF. # Diarrhea: Concern from BMT with regard to GVHD. Patient has had negative C.diff, last checked on [**2165-5-21**], last O+P on [**5-9**]. Likely represents GVHD, although infectious etiology including C.diff, viral (i.e. CMV colitis), or parasite is possible. In addition, can also be a side effect of mycophenolate mofetil. - C.diff: negative - f/u: O+P, stool culture??????negative to date - CMV: negative - Continue solumedrol 60 mg IV BID - F/u with BMT - f/u GI recs. NPO for colonoscopy on [**2165-5-29**]/ # ESBL E.coli asymptomatic bacteruria: Patient currently asymptomatic but with UA x2 speciated as ESBL E.coli. ID currently following, with recommendation to treat with meropenem. Patient is penicillin allergic, so being desensitized in the ICU. Will receive first full dose on [**2165-5-28**]. - [**Last Name (un) **] densensitization per protocol. Infused over 30 minutes in 100 cc NS: dose 1 0.001 mg, dose 2 0.01 mg, dose 3 0.1 mg, dose 4 1 mg, dose 5 10 mg, dose 6 100 mg, dose 7 1000 mg. Tolerating desensitization well. . # Pulmonary infiltrates: Stable pulmonary exam currently without supplemental oxygen requirement. - Continue [**Last Name (un) 2830**], vanco, levofloxacin as above. Per ID, will hold flagyl given meropenem. - Unable to get expectorated sputum. Ordered induced sputum culture on [**2165-5-29**]. - Check galactomannan and beta-glucan. - Monitor respiratory status, no current signs or symptoms of respiratory distress . # Acute renal failure: Most recent elevation in creatinine attributed by renal to be secondary to ATN from diarrhea, acyclovir toxicity, and elevated uric acid. - Trend creatinine. - Gentle IVF repletion with NaHCO3 given low bicarb in setting of diarrhea. - Continue allopurinol and acyclovir - Follow-up renal recs -[**Hospital Unit Name 153**] Course [**Date range (1) 12474**] # GI Bleed: Pt arrived in [**Hospital Unit Name 153**] early AM after having profuse bright red blood per rectum with hemdynamic instability on BMT floor. Pt was given emergent fluid resucitation and pRBC transfusions (as of [**6-9**], had 6 units of pRBCs and 3 units of platelets). He underwent emergent EGD by GI and were able to inject and endoclip a large healing ulcer that is the likely cause of the bleed. He had required intermittent pressor support to maintain pressures. Given HCT drop, GI rescoped and found that the clips fell out of the large duodenal ulcer and it was actively oozing. GI replaced clip and felt that they maximized their treatment. Surgery did not feel that the patient would be a good surgical candidate given his co-morbidities. Both surgery and GI recommend possible IR embolization, which the patient never needed as he last required blood products on evening [**6-8**]. Since that time he has had decreasing amounts of melanotic stools recently, however, his HCT has been stable above 31. His H pylori was negative. Upon transfer to BMT, the pt is currently NPO except meds, and on IV PPI [**Hospital1 **]. Will leave it up to BMT as to whether pt can advance diet as tolerated given his h/o GVHD/diarrhea. . # Afib: Currently in afib with tachycardia. No anticoagulation given GI bleed. Patient has episodes of tachycardia to 140s-150s. Since the patient had a GI bleed, all of his PO nodal agents were D/C??????ed. IV Lopressor and diltiazem were given to control the rate before switching back to a PO regimen of metoprolol 75 TID (transferred on 100 mg TID) and dilt 90 mg QID. He was monitored on tele without any other complications. . #. Acute on chronic renal failure / hyponatremia: Patient initially presented with oliguria in setting of baseline Cr of 1.5 (feNa=0.04%), which was likely due to volume depletion from GI blood loss. However, given prolonged hypotension, the patient may have also developed ischemic ATN. Upon transfer he was with BUN 81 Cr 1.6, FeNa 1.9, Uosm>500, CVP 11 c/w SIADH, which initially may have been [**12-17**] extubation, however, now etiologies unclear but may include pulmonary process, malignancy, pain, intracranial process (unlikely). His length of stay fluid balance is net +18L. We will free water restrict him 1L today, and continue to monitor his lytes. We have also renally dosed his meds. . # Refractory multiple myeloma admitted on [**2165-2-25**] now s/p mini-allogeneic SCT: His course has been extremely complicated and now with increasing immunosuppression for GVHD. BMT was actively following and had recs including: Tacrolimus re-started on [**6-10**], then d/c'd due to Cr 1.6 from 1.5. Following daily tacro levels and LFTs. We are continuing to hold etanercept in the acute setting. We tapered his methylprednisone to 30 IV q12h, and will continue to taper as tacro levels are reviewed. We have continued his Cellcept [**Pager number **] mg IV BID and ID prophylaxis with Acyclovir, Bactrim, voriconazole . # HTN: Started on metoprolol PO and home dilt per above. . # Stage 4: sacral decubitus ulcer: Continue wound care. Notably, keep a low threshold for osteo if clinically suspicious, although at this time wound does not show any evidence of infection only necrosis. . # ID: --Worsening opacities on CT from [**6-3**]: ID initially suggested doing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1066**] for treatment, however this was deferred since galactomannan and beta glucan markers for aspergillus negative. Vori was also changed to prophylactic dose. On the day of transfer there was a new lingular infiltrate vs atalectasis on CXR, however since the patient is clinically/respiratory stable for now, we suggest that it is followed with a repeat CXR tomorrow AM -- ESBL E.coli bacteruria: Finished 14/14 day course of meropenem. ID following. . #. Respiratory Failure--resolved: Initially, pt was intubated emergently for airway protection for emergent EGD especially in setting of recent tracheostomy cap. Pt given aggressive ressusitation with crystalloid and colloid. His length of stay fluid status is net +18L. He was extubated without any complications and is comfortable on room air upon transfer. . #. Hypotension: Issue resolved. Pt has initially required intermittent pressor support with neo and levo. Likely secondary to hypovolemia in the setting of GI bleed. Also sedation following intubation. Pt without WBC although immunosuppressed. No evidence new acute infection. Pt has been afebrile. Currently normotensive. . # DM 2: Continue ISS . # FEN: Pt is currently NPO except meds, and we will leave it at discretion of BMT to determine how long pt must be NPO. He is currently on TPN through his midline. We suggest a PICC for TPN in the future if this is ok with BMT team. [**Hospital Unit Name 153**] course [**Date range (1) 68147**] . # Hemorrhagic shock: Patient had large GI bleeds with copious BRBPR on [**6-27**] and [**6-28**] both sent to IR for embolization of gastroduodenal artery. He had another bleed on [**8-1**] that responded to pressors and massive transfusion protocol. He had episodes of hypotension due to upper GI bleed, not responsive to fluids, requiring levophed. He received massive transfusion protocol blood products for these bleeds. Gastric lavage showed coffee grounds as well as some bright red blood. Blood loss on the order of [**12-18**] liters initially then progressed to 5 liters. Surgery was consulted to help manage this recurrent bleeding duodenal ulcer but determined he was not a surgical candidate. His dosage of steroids was reduced to aid in ulcer healing, and he was briefly empirically treated with ganciclovir to cover for possible CMV duodenitis as a cause of the ulcer. This was later discontinued as his WBC count fell. After the three massive GI bleeds and massive transfusions, patient's familiy decided to not escalate his care, electing not to give any further blood products, pressors, or any further interventions should patient develop another bleed. Patient remained relatively stable for the next 5-6 days without any episodes of GI bleeding and not requiring pressors. On [**7-6**], patient passed melenotic stools and was found to have new blood via his OG tube. Patient's family were informed, and after another family meeting with oncology and the ICU team, decided to change the direction of care to focus on patient comfort. Patient was terminally extubated on [**7-6**] as per family wishes, and peacefully expired on [**2165-7-6**] at 8:27 PM. . # Sepsis: Pt with continued enterococcus bacteremia resistant to vancomycin as well as pseudomonas bactermia and pneumonia. He received linezolid and gentamicin for the VRE and cipro with meropenem for pseudomonas coverage. The meropenem was also used to treat an E. coli ESBL in his urine. . # Respiratory failure: Pt was intubated for respiratory failure due to pneumonia and later complicated by pulmonary edema. He had difficulty weaning off of the ventilator given his large positive fluid balance and respiratory weakness. . # Anasarca: Although he was total body fluid overloaded, he was frequently intravascularly dry requiring more fluids. His albumin was low, 1.6, likely the reason that he was unable to retain fluids intravascularly. He received large numbers of blood products and intravenous fluids for the acute bleed resuscitation and hypotension. Patient was placed on lasix drip to help diurese patient's overwhelming fluid load, however in the end patient was still +60L fluid balance. . # Atrial fibrillation with RVR: Pt remains tachycardic with atrial fibrillation despite numerous interventions including amniodarone drip, esmolol drip, diltiazem drip and digoxin. . # Anemia and thrombocytopenia: Pt s/p two IR sessions of embolization after massive GI bleeds with likely source being duodenal ulcer. He was aggressively resuscitated with blood products. . # Hyperglycemia: He has a history of diabetes and was treated with an insulin sliding scale and insulin in his TPN feeds. . # LFT abnormalities: With e/o cholestatic picture with transaminitis of unclear etiology. Differential diagnosis includes hemolysis, acalculous cholecystits, medication effect, progression of GVHD to liver. His liver enzymes were monitored. . #. Multiple myeloma: His course has been extremely complicated and now with increasing immunosuppression for GVHD. Per BMT, currently in remission. His immunosuppressants were continued with decreasing steroid dosing to aid ulcer healing and prophylaxis with atovaquone, acyclovir & voriconazole. As patient became unable to take PO medications because of the massive GI bleeds, atovaquone was switched to inhaled pentamidine, voriconazle was discontined, and acyclovir switched to IV dosing. . # Family meetings: patient's family had initially wanted everything to be done for the pt, but after the multiple massive GI bleeds requiring massive transfusions, patient's family decided not to escalate care in the event of a massive GI bleed (no blood products, no pressors, no IR intervention, no surgical intervention). On [**7-6**], with a recurrence of some upper GI bleed, patient's family decided to make pt comfort measures only. . Patient was pronounced dead on [**7-6**] at 8:27 PM. chief cause of death - sepsis immediate cause of death - GI bleeding other antecedent causes - multiple myeloma . Family (wife) declined autopsy Medications on Admission: Acyclovir 400 mg PO TID Albuterol 90 mcg 2 puffs QID:PRN Amlodipine 2.5 mg PO daily Atorvastatin 10 mg PO QHS Klonopin 1 mg PO QHS Cymbalta 120 mg ER PO daily Erythromycin 5 mg/gram ointment 1 cm OU QHS Fluticasone 110 mcg 1-2 puffs INH [**Hospital1 **] Neurontin 600 mg PO BID (tapered recently) Hydroxyzine 25 mg PO TID:PRN pruritis Aspart Insulin SS Lantus 55 U SQ QHS Ativan 1-2 mg PO q6H:PRN anxiety/insomnia Metoprolol XL 50 mg PO BID??? Oxycodone 5-10 mg PO q4-6H:PRN pain OxyconTIN 10 mg PO TID Timolol 0.5% eye drops OU QHS Trazodone (tapered off by [**2-24**]) Bactrim SS 1 PO daily OTC: Magnesium Oxide 400 mg PO daily MVI PO daily Prilosec 20 mg PO BID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: pronounced dead on [**7-6**] at 8:27 PM chief cause of death - sepsis immediate cause of death - GI bleeding other antecedent causes - multiple myeloma Discharge Condition: pronounced dead on [**7-6**] at 8:27 PM Discharge Instructions: none. Followup Instructions: none. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "785.59", "293.0", "E932.0", "427.31", "584.5", "482.82", "518.81", "250.60", "453.8", "996.85", "729.92", "038.42", "785.52", "276.4", "E878.4", "038.43", "599.0", "038.0", "287.4", "389.9", "279.51", "997.31", "707.03", "357.2", "416.8", "482.1", "528.01", "E878.1", "999.31", "300.4", "995.92", "253.6", "487.0", "693.0", "532.40", "E933.1", "203.00", "E931.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "99.15", "44.43", "92.29", "96.72", "96.6", "03.31", "86.22", "44.44", "45.25", "38.93", "86.05", "48.24", "41.04", "33.23", "39.95", "86.11", "86.07", "38.95", "31.1", "33.24", "96.04", "41.31", "86.28", "45.16", "00.14" ]

icd9pcs

[ [ [] ] ]

35087, 35096

9449, 15100

407, 478

35292, 35333

4112, 9426

35387, 35521

3327, 3435

35058, 35064

35117, 35271

34368, 35035

35357, 35364

3450, 4093

268, 369

506, 1801

17134, 34342

1823, 2444

2460, 3311

30,047

172,127

32159

Discharge summary

report

Admission Date: [**2154-1-17**] Discharge Date: [**2154-2-22**] Date of Birth: [**2079-7-17**] Sex: F Service: CARDIOTHORACIC Allergies: Trovafloxacin / Albuterol Attending:[**First Name3 (LF) 165**] Chief Complaint: transfer from OSH with fever/shortness of breath/left sided effusion Major Surgical or Invasive Procedure: chest tube placement History of Present Illness: s/p CABG [**2153-11-29**] transferred to rehab after prolonged hospital stay on [**1-10**]. Transferred from rehab to [**Hospital3 **] on [**1-14**]. Transferred back to [**Hospital1 18**] on [**1-17**] Past Medical History: CAD with ostial LCX 90% lesion per cath on [**2153-8-8**] with successful BMS HTN Hyperlipidemia CVA 4 yrs ago with R scotoma esophageal ulcer. + GERD + Asthma/Emphysema, home O2 not required osteoporosis R carpal tunnel surgery Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension Social History: Patient lives with husband in [**Name (NI) 487**]. Quit smoking 11 yrs ago, smoked 1ppd since age 14. Social EtOH, no recreational drugs Family History: Family history is significant for mother who died from alcoholism at age 50. Father died at age 62 of unknown cause. No early death. Physical Exam: Admission VS T 99.7 HR 80 SR BP 98/63 RR 21 O2sat 96%(assist control) Gen NAD Neuro Alert, generalized weakness. non focal exam Pulm coarse throughout, no wheezes CV RRR no M/R/G. Sternal wound healing w/exception of distal wound which had VAC in place Abdm soft, NT/+BS Ext warm, 2= edema bilat. doppler pulse Pertinent Results: RADIOLOGY Final Report CHEST (PORTABLE AP) [**2154-2-18**] 10:48 AM CHEST (PORTABLE AP) Reason: eval effusion, ? pneumothorax- please do this study at 11 am [**Hospital 93**] MEDICAL CONDITION: 74 year old woman s/p removal of left sided chest tube today REASON FOR THIS EXAMINATION: eval effusion, ? pneumothorax- please do this study at 11 am INDICATION: 74-year-old female status post removal of left-sided chest tube. COMPARISON: [**2150-2-12**]. FRONTAL CHEST RADIOGRAPH: A tracheostomy tube is in unchanged position. There has been interval removal of the left-sided chest tube. There is no recurrent or residual pneumothorax. The remainder of the examination is little changed with no significant improvement in the degree of moderate pulmonary edema, bibasilar atelectasis and small pleural effusions. IMPRESSION: 1. No pneumothorax. 2. Moderate pulmonary edema and small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: MON [**2154-2-18**] 6:42 PM CT CHEST W/O CONTRAST [**2154-1-27**] 10:09 AM CT CHEST W/O CONTRAST Reason: re-evaluate left pleural effusion [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with REASON FOR THIS EXAMINATION: re-evaluate left pleural effusion CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 74-year-old female for re-evaluation of left pleural effusion. COMPARISON: [**2154-1-23**]. TECHNIQUE: MDCT-acquired axial imaging of the chest without intravenous contrast. Multiplanar reformatted images were obtained and reviewed. FINDINGS: Left PICC remains in place, tip in the upper right atrium. Evidence of prior coronary artery bypass grafting is unchanged, with sternotomy wires, unchanged sternal dehiscence, and densely calcified native coronary arteries. Moderate cardiomegaly is unchanged. Multiple prominent mediastinal and hilar lymph nodes are unchanged. Tracheostomy tube remains in place, approximately 5 cm above the carina. Left chest tube remains in place, with tip positioned medially near the apex. New drainage catheter is in place at the left lung base, and the small left pleural effusion is slightly decreased in size, with small foci of gas now seen within the effusion . Small right pleural effusion is little changed. Diffuse ground-glass opacity throughout both lungs, along with small centrilobular nodules, and mild apical predominant interlobular septal thickening is again noted, slightly improved since prior exam. Osseous structures are unremarkable. IMPRESSION: 1. Slightly decreased size of small left pleural effusion, with new left basilar chest tube in place, and second old left chest tube unchanged in position medially near the left apex. 2. Unchanged small right pleural effusion. 3. Slightly improved appearance of diffuse ground-glass opacity, small centrilobular nodules, and apical predominant interlobular septal thickening. This could represent improvement in pulmonary edema, infectious process, or both. [**2154-2-22**] 02:37AM BLOOD WBC-13.4* RBC-2.78* Hgb-8.1* Hct-25.1* MCV-90 MCH-29.1 MCHC-32.2 RDW-17.9* Plt Ct-303 [**2154-2-21**] 01:46AM BLOOD PT-13.6* PTT-30.3 INR(PT)-1.2* [**2154-2-22**] 02:37AM BLOOD Glucose-86 UreaN-37* Creat-1.8* Na-132* K-4.9 Cl-99 HCO3-23 AnGap-15 [**2154-2-14**] 01:31AM BLOOD ALT-21 AST-24 AlkPhos-149* TotBili-0.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 75233**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75234**]Portable TTE (Complete) Done [**2154-2-8**] at 11:34:54 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: [**2079-7-17**] Age (years): 74 F Hgt (in): 58 BP (mm Hg): 100/56 Wgt (lb): 163 HR (bpm): 77 BSA (m2): 1.67 m2 Indication: Left ventricular function. Right ventricular function. ICD-9 Codes: 428.0, 414.8, 424.0, 424.2 Test Information Date/Time: [**2154-2-8**] at 11:34 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2008W000-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 30% >= 55% Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 3.25 Mitral Valve - E Wave deceleration time: 172 ms 140-250 ms TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RAP (10-20mmHg). LEFT VENTRICLE: Depressed LVEF. RIGHT VENTRICLE: RV not well seen. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic tricuspid valve supporting structures. No TS. Mild [1+] TR. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality - poor subcostal views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions The estimated right atrial pressure is 10-20mmHg. LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2153-12-24**], findings are grossly similar although the suboptimal nature of both studies precludes definitive comparison. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2154-2-8**] 12:27 Brief Hospital Course: Patient well know to our service, was transferred to rehabilitation on [**1-10**]. transferred from rehabilitation center to [**Hospital6 19155**] because of hypotension associated with atrial fibrillation, started on Neosynephrine gtt. Patient then transferred from [**Hospital6 19155**] to [**Hospital1 18**] for further management. Atrial fibrillation converted to sinus rhythm after treatment with IV Amiodarone, Neosynephrine infusion then weaned to off. Patient arrived on full ventilatory support and was changed to pressure support ventilation and weaned from there. She had a chest CT which revealed a left effusion Thoracic surgery was consulted and a chest tube was placed, the pleural fluid was positive for VRE. A subsequent pigtail catheter was placed to drain a small loculated effusion. After the pigtail catheter was removed the pleural chest tube was gradually pulled back by the thoracic surgery team. It was then changed to an empyema tube. TPA was instilled x 3. The patient was also followed by the infectious disease service. She remains on fluconazole (8 weeks from [**12-21**]) for her previous candidemia and candidal sternal wound infection, and daptomycin (total 6 weeks from [**1-19**]) and ciprofloxacin (4 weeks from [**1-24**]) for VRE in pleural effusion and E coli and VRE in thigh wound. Bronchoscopy showed tracheomalacia and she was seen by IP. BAL grew psuedomonas. On [**2-5**] she again underwent bronchoscopy, a Y stent was placed for severe tracheobroncheomalacia, and her trach was changed. She was started on mucinex, normal saline via trach tube and mucomyst nebs for stent maintenance. She continued to have low urine output, and her BUN and creatinie rose. THis did not improve with multiple interventions including milrinone, netrecor, lasix drip, and albumin. She was seen by renal, and eventually started on CVVH. She was continued on CVVH until [**2-20**] and was going to be transitioned to HD. It was felt she would not tolerate HD and the family discussed the options with the patient. She had a living will and after multiple meetings with all of the family members and Dr. [**First Name (STitle) **] they decided to withdraw support. On [**2-22**] the ventilator was discontinued and the pt. expired at 3:16PM with the family present. Medications on Admission: ASA 81' Vit C 500" Iron 325' Metalazone 5' Lasix 40' Celexa 20' MVI Colace 100' Heparin 5000 TID Cardizem 60 QID Reglan 10 TID Zosyn 3.25 QID Discharge Medications: None Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: CAD s/p cabg Respiratory failure s/p tracheostomy/PEG HTN Afib Asthma Emphysema Anemia GERD Anxiety ^chol Carpal tunnel Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2154-2-22**]

[ "492.8", "041.04", "510.9", "511.1", "519.19", "427.31", "414.00", "530.81", "584.9", "V44.0", "285.9", "518.81", "V45.81", "998.59", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "34.04", "97.23", "38.93", "33.21", "39.95", "99.10", "38.91", "96.72", "31.99" ]

icd9pcs

[ [ [] ] ]

11179, 11249

8660, 10957

360, 382

11413, 11422

1596, 1759

11475, 11601

1108, 1243

11150, 11156

2899, 2922

11270, 11392

10983, 11127

11446, 11452

1258, 1577

252, 322

2951, 8637

410, 614

636, 935

951, 1092

28,340

159,718

14429

Discharge summary

report

Admission Date: [**2182-8-3**] Discharge Date: [**2182-8-23**] Date of Birth: [**2108-4-27**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: cardiac catheterization redo sternotomy/ AVR(#21 StJude [**First Name3 (LF) 9041**] Porcine)[**8-13**] History of Present Illness: 74 yo F with pmh of CAD s/p CABG [**2177**] (lima to LAD and SVG to circ) and s/p PCI (BMS of RCA in [**6-1**]), severe AS ([**Location (un) 109**] 0.7 /echo; 0.5/cath), CHF, HTN, asthma presents from an OSH (admitted there on [**2182-7-25**]) for surgical/ cardiology evaluation of her AS. She has had progressive DOE x 1 year. This had worsened over the past 1 week (DOE with 5 steps), accompanied by cough. She was initially treated with levaquin by her PCP for presumed PNA with little relief. She also has c/o orthopnea. When she did not improve she was sent to the ED by her PCP. [**Name10 (NameIs) **] the OSH she was treated for pneumonia (total 14 days levaquin), CHF (BNP in 6000's), and eval. by CT [**Doctor First Name **] for AVR. She also had elevated LFTs thought [**12-28**] to hepatic congestion. Per records she was HIT positive with a plt drop of 273 to 151 (?borderline via criteria). She was started on lepirudin, which was briefly held for gum bleeding after surgery (teeth extraction x 3). Additionally, she was found to have a EF of 15% by ECHO (previously 60% in [**6-1**]). CT [**Doctor First Name **] felt she was too high risk for surgery. She was then transferred to [**Hospital1 18**] per family wish for further eval/2nd opinion. Of note, plavix was stopped at OSH. On transfer the pt. was tachypneic (rr>30's), using accessory muscles for breathing, tachy to 110, but maintaining her BP. Due to her respiratory distress the patient was transferred to the CCU. Past Medical History: Chronic systolic heart failure MI s/p CABG ('[**77**] LIMA to LAD; SVG to LCx), RCA stent in [**2181**] (BMS), Asthma, HTN, aortic stenosis (0.7cm on echo, 0.5cm on c.cath), diverticulitis s/p abscess w/ surgical correction, herpes zoster, psoriasis, PE in [**2177**], h/o DVT, IVC filter in [**2176**], APPY, ventral hernia repair, shoulder ORIF, recent tooth extraction for periodontal disease. Social History: daughter lives nearby, involved in her mother's care Family History: not contributory Physical Exam: VS - 97.1 107 104/57 70 18 93% 5L Gen: elderly F in bed in mild discomfort [**12-28**] to SOB HEENT: ecchymosis on lower jaw [**12-28**] to teeth removal for pre-op CV: SEM at RUSB. Chest: expiratory wheezes, rales 1/3 up lungs bilaterally. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: trace edema Pertinent Results: OSH Echo [**2182-6-11**] shows preserved LV fxn w/ EF 20%, normal LV dimensions. mild concentric LVH, severe AS w/ [**Location (un) **] and peak gradients of 56 and 91mmHg with calculated calce area of 0.7cm2. . TTE [**2182-8-12**]: The left atrium is mildly dilated. The estimated right atrial pressure is [**4-4**] mmHg. A small secundum type atrial septal defect is seen with left-to-right flow. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe regional left ventricular systolic dysfunction with near akinesis of the septum, anterior wall and apex. The inferior and inferolateral walls contract best.[Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (?#) are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Cardiac Cath [**2182-8-12**]: 1. Coronary angiography of this right dominant system revealed native 3 vessel CAD. The LMCA had no angiographically apparent flow limiting disease. The proximal LAD had a 70% stenosis with competitive LIMA flow. The LCx had a severely diseased OM branch with competitive SVG flow. The RCA had a patent proximal proximal stent. 2. Arterial conduit angiography revealed the LIMA-->LAD graft to be widely patent. The SVG to OM was widely patent. 3. Resting hemodynamics revealed normal systemic arterial systolic and diastolic blood pressures. 4. Severe aortic stenosis as described by echocardiogram. No attempt was made to cross the aortic valve due to patient's clinical condition. 5. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Widely patent LIMA and SVG grafts. 3. Cardiomyopathy with severe aortic stenosis. [**2182-8-21**] 06:00AM BLOOD WBC-13.3* RBC-3.10* Hgb-9.2* Hct-28.5* MCV-92 MCH-29.7 MCHC-32.3 RDW-17.4* Plt Ct-316 [**2182-8-21**] 06:00AM BLOOD WBC-13.3* RBC-3.10* Hgb-9.2* Hct-28.5* MCV-92 MCH-29.7 MCHC-32.3 RDW-17.4* Plt Ct-316 [**2182-8-19**] 02:42AM BLOOD WBC-14.5* RBC-3.26* Hgb-9.5* Hct-29.5* MCV-91 MCH-29.0 MCHC-32.1 RDW-17.1* Plt Ct-281 [**2182-8-21**] 06:00AM BLOOD Plt Ct-316 [**2182-8-19**] 02:42AM BLOOD PT-13.4* PTT-28.2 INR(PT)-1.2* [**2182-8-21**] 06:00AM BLOOD Glucose-79 UreaN-13 Creat-0.7 Na-134 K-3.7 Cl-103 HCO3-24 AnGap-11 Brief Hospital Course: Pt admitted to CCU for respiratory distress and diuresis in the setting of severe AS. Patient was diuresed while awaiting valve replacement. Patient's respiratory distress improved with diuresis. It was felt to be secondary to chronic pulmonary edema and aortic stenosis. According to medical records, platelets decreased from 273 to 140's, pt HIT Ab positive. Started on lepirudin at OSH per Heme/onc consult, which was briefly held [**12-28**] to gum bleeding post-dental surgery then restarted. Upon admission, patient was started on argatroban, which was continued until her serotonin release assay came back negative and it was decided she did not have HIT. Treated at OSH for presumed PNA with 14 days of levaquin. She did develop asymptomatic bacturia with coagulase negative staph. Given that she was awaiting surgery, there was a low threshold for treatment. She received vanc until sensitivities came back, at which time she was switched to doxycycline. Plavix was held in anticipation of surgery as she had received a bare metal stent more than six weeks prior to presentation. Incidental finding of right kidney on CTA of chest and abdomen: "There is 9.4 x 6.9 mm exophytic enhancing lesion arising from the interpolar cortex of the right kidney. This lesion is worrisome and may be further assessed with an MRI." Patient requires follow-up as an outpatient. She was taken to the operating room on [**8-13**] where she underwent a redo-sternotomy, AVR (#21 St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] Porcine). She was transferred to the ICU in critical but stable condition on vasopressin, levophed and epinephrine. She was extubated later that same day. She was weaned from her vasoactive srips by POD #2. She initally had poor oxygenation but improved with aggresive diuresis. She was transferred to the floor on POD #6. She complained of difficulty swallowing and swallow evaluation but refused speech and swallow evaluation and she had no further problems with eating or drinking. She required a 1:1 sitter for confusion but improved when her narcotics were discontinued and she was given small doses of haldol. She was ready for discharge to rehab on [**2182-8-23**] Medications on Admission: On admission to CCU: atrovent nebs q6h prn albuterol nebs q4h prn trazodone 25mg hs prn asa 81mg qday ezetimibe 10mg qday paroxetine 20mg qday mupirocin nasal ointmnet 2% 1 app [**Hospital1 **] x 5 days protonix 40m gpo qday neurontin 100mg tid Lepirudin 0.15mg/kg per hour, no bolus . Home meds: ASA 81 qday plavix 75 qday (held at OSH on [**7-27**] per cardiology 6 wks s/p stent) zetia 10 qday cartia xt 180 qday (held at OSH [**12-28**] to hypotension) paxil 20mg qday albuterol 2 puffs flovent 2 puffs Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: PMH: CAD-MI s/p CABG ('[**77**] LIMA to LAD; SVG to LCx), PTCA(BMS)->RCA '[**81**], Asthma, HTN, AS , diverticulitis s/p abscess w/ surgical correction, herpes zoster, psoriasis, PE '[**77**], DVT, IVC filter '[**76**], APPY, ventral hernia repair, shoulder ORIF, Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds ion one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 42718**] 2 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2182-8-23**]

[ "787.2", "427.69", "428.22", "593.9", "272.4", "401.9", "V45.81", "V12.51", "428.0", "V12.79", "496", "412", "599.0", "414.01", "424.1", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "99.04", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

9161, 9208

5596, 7822

310, 415

9515, 9523

2864, 4881

9823, 9973

2444, 2462

8379, 9138

9229, 9494

7848, 8356

4898, 5573

9547, 9800

2477, 2845

255, 272

443, 1937

1959, 2358

2374, 2428

27,447

104,263

4735

Discharge summary

report

Admission Date: [**2153-4-23**] Discharge Date: [**2153-4-29**] Date of Birth: [**2083-5-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11892**] Chief Complaint: fever, altered mental status Major Surgical or Invasive Procedure: None. History of Present Illness: History obtained from MICU team; patient appears to be unreliable historian. Pt is a 69M with dementia, s/p cardiac arrest [**2149**] with anoxic brain injury, paroxysmal atrial fibrillation, DM2, and HTN admitted from [**Hospital3 537**] with fever and altered mental status. Per [**Hospital3 537**] staff, "hasn't been himself" since day prior to admission; testing there demonstrated leukocytosis (WBC 15.5K) with borderline pyuria (5 WBCs) and received empiric ciprofloxacin for possible UTI. On day of admission, noted to have unstable gait, "leaning to right", unable to get to bathroom by himself (apparently normally able to ambulate independently with walker). Sent to [**Hospital1 18**] ED for further evaluation. Further history obtained from daughter [**Name (NI) 7346**], who reports patient was lethargic, "not talking", "wincing" when touched approximately 48hrs prior to his admission. Patient was not reporting any specific symptoms, however has noted to be recently "choking on his food". Has a chronic cough (since his VF arrest in [**2149**]), but recently more productive. Poor PO intake prior to admission. Daughter reports that patient is currently (evening of [**4-25**]) very close to his baseline mental status. In ED, febrile ro 103.8, in afib with RVR 150s-170s, with serum Na=153. Treated with IV fluids (2L), vancomycin/ciprofloxacin, diltiazem, and right IJ CVL placed. Subsequent transient hypotension to 80s, resolved spontaneously without pressor support. Admitted to [**Hospital Unit Name 153**] for possible sepsis. In [**Hospital Unit Name 153**], converted to sinus rhythm with HR 70s. Antibiotics continued empirically. D5W infusion administered in setting of hypernatremia. Blood, urine cultures unrevealing. Chest x-ray without overt infiltrate. Head CT without mass or acute bleed. Abd/pelvis CT unremarkable per preliminary report. Per MICU notes, overall mental status much improved according to patient's daughter, though not yet at baseline. Past Medical History: 1. DM2 2. Hypertension 3. Hyperlipidemia 4. h/o VFIB arrest in [**12-17**] secondary to cocaine/EtOH use, complicated by coma, anoxic brain injury, and evidence if IMI, inferior ischemia with resultant improvement in heart function 5. Paroxysmal AFib: not on anticoagulation due to fall risk 6. Anoxic Brain Injury/Dementia 7. Pulmonary Hypertension 8. BPH with urinary retention 9. GERD Social History: [**Hospital3 537**] resident. Daughter [**First Name8 (NamePattern2) 7346**] [**Last Name (NamePattern1) 3924**] is his legal guardian; she is a registered nurse. Prior history of EtOH/cocaine abuse. Ambulates with cane at baseline. Family History: Non-contributory. Physical Exam: T 99.2 / BP 154/92 / HR 90s / O2 sat 96% RA / RR 21 GEN: Awake and alert in NAD. Disoriented. HEENT: Pupils 2mm round and reactive, anicteric sclerae, moist mucous membranes, atraumatic. NECK: Right IJ CVL in place, no palpable lymphadenopathy. Supple. CHEST: Clear to auscultation and resonant to percussion bilaterally. COR: S1 S2 tachycardic regular without audible murmur. ABD: Soft, non-tender, non-distended, without organomegaly. NABS. EXTREM: Trace ankle edema. Dupuytren's contracture right hand. No clubbing or cyanosis. NEURO: Oriented only to self. Counts 10 to 1 fluently, names days of week forward but not backwards. CN II-XII intact. No asterixis. No pronator drift. Motor strength 5/5 bilateral delt/tri/[**Hospital1 **]/wrist ext/wrist flex, iliopsoas/quad/hams/ankle ext/ankle flex. Toes downgoing bilaterally. DTRs 2+ biceps, brachioradialis, patella bilaterally. Sensation to LT grossly intact throughout. Pertinent Results: Admission labs: Na 157 K 4.0 Cl 122 CO2 25 BUN 37 Cr 1.3 Gluc 80; AG 10 CPK 1050, Trop 0.08, CK-MB 4 Ca 8.3, Phos 3.2, Mag 1.9 WBC 12.5, HCT 40.7, PLT 174 Lact 2.7 -> 4.5 UA negative Repeat labs: Na 153, Cr 1.7, AG 19 CPK 1348, Trop 0.06, CK-MB 5 LFTs wnl WBC 12.4 (91N) EKG: Afib/flutter 155, QRS axis WNL, Q waves in III/F, 1mm ST depression in I, avL IMAGING: HEAD CT: No mass or bleed. CT ABD/PELVIS: No source of infection identified; stable peri-renal stranding since [**2151**] study. CXR: No acute infiltrate. Brief Hospital Course: Mr. [**Known lastname 10321**] is a 69 yo M with a history of dementia/anoxic brain injury, DM2, HTN admitted with fever and altered mental status, noted to be in atrial flutter with RVR. Transferred to [**Hospital1 1516**] cardiology floor for diltiazem drip as rate not responding to IV metoprolol and diltiazem. Converted to NSR on dilt gtt so was switched to po dilt 240 mg SR, and went back into aflutter with RVR. EP consulted and recommended starting quinidine on [**2153-4-26**]. Patient was successfully converted to NSR on quinidine. His hospital course is outlined by problem below: . #. Atrial Flutter with intermittant RVR: Hemodynamically stable. Patient had been in AFib with RVR when initially admitted to the ICU, but spontaneously converted to NSR during his stay. After being called out, the patient has had sustained ventricular rates in 130-150s and had not responded to IV metoprolol and diltiazem. The patient was transferred for IV diltiazem gtt. Per medical record, no anticoagulation in setting of baseline fall risk. He was started on a heparin gtt and dilt gtt on [**2153-4-25**]. Converted to NSR on dilt gtt so was switched to po dilt 240 mg SR, and went back into aflutter with RVR. EP consulted and recommended starting quinidine on [**2153-4-26**]. Patient was successfully converted to NSR on quinidine. Continue quinidine at 324 mg q8H as outpatient with close monitoring of QTc with daily EKGs. Baseline QTc [**2153-4-23**] was 466. Monitor for QT prolongation of increase in QTc 25% above baseline. His QTc at time of discharge was ~480. Continue to replete K<4.0 and Mg<2.0; he will be discharged on 400mg magnesium oxide [**Hospital1 **]. Continue daily aspirin per baseline regimen. PT consult to evaluate fall risk; pt is significant fall risk. Because of this, he will not be anticoagulated with coumadin as outpatient at time of discharge. . #. Fever/leukocytosis: Resolved. Afebrile, pt has clinically improved since admission. Potential sources urinary, pulm have been ruled out. Only symptom appears to be mildly productive cough. Patient had been on antibiotics (Vanc/Levo) while in the ICU, but these were discontinued in the absence of identified bacterial process and clinical improvement. NGTD on urine or blood cultures suggestive of infection. Since transfer to [**Hospital1 1516**] cardiology on [**2153-4-25**] patient was afebrile and had resolution of leukocytosis with normal WBC at time of discharge. . #. Anemia: Stable HCT of 38.4. Asymptomatic. . #. AMS: Improved. Suspect that patient had waxing and [**Doctor Last Name 688**] delirium in setting of fever, hypernatremia, and hypovolemia when he was admitted. Patient has had CT head that did not show new infarct or bleed. Continued baseline fluoxetine, donepezil, risperidone, and prn Haldol. Haldol was discontinued without issues regarding agitation on morning of [**2153-4-28**], given increase in QTc. . #. Hypernatremia: Na 148 on admission, resolved with normal serum sodium of 141 with po free water repletion. . #. HTN: Held beta blocker and ACEI while on dilt gtt. Restarted lisinopril [**4-26**]. . #. ARF, pre-renal: Improved s/p fluid resusitation. Cr 1.1, at baseline. . #. Mild Rhabdo, elevated CPK: CK 815. Unclear etiology. Suspect related to acute illness. Held statin initially with improvement. Restarted at time of discharge. . # FEN: Patient had speech and swallow evaluation on [**2153-4-25**]. No evidence of aspiration. Okay to continue on regular diet with distant supervision per their recommedations. . # Continue DVT prophylaxis with Heparin SC. . # Emergency Contact: daughter [**Name (NI) 7346**] [**Name (NI) 3924**] who is guardian and HCP: [**Telephone/Fax (1) 19907**]. . # Code: Full (confirmed) this admission. The patient will have follow-up with Dr. [**Last Name (STitle) 19911**] and his PCP as an outpatient within 2 weeks of discharge. Medications on Admission: 22LiPer [**Hospital3 537**] [**Month (only) 16**]: 1. Omeprazole 20 daily 2. Glipizide 5 daily 3. Aspirin 325 daily 4. Doxazosin 4 daily 5. Fluoxetine 40 daily 6. Furosemide 20 daily 7. Lisinopril 2.5 daily 8. Trazodone 25 at noon, 50 at night 9. Aricept 10 daily 10. Colace 200 daily 11. Simvastatin 40 daily 12. Metformin 1000 twice daily 13. Senna 1 twice daily 14. Risperidone 0.5 twice daily 15. Metoprolol 25 three times daily 16. Lantus 20 units each morning 17. Novolin insulin sliding scale Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous QAM. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Tablet Sustained Release(s) 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection every eight (8) hours. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Atrial flutter. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 10321**], you were admitted to the hospital because of a fever and change in your mental status. We think that the fever and mental status changes were caused by an infection and you were treated with antibiotics for this and improved. During your hospitalization, your heart rate became very fast and you had an irregular heart beat called atrial flutter. You were treated with medications called diltiazem and quinidine for this, and your heart beat returned to [**Location 213**]. You are now deemed medically stable and fit for discharge back to [**Hospital3 537**]. . The following changes have been made to your medications: 1. STOP Metoprolol Tartrate 25 mg TID. 2. START Diltiazem 240 mg SR by mouth once daily. 3. START Magnesium Oxide 400 mg by mouth twice daily. 4. START QUINIDINE Gluconate ER 324 mg by mouth every eight hours. . It was a pleasure caring for you during this hospitalization. Followup Instructions: Please make a follow-up appointment with your primary care doctor within 2 weeks of discharge from the hospital. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU Completed by:[**2153-4-29**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10255, 10326

4607, 8503

344, 352

10386, 10386

4062, 4062

11522, 11801

3070, 3089

9053, 10232

10347, 10365

8529, 9030

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10401, 10547

2411, 2801

2817, 3054

79,539

186,192

38564

Discharge summary

report

Admission Date: [**2107-5-15**] Discharge Date: [**2107-5-24**] Date of Birth: [**2029-7-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left 2nd toe ulcer Major Surgical or Invasive Procedure: 1) Angiogram Diagnostic 2) Left femoral to PT bypass with in-situ saphenous vein. History of Present Illness: 77 year old male with extensive past medical history including dementia who presents for an angiogram of his LLE. He was transferred from his nursing care facility. He is a very poor historian but on exam he has an area of wet gangrene over the dorsal aspect of his left 2nd toe and ulcerations over his left 3rd and 4th toes as well. He does not complain of pain or fevers. He has evidence of bilateral lower extremity arterial disease. Patient also with abrasions over his left knee from recent fall per patient. Patient with [**First Name9 (NamePattern2) **] [**Name (NI) **] as health care proxy. Past Medical History: PMH: Encephalopathy (EtOH), dementia (Alzheimers), DM, CAD, DM, CVA, NSTEMI, HTN, paranoia, diabetic ketoacidosis PSH: denies All: KNDA Social History: EtOH abuse with encephalopathy, lives in a nursing home, denies tobacco or illicit drug use Physical Exam: Exam: 97.0 65 148/81 18 97%RA Gen: A+Ox1, NAD Chest: CTAB CV: RRR, -MRG Abd: soft/NT/ND/+BS, no pulsatile mass palpated Ext: LLE with abrasions over knee from recent trauma, wet gangrenous ulcer over dorsal aspect of his 2nd toe, smaller ulcers over toes 3 and 4. RLE with diffuse evidence of arterial disease. Sensation decreased in both feet bilaterally, +motor function. Pulses: On Admission: fem [**Doctor Last Name **] DP PT L palp palp - dop R palp palp dop dop On Discharge: fem [**Doctor Last Name **] DP PT L palp palp dop dop R palp palp dop dop Pertinent Results: [**2107-5-15**] 08:50PM PT-12.1 PTT-33.2 INR(PT)-1.0 [**2107-5-15**] 08:50PM PLT COUNT-373 [**2107-5-15**] 08:50PM WBC-6.4 RBC-3.12* HGB-9.5* HCT-29.0* MCV-93 MCH-30.4 MCHC-32.7 RDW-13.5 [**2107-5-15**] 08:50PM ALBUMIN-3.0* CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-2.5 [**2107-5-15**] 08:50PM ALT(SGPT)-23 AST(SGOT)-23 ALK PHOS-144* TOT BILI-0.1 [**2107-5-15**] 08:50PM estGFR-Using this [**2107-5-15**] 08:50PM GLUCOSE-354* UREA N-36* CREAT-2.0* SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12 Cardiology Report ECG Study Date of [**2107-5-16**] Sinus bradycardia. Left ventricular hypertrophy. Rightward axis is non-specific but raises the consideration of possible biventricular hypertrophy. Modest ST-T wave changes are non-specific. Clinical correlation is suggested. No previous tracing available for comparison. PORTABLE ABDOMEN Study Date of [**2107-5-17**] 10:42 PM Nonspecific bowel gas pattern. No evidence for ileus. Labs at Discharge: 138 105 39 -------------<153 4.1 27 1.9 Ca: 8.0 Mg: 2.0 P: 2.4 92 7.9>----<9.9 29.5 Micro: [**2107-5-15**] 9:17 pm SWAB ETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- 4 R GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 0.5 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2107-5-15**] for evaluation and treatment. On [**2107-5-17**] he underwent a diagnostic angiogram which showed diffuse SFA disease and PT origin stenosis. At this time the patient was to be considered for possible bipass. On [**2107-5-19**] he underwent vein mapping in preparation for operative repair. On [**2107-5-20**] the patient underwent Left femoral to PT bypass with in-situ saphenous vein, which went well without complication (reader referred to Dr [**Last Name (STitle) 1391**] the Operative Note for details). The patient required 2 units PRBC on day of operation. After an uneventful stay in the PACU, the patient arrived to the VICU floor NPO, on IV fluids and antibiotics, for close monitoring and frequent pulse checks. The patient remained hemodynamically stable throughout his hospital course. He appropriately proceeded on the [**Hospital1 18**] lower extremity bypass pathway. His course can be summarized by follow systems: Neuro: The patient received narcotic medication with good effect and adequate pain control. When tolerating oral intake, the patient was transition ed to oral pain medications and his pain was ultimately controlled with Tylenol. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repeated when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. A micro culture of his foot [**5-20**] revealed BETA STREPTOCOCCUS GROUP B sensitive to Bactrim for which he is being discharged with. He was initially started on Vancomycin, Ciprofloxacin and Flagyl which was then converted to Levo/Flagyl when once appropriate cultures were negative for which he will complete a 2 week course on discharge. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly however his blood sugars varied significantly throughout his course. It is recommended that his blood sugars be closely monitored and adjusted per nursing home protocol and over site of diabetic specialist. Hematology: The patient's complete blood count was examined routinely; He required an additional 2 units of PRBC for a total of 4 transfusion during his hospital stay. At time of discharge the patient HCT was stable and at his baseline when admitted. Prophylaxis: The patient received subcutaneous heparin through his hospital care. Physical Therapy evaluated the patient prior to discharge and recommend nurse assistance for stand-pivot-transfer from bed to chair. Also, they recommend that Physical therapy at [**Hospital1 1501**] see and evaluate patient as they fell patient may benefit from 2-4x/week of progressing gait training which may ultimately improve his ambulation from that of baseline on admission. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, voiding, and pain was well controlled. The patient received discharge instructions and discharged to [**Last Name (un) **] Skilled Nursing Facility. Medications on Admission: MOM PRN, dulcolax PRN, Tylenol PRN, catapres 0.3''', lactulose 15', keflex 500'', campral DR 666''', pilocarpine 4% eye gtt'''', amlodipine 10 QHS, lumigan 0.03% eye gtt', senna 2 tabs QHS, zyprexa 5', protonix 40', MVI, simvastatin 80', colace 100'', metoprolol 150'', potassium 10', timolol 0.5% gtt'', ASA 325', iron 325', folic acid 1', HCTZ 25', plavix 75', lantus 19 QHS, Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Acamprosate 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Insulin SC Fixed Dose Orders Bedtime Glargine 19 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 3 Units 3 Units 3 Units 3 Units 160-199 mg/dL 6 Units 6 Units 6 Units 6 Units 200-239 mg/dL 9 Units 9 Units 9 Units 9 Units 240-279 mg/dL 12 Units 12 Units 12 Units 12 Units 280-319 mg/dL 15 Units 15 Units 15 Units 15 Units 320-359 mg/dL 18 Units 18 Units 18 Units 18 Units 360-399 mg/dL 21 Units 21 Units 21 Units 21 Units 10. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 11. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain: Not to exceed 3g in 24 hrs. 13. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 18. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 20. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 22. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days. Disp:*18 Tablet(s)* Refills:*0* 23. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Left lower extremity ischemia with gangrene. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Discharge Instructions ACTIVITIES: - ambulate essential distances untill FU with Dr. [**Last Name (STitle) 1391**] as tolerated - Ace wrap leg from foot-knee when ambulating, to prevent swelling - Your operated leg is expected to have some swelling and will resolve over time - Elevate leg when sitting - no driving till FU - may shower, pat dry your incisions, no tub baths WOUND: - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Your staples will be removed on your FU with Dr. [**Last Name (STitle) 1391**] DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications MEDICATIONS: - Continue all medications as directed - Take your pain medications conservatively - Your pain will get better over time FU APPOINTMENTS: - Keep all FU appointments - Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone [**Telephone/Fax (1) 1393**] Followup Instructions: Please follow up with Dr [**Last Name (STitle) 1391**] in 2 weeks. Call ([**Telephone/Fax (1) 29063**] to schedule an appointment. Please have your blood sugars monitored and adjusted appropriately per nursing home protocol and diabetic specialist. Follow up with your PCP. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2107-9-5**] 11:00 Completed by:[**2107-5-24**]

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icd9cm

[ [ [] ] ]

[ "39.29", "88.42", "88.48" ]

icd9pcs

[ [ [] ] ]

10656, 10727

3817, 7427

333, 417

10816, 10816

2005, 2962

12176, 12641

7856, 10633

10748, 10795

7453, 7833

10991, 12153

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275, 295

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445, 1053

1746, 1857

10831, 10967

1075, 1214

1230, 1324

28,100

130,862

33997

Discharge summary

report

Admission Date: [**2106-6-17**] Discharge Date: [**2106-6-24**] Service: SURGERY Allergies: Lisinopril Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p fall in Nursing Home Major Surgical or Invasive Procedure: [**6-18**]: S/P ORIF R femur w/ retrograde nail & [**Last Name (un) 101**] plate L femur [**6-21**]: s/p ORIF left proximal humerus fx, dislocation History of Present Illness: 86 year-old woman s/p fall at nursing home ([**6-16**]). Initial X-rays revealed a left proximal humeral fx with inferior dislocation, a right spiral femur fracutre (oblique fracture through the distal femoral diaphysis) s/p traction splint, and a new left distal femur fracture. She has a history of multiple falls related to her Parkinsonism. The first fall was in [**2094**], which left her with a fractured left hip, s/p surgery. She subsequently sustained injuries to her right knee, left ankle, and left femur. Her family is unclear about the detials of these injuries. She was transferred from [**Hospital 1474**] Hospital to [**Hospital1 18**] on [**2106-6-17**] for further evaluation and management. Past Medical History: CAD Hypothyroidism Lumbar disc disease HTN High cholesteraol Aortic stenosis AFib Parkinson's Disease Social History: Nursing home resident Physical Exam: (on admit): PE: T 97.6, P 100, BP 110/46, RR 18, O2 93% RA Gen- NAD, AxOx1 heart- RRR lungs- CTA b/l, diminished effort abd- BS+, soft, NT/ND Ext- + cogwheel rigidity. Tender and swollen LUE and b/l LE. RLE is in traction. She has palpable distal pulses on all extremities. She can mover her fingers and toes to command. Rectal- copious impacted stool, stage 2-3 decubitus ulcer 1-2 cm on left buttock Pertinent Results: [**6-17**] CTOH: IMPRESSION: No acute intracranial process [**6-18**] CT c-spine: IMPRESSION: 1. Equivocal C5 spinous process fracture, chronicity indeterminate. No other fracture seen. No malalignment. 2. Mild-to-moderate multilevel degenerative change as described above [**6-18**] CT abd/pelvis: IMPRESSION: 1. No significant hemorrhage is identified to explain hematocrit drop. 2. Fracture of the left humerus. 3. Choledocholithiasis. [**6-18**] Femur Xray RIGHT FEMUR: Seven fluoroscopic images of the right femur demonstrate interval placement of a retrograde intramedullary rod with proximal and distal interlocking screws. There are no signs for hardware-related complications. This is fixating a fracture through the mid shaft of the right femur. LEFT FEMUR: Seven fluoroscopic images demonstrate placement of an intramedullary rod with interlocking screws as well as a lateral distal femoral fracture plate. This is fixating a fracture involving the shaft of the left femur. [**6-18**] Humerus Xray FINDINGS: Seven fluoroscopic images from the operating room demonstrates interval placement of a large fracture plate and multiple associated cortical screws within the proximal humerus. There is a bony defect at the superolateral aspect of the humerus. [**6-22**] Wrist Xray: FINDINGS: No previous images. Extensive soft tissue swelling and demineralization. However, no evidence of acute fracture. There is evidence of an old healed fracture of the distal radius Brief Hospital Course: The patient was admitted to medicine, but shortly thereafter transferred to the Trauma Surgery service. During her admission, she was followed by Trauma, Orthopaedics, Medicine, Cardiology, and Palliative Care services. On [**2106-6-18**], she underwent ORIF right femur with retrograde nail & [**Last Name (un) 101**] plate left femur, followed by ORIF left proximal humerus fracture on [**2106-6-21**] by orthopaedics. She remained intubated between surgeries and was placed "full code" during the peri-operative period. She was transfused as needed to maintain Hct>22-23 and placed on levophed to maintain adequate blood pressure. She was placed on a lasix drip for continued diuresis. A CPAP trial was attempted on [**2106-6-19**], yet was unsuccessful and she was placed back on full vent support. For nutrition, a Dobhoff was placed and she received tube feeds, reaching goal of 65cc/hr. She received 4 days of ciprofloxacin prior to ceftriaxone for a cipro-resistant E.Coli urinary tract infection. A family meeting was held on [**2106-6-22**], during which the patient's condition was reviewed and management options presented. The family decided to extubate and place the patient CMO on [**2106-6-24**]. The patient expired hours after extubation. The medical examiner was contact[**Name (NI) **] and accepted the case. Medications on Admission: Tylenol PRN Milk of Magnesia Duoneb Robitussin SL NTG PRN Lodosyn 25 mg QID w/sinemet Sinemet 25-100 2 tab 6AM, noon, 6PM, 1 tab HS Simvastatin 20 mg daily Digoxin 0.125 daily Calcium 500 mg TID Fleets Colace MVI Iron Vitamin c 500 mg Discharge Disposition: Expired Discharge Diagnosis: Multiple long bone fractures (Femur x2, humerus) Cardiopulmonary Arrest Discharge Condition: Expired

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icd9cm

[ [ [] ] ]

[ "99.04", "79.35", "96.6", "96.72", "38.91" ]

icd9pcs

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19032

Discharge summary

report

Admission Date: [**2141-6-30**] Discharge Date: [**2141-7-10**] Date of Birth: [**2101-11-13**] Sex: F Service: MEDICINE Allergies: Codeine / Doxycycline Attending:[**First Name3 (LF) 2145**] Chief Complaint: Hypoxia, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 39 y/o F with PMHx of HIV(last CD4 of 401 in [**3-25**]), HCV coinfection, peripheral neuropathy, chronic pain w/narcotic and benzo dependence who was transferred to [**Hospital1 18**] after adm to [**Hospital1 **] [**2141-6-27**] for fever and MS changes with suspicion of narcosis. Pertinent results include CT head neg, urine CX negative, urine tox + methadone/oxycodone, cbc/cmp wnl, wbc not elevated. CXR with mild/mod chf. Pt was evaluated by psych service who was consulted for addiction issues. Pt was c/o cough, N/V & dysuria. Pt received Acyclovir, Vancomycin, Diflucan, Reyataz, Epzicom. MS improved on [**2141-6-29**] and pt requested transfer to [**Hospital1 18**] where she receives outpt HIV care. Pt had an episode of chest pain, sob, ekg w/o acute ischemic changes. CE enzymes negative x2, repeat CXR showed mild/mod chf and pt received lasix 80mg IV. . Upon arrival to [**Hospital1 18**]: T 98.8 HR 97 BP 128/77 RR 22 initially sats in 80s on 6L but improved to sats of 95-100% 4L NC. CTA was neg for PE, but revealed multifocal infiltrates. Pt received Vanco, levo for CAP and methylprednisolone 125mg IV, bactrim IV 600mg Q6H for PCP [**Name Initial (PRE) 31304**] . Pt initially arrived at medical floor and desated to 80s on 4L NC and required Bipap. Her ABG pH 7.35 pCO2 63 pO2 61, she was transferred to the MICU for further care. Pt was initially treated with bipap & weaned to NC supplemental oxygen with bipap overnight for OSA. Per ID consult, Bactrim/steroids were stopped due to low suspician for PCP & sputum sent for PCP is [**Name9 (PRE) 5692**] negative. Three induced sputums have been collected to r/o TB, [**2-19**] gram stains negative. Pt was continued on CAP treatment with Ceftriaxone & Azithromycin, levofloxacin was stopped due to TB rule out. Urine legionella negative. Pt has remained afebrile and sats are maintained from 88-92% on 4L NC. She has been continued on Acyclovir for genital herpes outbreak with some improvement in lesions. ID fellow confirmed that current MS status has been present for 3mths but is a change from prior baseline. . Currently, pt is denying SOB but has ongoing cough, sating 92% on 4L NC and completing sentences easily. She is reporting some chest pain associated with coughing and deep breathing. Pt is tolerating po but reports that she has not had a BM in days & has some discomfort at foley insertion site. Otherwise, she is concerned about her narcotic regimen and possibility of withdrawl. Past Medical History: 1)HIV/AIDS- dx in [**2130**] [**2141-4-17**] last CD4: 401, last VL: < 50 copies/ml Genotype [**10-22**] NRTI / NtRTI mutations: 333E NNRTI mutations: None PI mutations: 63P Nadir CD4 43 OI: PCP [**Last Name (NamePattern4) **] [**2132**] Prior ARVs: Trizivir in [**2135**] 2)HCV - Genotype 2B Liver Bx [**5-23**] Grade1-2 inflammation, stage 3 fibrosis 3)Diverticulitis- hx of colovaginal fistula [**2136**] 4)DM on insulin complicated by diabetic neuropathy 5)HepBcAb positive, sAb negative, sAg negative 6)Peripheral neuropathy - thought to be [**2-18**] HIV, prior AZT, exacerbated by DM - B12 nl on [**2136**] 7)GERD 8)Bipolar/Anxiety 9)TAH/BSO 10)HTN 11)Genital HSV 12) ASD 13)Substance abuse 14)Chronic pain Social History: She lives alone, has the care of a PCA. + tobacco. Denies significant EtOH. +Hx IVDU, last [**2133**]. Family History: The patient is adopted and is not aware of familial illnesses. Physical Exam: T 97.1 BP 118/70 HR 72 RR 18 Sats 92 % on 4L NC General: NAD, comfortable, coughing intermittently HEENT: PERRL, EOMi, anicteric sclera, supple neck, no rash Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, no m/r/g, diff to JVD given neck size Pulmonary: diffuse inspiratory/expiratory wheezes, no crackles, [**Month (only) **] expiratory breath sounds Abdomen: midline scar noted, [**Month (only) **] BS, soft, mildly tender diffusely, obese, distended Extremities: warm, 2+ DP pulses, no edema noted Neuro: Alert & oriented x 3, moves all 4 extremities, CNII-XII intact Pertinent Results: [**2141-6-29**] 09:00PM WBC-7.3 RBC-4.36 HGB-12.6 HCT-38.6 MCV-89 MCH-28.8 MCHC-32.6 RDW-16.3* [**2141-6-29**] 09:00PM NEUTS-86.9* BANDS-0 LYMPHS-8.3* MONOS-2.9 EOS-1.7 BASOS-0.1 [**2141-6-29**] 09:00PM PLT SMR-NORMAL PLT COUNT-302 [**2141-6-29**] 10:00PM GLUCOSE-103 UREA N-7 CREAT-0.7 SODIUM-138 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13 [**2141-6-29**] 10:00PM CK(CPK)-19* [**2141-6-29**] 10:00PM CK-MB-NotDone [**2141-6-29**] 10:00PM CALCIUM-9.4 PHOSPHATE-3.3# MAGNESIUM-1.8 . CXR: Limited study, with findings suggestive of pulmonary vascular congestion and interstitial edema; the right-sided predominance raises the possibility of underlying mitral valvular disease, particularly regurgitation . CTA: 1. No central or segmental pulmonary embolism. 2. Multifocal airspace opacities and consolidations, most prominent in the right upper lung. Findings are most consistent with an infectious process, and PCP and other opportunistic pathogens should be considered given the patient's immunosuppressed status. 3. Trace bilateral pleural effusions, but no septal thickening or other evidence of pulmonary edema. . MRI [**2141-7-4**]: IMPRESSION: Normal MR of the head with gadolinium, somewhat limited by patient motion. . Lower extremity U/S from [**7-5**]: No evidence of right lower extremity DVT. . [**2141-7-4**] Sinus rhythm. Normal tracing. Compared to tracing #1 the anterior ST-T wave changes have resolved. HR PR QRS QT/QTc P QRS T 73 160 98 422/444 45 13 48 Brief Hospital Course: # Upper lobe infiltrates/PNA: Pt was transfered with fever, mental status changes & hypoxia/hypercarbia. CTA showed upper lobe infiltrates and pt was started on broad spectrum antibiotics including Bactrim for possible PCP. [**Name10 (NameIs) **] was consulted and pt was ruled out for TB. Sputum was negative for PCP and Bactrim was discontinued. Pt briefly required BIPAP to support oxygenation while awake but was quickly weaned to NC oxygen and maintained sats in low 90s. Pt was noted to desat when sleeping thought likely due to apneic episodes and she was offered BiPAP as tolerated when sleeping. Pt was explained that she will need an outpt sleep study in order to qualify for bipap machine at home. Ultimately, pt was switched to Levofloxacin 750mg daily to complete a 10 day course of treatment for community acquired pneumonia. PT was consulted and her ambulatory sats improved and pt was encouraged to continue with home PT & albuterol/atrovent nebs as needed for wheezing and SOB. # Hypoxia: Pt presented with community acquired PNA and has a signficant restrictive defect on PFTs. Pulm pressures were unable to be assessed on a recent ECHO from [**12-24**]. However, pt likely has some component of pulm HTN from obesity/hypoventilation & untreated OSA. Pt was offered BIPAP at night for significant desaturations that occured when she was sleeping but was non-compliant. Pt was given education on the importance of treating OSA to prevent progression of this process. Pt will need a follow up sleep study performed as an outpatient. . # HIV/HCV: Pt has co-infection with HIV/HCV and has been followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**], ID was consulted on admission. Pt has been managed on HAART with most recent CD4 count of 400. Additional labs were drawn while pt was in the ICU and the Abs CD4 was low at 90. However, CD4 percentage preserved at 25% suggesting that this number is falsely depressed due to her acute infections. According to ID, the true CD4 count likely closer to 400. HIV viral load is <50 and pt was continued on outpt HAART regimen while in house. Pt had an MRI performed for question of subacute mental status changes that was read as normal. Pt was also noted to have an outbreak of HSV2 genital lesions, this was treated empirically with Acyclovir for a 7 day course and symptoms/lesions resolved. Pt will be following up with ID in [**7-25**]. . # Chronic Pain: Pt has a long history of chronic pain thought due to neuropathy that has been managed most recently on Methadone. There was concern on admission regarding narcosis affecting her mental status. The methadone dose was decreased and pt was continued at Methadone 45mg TID with oxycontin increased to 30mg [**Hospital1 **] and Oxycodone 5-15mg prn severe breakthrough pain. The goal is for the patient to be weaned slowly from methadone given that this pain regimen has not been very effective for her and she had signs of prolonged QT on admission likely due to her methadone regimen on admission. QTc remained stable in the 420-440ms range for the week at Methadone 45mg TID and pt is scheduled to follow up with chronic pain clinic on [**7-12**]. . # Mental Status Changes: There was concern on arrival from the OSH for ongoing mental status changes. This was thought possibly due to narcotic regimen and Methadone dose was decreased on admission. Pt was evaluated by the ID fellow who follows here as an outpatient and she felt comfortable the patient was functionning at her baseline. Pt did have an MRI that was read as normal while in house and remained alert & oriented while on the floor. . # BRBPR: Pt reported having BRBPR & scant red blood was seen around anus, guaic positive stool apprec on rectal exam. Pt has history of hematochezia thought due to internal hemorrhoids vs diverticulosis. Pt was evaluated by GI in [**2137**], however, she did not get a follow up colonoscopy. Hematocrit remained stable over 40 while in house and pt was scheduled to see GI for colonoscopy in [**7-25**]. Medications on Admission: Epzicom 600-300 daily Acyclovir 400mg tid Duonebs q4h prn ASA 325 mg daily Reyataz 400mg daily Estradiol 2mg daily Diflucan 200mg daily Prozac 60mg daily Advair 250/50 1 puff [**Hospital1 **] Heparin 5000 units sc tid ISS Lantus 40 units daily Methadone 60mg tid Oxycontin 20mg [**Hospital1 **] Tylenol 650mg q6h prn Xanax 2mg [**Hospital1 **] prn Tussionex 5ml q12h prn Phenergan 25mg q4h prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days. Disp:*15 Capsule(s)* Refills:*0* 8. Nystatin 100,000 unit/mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed for oral thrush. 9. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID prn 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Methadone 10 mg Tablet Sig: four and [**1-18**] Tablet PO TID (3 times a day) as needed for for pain. 14. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days. 15. Oxycodone 5 mg Tablet Sig: up to three Tablet PO every six (6) hours as needed for severe breakthrough pain. 16. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 21. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day as needed for per sliding scale. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Community Acquired Pneumonia Mental status changes Hypoxia/Hypercapnea . Secondary: HIV on HAART Hepatitis Type II Diabetes Obesity Discharge Condition: stable Discharge Instructions: You were admitted with mental status changes and were found to have a community acquired pneumonia. You have been treated with a course of antibiotics and your symptoms are much improved. We have also started a new inhaler called Advair to help with your breathing. It is important that you call the Pulmonary clinic on Tuesday morning to schedule a follow up appointment and sleep study. . We have made some changes to your medications as seen below: Methadone decreased to 45mg three times daily Oxycontin increased to 30mg twice daily . We have started two new medications: Oxycodone 5-10mg every 8hrs as needed for severe breakthrough pain Nystatin Powder topical three times daily for rash . If you develop any new chest pain, shortness of breath, mental status changes, weakness, fevers or any other general worsening of condition, please call your PCP or come directly to the ED. Followup Instructions: You have a follow up appointment with Pain Clinic on Wednesday, [**7-12**] at 3:40pm at [**Location (un) 8170**]. [**Telephone/Fax (1) 1652**] . You have a follow up appointment with Dr. [**Last Name (STitle) 51969**] on [**7-12**] at 1:30pm. . You have a follow up appointment with Dr. [**Last Name (STitle) **]/Dr. [**First Name (STitle) **] on [**7-19**] at 10am. Phone:[**Telephone/Fax (1) 457**] . You have an appointment with Gastroenterology on [**7-24**] at 9:15am. . You need to call the Pulmonary Clinic at ([**Telephone/Fax (1) 3554**] to schedule outpatient follow up and sleep study. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

12552, 12601

5932, 9971

303, 310

12786, 12795

4409, 5909

13732, 14424

3691, 3756

10415, 12529

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338, 2816

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1,439

156,532

13121

Discharge summary

report

Admission Date: [**2115-7-4**] Discharge Date: [**2115-7-8**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Recurrent Meningioma Major Surgical or Invasive Procedure: Right parietal craniotomy for meningioma History of Present Illness: Ms [**Name13 (STitle) 40060**] fell in early [**Month (only) 116**] and had periods of dizziness following that fall, approx 2 weeks later she had a head CT showing a dense enhancing mass with edema in the right temp parietal area. She saw [**Doctor Last Name **] as an outpatient and decided to proceed with surgery Past Medical History: ESRD stage 6 gets dialysis Mon-Wed-Friday Hypertension Renal vascular disease CAD, CHF Recurrent Meningioma Social History: Lives with husband Does not drink or smoke Family History: Noncontributory Physical Exam: BP 215/98, HR 67 98% RA Heart S1 S2 RRR 2/6 sem @rsb radiating to nec Lungs: clear Abd soft Extre warm no edema Neuro awake, alert and orientated X3 specch fluent, face symmetric, PERRLA, Motor [**4-26**] Pertinent Results: [**2115-7-4**] 08:44AM freeCa-1.23 [**2115-7-4**] 08:44AM HGB-14.6 calcHCT-44 [**2115-7-4**] 08:44AM GLUCOSE-109* LACTATE-0.9 NA+-143 K+-4.0 [**2115-7-4**] 02:49PM PT-14.0* PTT-26.1 INR(PT)-1.2* [**2115-7-4**] 02:49PM PLT COUNT-222 [**2115-7-4**] 02:49PM WBC-6.2 RBC-4.63 HGB-13.7 HCT-40.3 MCV-87 MCH-29.5 MCHC-33.9 RDW-17.1* [**2115-7-4**] 02:49PM CALCIUM-9.2 PHOSPHATE-4.7* MAGNESIUM-1.8 [**2115-7-4**] 02:49PM GLUCOSE-166* UREA N-31* CREAT-5.5*# SODIUM-143 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16 Brief Hospital Course: Pt underwent a right sided parietal crani without complications. She remainted in the PACU overnight, bp kept less than 140. She was neurologically intact with the exception of a right drift noted immediatley post op period. A head CT showed: Renal was consulted and recommended continuing her dialysis in house, they set the service up for us. She was transferred out to surgical floor after spending overnight in the PACU, she was neurologically intact, with the exception of a left drift. Her post op MRI showed:Interval resection of right posterior parietal extraaxial mass with post- surgical changes seen. No definite residual mass or enhancing component is identified. On the surgical floor she was seen by physical theapy who felt she would benefit for rehab due to her gait. On discharge she was tolleting without difficulty, tolerating a regular diet and completed a round of hemodialysis. Medications on Admission: Amlodipine, Escitalopram, Metropolol, Sevelamar, B-Complex vitamin C, Folic acid, Keppra Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: please do not drive while taking pain medications. Disp:*45 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO AM (). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO every eight (8) hours for 1 days. 15. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO three times a day: start on [**7-10**] end on [**7-12**]. 16. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times a day: start on [**7-13**] for 2 days then stop. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Meningioma ESRD CHF Seizure Disorder HTN Discharge Condition: Neurologically stable Discharge Instructions: Watch incision for redness, drainage, bleeding, swelling, neurologic changes, fever greater than 101.5 call Dr[**Name (NI) 9034**] office No heavy lifting No driving on pain medication Followup Instructions: Have sutures removed on [**2115-7-14**] come to Dr [**Last Name (STitle) 17511**] office between 0900-1200 Follow up with Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2115-7-8**]

[ "780.39", "413.9", "428.0", "V10.05", "403.91", "585.6", "192.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "01.51", "39.95" ]

icd9pcs

[ [ [] ] ]

4296, 4370

1692, 2601

285, 327

4455, 4479

1139, 1669

4712, 4904

881, 898

2740, 4273

4391, 4434

2627, 2717

4503, 4689

913, 1120

225, 247

355, 674

696, 805

821, 865

7,923

126,679

24932

Discharge summary

report

Admission Date: [**2143-8-27**] Discharge Date: [**2143-9-2**] Date of Birth: [**2064-6-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6029**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 78 y/o man with PMH significant for COPD, hepattis C, and past CVA admitted to the MICU on [**8-27**] following an ASA overdose. Pt initially was brought to BICM from [**Location (un) 15383**] [**Hospital **] Facility following a fall. Per report, pt was found on the floor after staff heard a "thump". Per second hand reports, the pt has left the ALF in the past to do "drugs" and reports that he drank ETOH on the night prior to admission. . On arrival to the [**Hospital1 18**] ED, the pt's VS were 97.3 79 126/93 20 96% RA. He denied SOB, tinnitus, and nausea/vomiting. He was alert but agitated per notes when his baseline is reported to be alert and oriented x3. In the ED, his ASA level was significant at 50 mg/dL. He denied recent ASA use but reported that he had taken it in the past. Rest of her urine and serum tox screen was negative. Other labs were significant for a serum bicarb of 12 and an anion gap of 19. Urine pH was 6.0 and urine ketones were positive. ABG was 7.48/19/06 thus consistent with a primary respiratory alkalosis and primary metabolic alkalosis. Central access was obtained and the pt was given 1 amp of bicarb then place on a bicab drip. Pt was then admitted to the MICU for further care. Past Medical History: 1. COPD 2. Hepatitis C 3. H/O CVA with left sided hemiparesis 4. GERD 5. Chronic low blood pressure 6. Cervical stenosis 7. BPH with history of bladder outlet obstruction- Pt is s/p TURP in [**2140**]. 8. Cervical and lumbar spinal stenosis 9. GERD 10. Neurogenic bladder 11. AAA 12. H/O nephrolithiasis 13. H/O diverticulitis 14. H/O LE edema 15. Cataracts 16. Peripheral neuropathy 17. S/P multiple rib fractures 18. Multifactorial gait abnormality 19. Chronic peripheral edema 20. DJD of the right knee Social History: Pt lives at the [**Location (un) 15383**] [**Hospital3 400**] Facility. He used to sing with the BB [**Doctor Last Name **] Orchestra and he still sings the blues. Prior history of ETOH, tobacco, and IV drug use. I met the [**Hospital **] health care proxy [**Name (NI) 401**] [**Name (NI) **]. His phone numbers are [**Telephone/Fax (1) 62678**] and [**Telephone/Fax (1) 62679**]. Family History: n/c Physical Exam: 99.0 144/73 61 14 99% RA Gen- Alert. Oriented only to self. Does not know month, year, place, or where he normally lives. Does recognize his health care proxy who is with him. HEENT- NC AT. PERRL. EOMI. Anicteric sclera. MMM. No lesions in the oropharynx. Poor dentition. Cardiac- RRR. S1 S2. III/VI SEM. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. Mild diffuse tenderness. No rebound or gaurding. ND. Positive bowel sounds Extremities- No c/c/e. Neuro- CN II-XII intact. 5/5 strength in upper and lower extremities on the right. 4/5 strength in upper and lower extremities on the left. Pertinent Results: [**2143-8-27**] 01:49AM BLOOD WBC-5.2 RBC-4.23* Hgb-13.1* Hct-39.4* MCV-93 MCH-30.9 MCHC-33.2 RDW-15.4 Plt Ct-135* [**2143-8-30**] 04:49AM BLOOD WBC-3.4* RBC-3.92* Hgb-11.9* Hct-36.9* MCV-94 MCH-30.4 MCHC-32.3 RDW-15.1 Plt Ct-120* [**2143-8-27**] 01:49AM BLOOD Neuts-59.8 Lymphs-33.3 Monos-5.5 Eos-1.3 Baso-0.2 [**2143-8-30**] 04:49AM BLOOD Neuts-50.7 Lymphs-36.0 Monos-5.5 Eos-7.6* Baso-0.3 [**2143-8-27**] 01:49AM BLOOD PT-16.2* PTT-31.4 INR(PT)-1.8 [**2143-8-30**] 04:49AM BLOOD PT-16.0* PTT-87.1* INR(PT)-1.8 [**2143-8-27**] 01:49AM BLOOD Glucose-85 UreaN-19 Creat-1.0 Na-137 K-3.9 Cl-106 HCO3-12* AnGap-23* [**2143-8-30**] 04:49AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-139 K-3.8 Cl-109* HCO3-23 AnGap-11 [**2143-8-27**] 01:49AM BLOOD ALT-84* AST-161* AlkPhos-81 Amylase-54 TotBili-0.6 [**2143-8-27**] 01:49AM BLOOD Lipase-14 [**2143-8-27**] 01:49AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.2 Mg-2.4 [**2143-8-30**] 04:49AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7 [**2143-8-28**] 03:20AM BLOOD calTIBC-268 VitB12-805 Hapto-23* TRF-206 [**2143-8-27**] 08:00AM BLOOD Osmolal-288 [**2143-8-28**] 03:20AM BLOOD TSH-0.76 [**2143-8-27**] 01:49AM BLOOD ASA-50* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2143-8-27**] 05:40AM BLOOD Type-ART pO2-96 pCO2-19* pH-7.48* calHCO3-15* Base XS--5 Intubat-NOT INTUBA CT C Spine ([**8-27**])- Extensive degenerative change throughout the cervical spine with loss of intervertebral disc space height at multiple levels and vaccum disc degeneration. Loss of vertebral body height and sclerosis seen at C3, C4, and C5. Pt is s/p laminectomy of C3 through C7. Mild retrolisthesis of C3 on C4 and C4 on C5. Also mild anterolisthesis of C7 on T1. Disc herniations are seen at C3/4, S4/5, and C5/6. Soft tissues are unremarkable. . CT head ([**8-27**])- No evidence of intracranial hemorrhage, hydrocephalus, shift of normally midline structures, or edema. Small-to-moderate amount of periventricular white matter hypoattenuation consistent with chronic small vessel ischemia. [**Doctor Last Name **]-shite matter differentioation appears intact throughout. Opacified right sphenoid sinus with sclerotic sinus wall indicative of chronic sinusitis. Brief Hospital Course: 78 y/o man with PMH significant for COPD, hepattis C, and past CVA admitted to the MICU on [**8-27**] following an ASA overdose. . 1. Overdose - The pt was followed by the toxicology and renal services. Pt was continued on a bicarb drip in the MICU and 5 mg SQ vitamin K for coagulopathy. Pt's potassium was also agressively repleated. He did not require hemodialysis. On [**8-28**], the bicarbonate drip was discontinued per toxicology recommendations. He was called out to the floor and remained stable while there. Psychiatry was consulted and felt that the overdose was not a suicide attempt and may have been the result of underlying dementia. His lytes were followed closely and repleted prn. . 2. Altered mental status- The pt is oriented only to himself and has very poor short term memory at baseline likely secondary to a strong pmh of alcoholism. On admission he was acutely agitated and oriented x0. However, this cleared well throughout his admission and he returned to baseline prior to his d/c. Psychiatry felt that he had underlying dementia and recommended outpatient monitoring for this condition. He was originally maintained on a CIWA scale but this was d/c prior to his d/c. He also required a sitter early in his admission but this also was d/c prior to his discharge. . 3. COPD - His breathing, per pt report, was at baseline on the floor and no interventions were attempted. . 4. Gerd - the patient was maintained on protonix during his admission. . 5. Fall - The etiology of his fall was either mechanical or related to his aspirin overdose. He was evaluated by PT who recommended that he be d/c to a rehab facility and this was done. . Medications on Admission: ALF Medications: 1. ASA 81 mg daily 2. Docusate 100 mg [**Hospital1 **] 3. Tramadol 50 mg QID 4. MOM 30 ml PRN 5. Tylenol 600 mg Q4H PRN 6. Capsacian cream Discharge Medications: 1. Nicotine 2 mg Gum Sig: Two (2) mg Buccal Q1H (every hour) as needed. 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Agitation. Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Primary diagnosis: ASA overdose Secondary diagnosis: Mental status changes S/P fall Discharge Condition: Stable Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, abdominal pain, shortness of breath, or any other concerning symptoms. Followup Instructions: 1. You will be followed by the physician at [**Location (un) 15383**] [**Hospital3 400**] when you return there following your rehab stay. 2. Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the VA on [**9-12**] at 3:00 PM. Call [**Telephone/Fax (1) 41354**] if you have any questions about this appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**] Completed by:[**2143-9-2**]

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Discharge summary

report

Admission Date: [**2187-9-10**] Discharge Date: [**2187-11-1**] Date of Birth: [**2136-5-25**] Sex: F Service: MEDICINE Allergies: Betalactams Attending:[**First Name3 (LF) 5893**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Intubation x 2, central line placement, pericardial drain placement History of Present Illness: Ms. [**Known lastname **] went to clinic today for evaluation of diarrhea which has been worsening over the last week. She was seen in clinic on Saturday and Sunday and was noted to have escalation of diarrhea at that time. Dr. [**Last Name (STitle) 410**] and Dr. [**Last Name (STitle) 60235**] saw her at that time, started her on Flagyl and arranged for today's visit. Her husband called the clinic this morning stating he did not think he could bring her in because of the frequency of her stooling. Advised him at that time that it was very important she come in due to the diarrhea and her previous low K. A second call from the husband reported they would be in shortly and he also reported that she had a fever to 100.5. She reports that she is having pain in her knee because she slipped in stool last night while trying to get to the bathroom. She has not eaten today. She has taken her immune-suppression only. Her husband did not yet pick up the Flagyl ordered on Saturday. She denies cramping with the diarrhea. Denies blood in her stool. Denies nausea/vomiting/SOB/CP. . In clinic, she had a fever to 98.8. She was started on IV fluid transfusions, and electrolyte repletion. She had peripheral blood cultures and cultures were drawn from her line. She was repleted with 1000n/s +40meq KCL and 4gm. Mag. She has been lethargic but alert and oriented she is weak but needs minimal assist getting oob. She was given doses of vanco, flagyl,and Aztreonam. Vital Signs: BP: 112/79. Heart Rate: 120. Temperature: 98.8. Resp. Rate: 18. O2 Saturation%: 100. Past Medical History: Oncologic History: [**Known firstname **] is a 51-year-old woman who was admitted to [**Hospital6 33**] on [**2187-2-4**] after a period of fevers, myalgias, tender cervical adenopathy, and worsening chronic back pain. On admission, she was noted for white blood count of 233,000 and a platelet count of 10,000. She was transferred to [**Hospital1 18**] and bone marrow aspirate and biopsy was notable for acute myeloid leukemia with monocytic differentiation. She required immediate leukapheresis and was started on hydroxyurea and allopurinol. On the second day after admission she went into a DIC with onset of acute renal failure, which resolved with IV fluids. She was treated with 7 and 3(cytarabine and idarubicin) with subsequent complications of prolonged febrile neutropenia, VRE bacteremia, cephalitis, and mucositis. She also was noted for some mental status changes concerning for CNS involvement. The lumbar puncture showed no specific malignant cells, but high monocyte count was concerning for leptomeningeal spread and she received five doses of intrathecal chemotherapy, two doses of methotrexate, and three doses of ARC. Unfortunately, she was noted for persistent disease and received a cycle of clofarabine. She required an admission for neutropenic fever. Her day 15 bone marrow aspirate and biopsy showed no evidence of disease. She was initiated on conditioning with fludarabine, Cytoxan, and TBI. Day 0 was on [**2187-5-18**]. . POST-TRANSPLANT COURSE: [**Known firstname 60231**] post transplant course has been complicated by a diffuse erythroderma rash with marked pruritus and dull epigastric discomfort. EGD was done which showed acute mild GVHD. She was initiated on IV Solu-Medrol, which was then switched to oral prednisone prior to her discharge. This has been discontinued as of [**2187-7-11**]. She has continued on CellCept [**Pager number **] mg q12h and Tacrolimus 0.5 mg q12h. She also has been on Entocort 3 mg three times per day. [**Known firstname **] and her husband stayed locally at the apartments for approximately two weeks after her discharge on [**2187-7-4**], which was on day 47 following her transplant. She was then cleared to go home, but continues to be seen frequently in clinic for IV fluid support and has been requiring potassium and magnesium supplementation. Social History: Tobacco: None, ETOH: None since [**Month (only) 404**] and occasional prior. Ms. [**Name14 (STitle) 60232**] is originally from [**Location (un) 620**] [**State 350**]. She lives with her husband, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] friend. They have a son and a daughter who are both college age. Family History: Mother with breast cancer. Maternal grandmother with [**Name2 (NI) 499**] cancer. Physical Exam: Vitals: 98.9 112/84 98 20 97RA General: lying in bed. Cachectic appearing. appears weak. HEENT: Sclera anicteric, MMM, oropharynx clear no lesions or petechial hemmorhages. Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: petechial bruising on dorsolateral wrists extending 4-5cm by 2 cm. No other rashes evident. Pertinent Results: Admission Labs: [**2187-9-9**] 10:00AM PLT SMR-LOW PLT COUNT-67* [**2187-9-9**] 10:00AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-2+ [**2187-9-9**] 10:00AM NEUTS-53 BANDS-11* LYMPHS-8* MONOS-26* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-4* [**2187-9-9**] 10:00AM WBC-5.1 RBC-2.67* HGB-8.2* HCT-23.9* MCV-90 MCH-30.7 MCHC-34.2 RDW-17.1* [**2187-9-9**] 10:00AM CALCIUM-7.7* PHOSPHATE-2.5* MAGNESIUM-1.7 [**2187-9-9**] 10:00AM GLUCOSE-142* UREA N-9 CREAT-0.6 SODIUM-144 POTASSIUM-2.7* CHLORIDE-106 TOTAL CO2-24 ANION GAP-17 [**2187-9-10**] 03:30PM PLT COUNT-41* [**2187-9-10**] 03:30PM NEUTS-61 BANDS-11* LYMPHS-6* MONOS-17* EOS-3 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-5* [**2187-9-10**] 03:30PM WBC-7.4 RBC-3.27* HGB-10.0* HCT-28.4* MCV-87 MCH-30.6 MCHC-35.2* RDW-18.4* [**2187-9-10**] 03:30PM CALCIUM-8.1* PHOSPHATE-2.0* MAGNESIUM-2.4 [**2187-9-10**] 03:30PM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-501* ALK PHOS-74 TOT BILI-0.4 [**2187-9-10**] 03:30PM UREA N-8 CREAT-0.6 SODIUM-143 POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-25 ANION GAP-14 Discharge labs: [**2187-10-30**] 04:22AM BLOOD WBC-7.2# RBC-2.86* Hgb-8.7* Hct-25.1* MCV-88 MCH-30.3 MCHC-34.7 RDW-20.8* Plt Ct-99* [**2187-10-30**] 04:22AM BLOOD Glucose-142* UreaN-14 Creat-0.6 Na-138 K-3.7 Cl-103 HCO3-28 AnGap-11 [**2187-10-30**] 04:22AM BLOOD ALT-6 AST-10 AlkPhos-96 TotBili-0.5 Imaging: ECHOCARDIOGRAMS: . [**2187-9-14**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [**2187-5-30**], a moderate circumferential pericardial effusion is now present. . [**2187-9-21**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 75-80%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a moderate to large sized pericardial effusion. The effusion appears circumferential but is distributed primarily posterolateral to the heart with patient in left lateral decubitus position. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. . [**2187-9-27**]: he estimated right atrial pressure is 0-10mmHg. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a moderate to large sized pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Moderate to large circumferential pericardial effusion without echocardiographic signs of tamponade. Normal global biventricular systolic function. Compared with the prior study (images reviewed) of [**2187-9-21**], findings are similar. . [**2187-10-5**]:Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with depressed free wall contractility (focal mid RV free wall akinesis). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a large pericardial effusion. There are no echocardiographic signs of tamponade. No right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2187-9-27**], the pericardial effusion is slightly larger but there is no tamponade. The RV is now more dilated with focal free wall hypokinesis with evidence of pressure/volume overload. Severe TR is now present. ? Acute RV strain? Acute pulmonary embolism? . CT TORSO [**2187-9-25**]: 1. Significant mucosal edema evident in the transverse and descending [**Month/Day/Year 499**]. The broad differential includes infection, inflammation, and graft-versus-host disease. 2. New bilateral pleural effusions and increase in the size of pericardial effusions. . CTA CHEST [**2187-9-29**]: 1. New scattered areas of nodular ground-glass opacities bilaterally, which raises concern for infection including atypical infections such as viral and fungal etiologies. 2. Focal airspace consolidation of the left lower lobe at site of prior thoracentesis that may be developing infection with adjacent ground glass opacities that may be a component of reexpansion pulmonary edema. 3. Unchanged to mildly increased moderate right pleural effusion with adjacent atelectasis. Decrease in size of the left pleural effusion status post thoracentesis. 4. Moderate pericardial effusion, unchanged. 5. No evidence of pulmonary embolism to the subsegmental levels. . [**2187-10-1**] CT CHEST: 1. Moderately large bilateral pleural effusions and pericardial effusions. The left pleural effusion has significantly worsened since [**2187-9-29**]. 2. Dense consolidated left lower lobe on the prior study is replaced by atelectatis. 3. Bilateral upper lobe consolidation has progressed and may represent viral pneumonia, central edema or graft versus host reaction. . [**2187-9-25**] ENDOSCOPIC BIOPSY: [**Month/Day/Year **], sigmoid, biopsy: - Colonic mucosa with mucosal edema and mildly distorted crypt architecture; no active inflammation identified. See note. - No viral cytopathic effect seen; immunohistochemical staining for CMV is negative with adequate controls. Brief Hospital Course: #ICU Course 1: She was initially admitted on [**9-10**] with dehydration and diarrhea. Infectious work-up was negative and her course was complicated by AFIB with RVR requiring admission to the [**Hospital Unit Name 153**]. She spontaneously converted to NSR after 2L IVF. Echo at that time showed a moderate pericardial effusion without e/o tamponade which was monitored on echo x 4 and remained stable until subsequently in course. #ICU Course 2: Ms. [**Known lastname **] is a 51-year-old woman with a history of AML day day 122+ s/p double cord allogeneic transplant who was admitted with fevers and diarrhea s/p 3 day [**Hospital Unit Name 153**] stay for hypotension and tachycardia now with hypotension in setting of rapid heart rate. Initial episode of hypotension felt to be due to a combination of dehydration and atrial flutter. BP improved to baseline with volume resuscitation and PRBCs. She spontaneously converted to NSR after 3-4 hrs in Afib. Echo at that time showed a moderate pericardial effusion without e/o tamponade. Her diarrhea improved spontaneously and was felt to be viral at the time of discharge. She was treated empirically for C.diff as well. The patient reports that she was sleeping this evening and was woken up for routine VS check. She was noted to have a rapid heart rate (150) at that time. She was given metoprolol 5mg IV x3 and on each occasion her HR did not change but her BP dropped to mid 80s. She was then given dilt 10mg IV with transient improvement in her HR to 85 bpm for approx 3 mins. However, she became hypotensive with SBPs in mid-60s and she felt generally unwell. She received 2L of IVF. Ms. [**Known lastname **] was transferred to the floor following normalization of her blood pressure with fluids and control of her heart rate with metoprolol. She was placed on telemetry and remained in sinus rhythm. She was afebrile with normal oxygen saturations. Daily pulsus was checked and demonstrated no abnormality. Repeat echo on [**9-21**] and [**9-27**] demonstrated no change in the size or the distribution of her moderate-large pericardial effusions, which remained posterior and not amenable to drainage. She once again became febrile to 100-101, and was placed on empiric broad spectrum antibiotics including daptomycin for her history of VRE, and aztreonam, though she continued to spike. She developed watery diarrhea on [**2187-9-23**], and underwent a negative infectious workup. A CT torso was explored to evaluate the cause of her persistent fevers, and it demonstrated some mild pleural effusions and transverse/descending colitis. GI was consulted and she underwent flexible sigmoidoscopy on [**2187-9-27**] demonstrating diffuse erythema of the sigmoid [**Date Range 499**]. Biopsies were taken, though they did not show evidence of suspected graft versus host disease or viral cytopathic changes. Her diarrhea subsequently stopped within a few days. She developed shortness of breath with new oxygen requirement, and given her moderate-large pleural effusions, she underwent thoracentesis of the left pleural space on [**2187-9-28**], and 800cc of clear fluid was withdrawn. The procedure was cut short due to patient inability to tolerate further fluid withdrawal. Pleural fluid analysis yielded a transudative fluid that showed atypical cells, yet pathology did not reveal signs of malignancy. Fungal markers were likewise negative. Her respiratory status improved acutely, though several hours post-procedure, she became suddenly short of breath with audible wheezing and diffuse crackles heard throughout the lung fields. CXR demonstrated a post-expansion pulmonary edema and she was diuresed with slight improvement. Following further respiratory distress, she again underwent CTA of the chest, which demonstrated worsened pleural effusions, with a moderate to large bilateral pleural effusion, in addition to diffuse bilateral upper lobe consolidations. Ciprofloxacin was added to her antibiotics to enhance gram negative coverage, and her daptomycin was substituted for by linezolid for better pulmonary penetration. IP was again called the following day, and she underwent thoracentesis and bronchoscopy on [**2187-10-2**]. 900cc of cloudy yellow fluid was taken from the right pleural space. Bronchoscopy was also undertaken. Pleural fluid analysis demonstrated a transudative process. No cytologic of the BAL fluid could be completed due to cell fragility. No malignant cells were seen on pleural fluid cytology. Cultures were negative of the pleural fluid and BAL washings. Following her bronchoscopy, she developed respiratory distress with desaturations and was directly transferred to the [**Hospital Unit Name 153**] without returning first to the floor. She was noted to have asymmetric lower extremity weakness that was initially felt to be secondary to deconditioning, though her right lower leg was peristently weaker than her left. She underwent LP on [**2187-9-30**] to evaluate for leptomeningeal infiltration of her malignancy. Her CSF analysis demonstrated leukcytosis to 32 with 92% lymphocytes. No malignant cells were seen. Viral studies including adenovirus, [**Male First Name (un) 2326**] virus, enterovirus, CMV, HHV-6, EBV, HSV were all normal. Immunophenotyping was within normal limits. #ICU course 3: Respiratory failure s/p bronchoscopy and pleurocentesis. Ms. [**Name14 (STitle) 60232**] developed sudden hypoxic respiratory failure requiring intubation on [**2187-10-2**] after bronchoscopy and pleural tap. Factors initially causing her to be in respiratory distress include a large multifocal pneumonia, her known pleural effusions, and also likely the effect of bronchoscopy fluid in her lungs. She was treated with broad-spectrum Abx (Vanc, Cefepime, Cipro, Flagyl with multiple prophylactic medications). Pt initially with hypotension and low urine output concerning for sepsis in context of PNA. Fluid boluses including albumin given to maintain BP along with pressors. UOP responsive to albumin. IP attempted repeat [**Female First Name (un) 576**] on [**10-4**] but not enough fluid to allow tap. Pt with sudden decrease in compliance and increase in peak pressures on vent 9/24. Unclear etiology. Also becoming hyponatremic with high BNP concerning for vol overload. Lasix gtt started. Head CT negative for acute change. CTA did not show PE and showed mild improvement in ground glass opacities bilaterally but increase in size of pericardial effusion. ECHO showed no evidence of tamponade and cardiology post-poned possible pericardiocentesis. Pt continuing to overbreathe vent with significant Barriers to extubation included total body volume overload as well as breathing over the vent. Pt was extubated on [**10-14**] but with significant agitation and tachypnea, so was re-intubated on [**10-17**]. Weaning attempts continued to be complicated by agitation. Repeat echo showed cardiac tamponade [**2-13**] pericardial effusions, which was tapped on [**10-19**] draining 800cc of pericardial fluid which was found to be + for AML. CNS also positive for AML. She was initially treated for toxoplasmosis but this was discontinued when toxo PCR from pericardial fluid was negative. Course further complicated by SVT requiring eletric cardioversion and amio ggt converted to PO amio, continued pressor dependence, skin impairments of the arms bilaterally with wound culture positive for coag + staph. Given ongoing vent/pressor dependence, there were ongoing discussions with family and [**Month/Day (4) 3242**] team throughout hospital course about goals of care. Pt was eventually determiend to be DNR/DNI with subsequent decision to change goals of care to comfort on [**10-30**] and morphine/ativan drips started. Pt was extubated and family was at bedside when she expired. Medications on Admission: Acyclovir 400mg IV q8h Atovaquone 750mg po q6h Chlorhexadine Cyanocobalamin 1000mcg po daily Docusate 100mg po daily prn Fentanyl Gtt Folic acid 1mg po daily Haldol 5mg IV q6h with daily ECG SC heparin ISS Ipratropium bromide 1 neb q6h prn Leucovorin 10mg po q6h Mag IV sliding scale Meropenem 500mg IV q6h Metoprolol Tartrate 12.5mg po tid Midazolam Gtt Mycophenolate Mofetil 500mg po bid Norepinephrine 0.03-0.25mcg/kg/min gtt Zofran 8mg IV q8h prn nausea Oxycodone 5mg po q4h prn Pantoprazole 40mg IV q24h Potassium phosphate IV sliding scale Pyrimethamine 75mg po daily Voriconazole 200mg IV q12h Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. AML status post allogeneic cord transplant day 128 with recurrence in pericardial fluid and CNS 2. diarrhea 3. atrial flutter 4. Tamponade Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "45.25", "03.92", "96.04", "99.25", "34.91", "03.31", "96.57", "37.0", "41.31" ]

icd9pcs

[ [ [] ] ]

20982, 20991

12461, 20301

281, 350

21177, 21186

5400, 5400

21242, 21252

4652, 4736

20953, 20959

21012, 21156

20327, 20930

21210, 21219

6583, 12438

4751, 5381

233, 243

378, 1944

5416, 6567

1967, 4291

4307, 4636

55,597

189,080

53980

Discharge summary

report

Admission Date: [**2122-4-13**] Discharge Date: [**2122-5-5**] Date of Birth: [**2070-2-15**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: malpositioned G-tube sepsis Major Surgical or Invasive Procedure: [**2122-4-14**] Exploratory G tube tract incision and drainage of the retro rectus and peri rectus space, and drain placement [**2122-4-18**] [**Last Name (un) 1003**] G tube placement History of Present Illness: 52M with anoxic brain injury secondary to substance abuse s/p tracheostomy, PEG placement [**1-/2122**], transferred from OSH for G-tube malpositioning. Pt underwent manual G-tube replacement at his rehab facility yesterday, after which water-soluble contrast was injected to confirm placement. It is unclear whether tube feeds were administered via this new G-tube. When residuals became bloody, the pt was transferred to an OSH for CT imaging. At the OSH the pt became febrile to 102.5, tachycardic, and was found to have a leukocytosis >18,000. CT A/P revealed a malpositioned G-tube located in the left rectus muscle, accompanied by air and fluid. The pt was subsequently transfered to [**Hospital1 18**] for further management; a surgical consult is requested for G-tube evaluation. Past Medical History: PMH: TBI secondary to anoxia during substance overdose PSH: Tracheostomy and PEG placement [**1-/2122**] Social History: Resides at longterm care facility. Family History: N/C Physical Exam: Admission Physical Exam Vitals: 98.9 122 146/86 28 97% trach collar GEN: Pt non-verbal. Awake. HEENT: PERRL. No scleral icterus. Mucous membranes moist. CV: Regular rhythm but tachycardic PULM: Rhonchi clear w/ suctioning. ABD: Soft, nondistended, appears nontender. G-tube in place with palpable superficial positioning. Mild fullness appreciated over left upper rectus muscle. Ext: LE warm without edema. Physical examination upon discharge: Vital signs: t=98.5, hr=109, bp=118/75, rr=16, 95% room air CV: rrr LUNGS: Coarse rhonchi throughout ABDOMEN: soft, [**Last Name (un) 1003**] button left side abdomen with DSD EXT: cool feet bil., no pedal edema, contractures of upper ext. NEURO: opens eyes to tactile stimuli, spontaneous cough SKIN: stage 2 ulcer left heel Pertinent Results: [**2122-5-4**] 05:04AM BLOOD WBC-11.4* RBC-4.50* Hgb-14.4 Hct-44.2 MCV-98 MCH-31.9 MCHC-32.5 RDW-13.8 Plt Ct-408 [**2122-5-4**] 05:04AM BLOOD Plt Ct-408 [**2122-5-4**] 05:04AM BLOOD Glucose-125* UreaN-20 Creat-0.8 Na-135 K-4.8 Cl-96 HCO3-24 AnGap-20 [**2122-4-15**] 05:06AM BLOOD ALT-33 AST-20 AlkPhos-46 TotBili-0.8 [**2122-5-4**] 05:04AM BLOOD Calcium-10.1 Phos-3.7 Mg-2.4 [**2122-5-1**] 05:35AM BLOOD WBC-10.8 RBC-4.37* Hgb-14.1 Hct-42.3 MCV-97 MCH-32.2* MCHC-33.2 RDW-13.7 Plt Ct-393 [**2122-5-1**] 05:35AM BLOOD Plt Ct-393 [**2122-5-1**] 05:35AM BLOOD Glucose-140* UreaN-19 Creat-0.8 Na-138 K-4.5 Cl-100 HCO3-25 AnGap-18 [**2122-4-15**] 05:06AM BLOOD ALT-33 AST-20 AlkPhos-46 TotBili-0.8 [**2122-5-1**] 05:35AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.5 [**2122-4-18**] 01:30PM BLOOD WBC-6.7 RBC-3.32* Hgb-11.0* Hct-30.9* MCV-93 MCH-33.0* MCHC-35.5* RDW-13.6 Plt Ct-398 [**2122-4-17**] 04:57AM BLOOD WBC-6.3 RBC-3.55* Hgb-11.4* Hct-33.4* MCV-94 MCH-32.2* MCHC-34.2 RDW-13.3 Plt Ct-365 [**2122-4-15**] 05:06AM BLOOD WBC-9.8# RBC-3.20* Hgb-10.4* Hct-31.2* MCV-98 MCH-32.6* MCHC-33.4 RDW-13.6 Plt Ct-309 [**2122-4-18**] 01:30PM BLOOD Plt Ct-398 [**2122-4-18**] 01:30PM BLOOD PT-14.9* PTT-28.5 INR(PT)-1.4* [**2122-4-19**] 04:45AM BLOOD Glucose-151* UreaN-5* Creat-0.6 Na-135 K-3.4 Cl-97 HCO3-27 AnGap-14 [**2122-4-18**] 01:30PM BLOOD Glucose-99 UreaN-7 Creat-0.5 Na-137 K-3.3 Cl-100 HCO3-24 AnGap-16 [**2122-4-15**] 05:06AM BLOOD ALT-33 AST-20 AlkPhos-46 TotBili-0.8 [**2122-4-14**] 12:43AM BLOOD ALT-60* AST-37 AlkPhos-58 TotBili-2.5* [**2122-4-13**] 09:35PM BLOOD ALT-55* AST-34 AlkPhos-54 TotBili-2.5* [**2122-4-19**] 04:45AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8 [**2122-4-17**] 04:57AM BLOOD Vanco-18.3 [**2122-4-15**] 09:00PM BLOOD Vanco-5.0* URINE CULTURE (Final [**2122-4-21**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. This isolate demonstrates carbapenemase production. Consider Infectious Disease Consultation.. SENSITIVE TO DOXYCYCLINE. SENSITIVE TO MINOCYCLINE. DOXYCYCLINE AND MINOCYCLINE sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ISOLATE SENT TO [**Hospital1 4534**] LABORATORIES FOR COLISTIN SUSCEPTIBILITY TESTING. . CEFEPIME = INTERMEDIATE (MIC: 16MCG/ML) RESULTS WERE OBTAINED BY ALTENATIVE METHOD (MICOSCAN). MEROPENEM sensitivity testing performed by Microscan. SENSITIVE TO Tigecycline (MIC: <=1 MCG/ML). SENSITIVE TO TETRACYCLINE (MIC: <=4 MCG/ML). Tigecycline AND TETRACYCLINE sensitivity testing performed by Microscan. COLISTIN <=2 MCG/ML, SENSITIVITY PERFORMED BY [**Hospital1 4534**] LABORATORIES . PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 8 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S 32 R CEFTAZIDIME----------- =>64 R 32 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S =>16 R MEROPENEM------------- 8 R 2 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ =>16 R 8 I TRIMETHOPRIM/SULFA---- <=1 S MRSA SCREEN (Final [**2122-4-15**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. /[**3-23**] 3:00 am URINE Source: Catheter. **FINAL REPORT [**2122-4-17**]** URINE CULTURE (Final [**2122-4-17**]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- =>64 R =>64 R CEFTRIAXONE----------- 16 R 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM------------- 1 S 1 S NITROFURANTOIN-------- 256 R 256 R TOBRAMYCIN------------ =>16 R =>16 R TRIMETHOPRIM/SULFA---- <=1 S <=1 S Time Taken Not Noted Log-In Date/Time: [**2122-4-17**] 2:52 pm IMMUNOLOGY **FINAL REPORT [**2122-4-20**]** HCV VIRAL LOAD (Final [**2122-4-20**]): 270,276 IU/mL. Performed using the Cobas Ampliprep / Cobas Taqman HCV Test. Linear range of quantification: 43 IU/mL - 69 million IU/mL. Limit of detection: 18 IU/mL. Rare instances of underquantification of HCV genotype 4 samples by [**Doctor Last Name **] COBAS Ampliprep/COBAS TaqMan HCV test method used in our laboratory may occur, generally in the range of 10 to 100 fold underquantitation. If your patient has HCV genotype 4 virus and if clinically appropriate, please contact the molecular diagnostics laboratory ([**Telephone/Fax (1) 6182**]) so that results can be confirmed by an alternate methodology. [**2122-4-13**]: chest x-ray: IMPRESSION: No significant interval change. Left basilar opacity, potentially due to atelectasis, effusion; however, consolidation from infection is not excluded. [**2122-4-20**]: G/GJ/tube check: After administration of Gastrografin via the gastrostomy tube in supine and semi-upright positions, there was normal opacification of the stomach without evidence of leak. Subsequently, a total of one liter of Gastrografin was administered via the gastrostomy tube and images of the stomach and small bowel were obtained without evidence of small-bowel obstruction, and noleak/extravasation was seen at the gastrostomy site. IMPRESSION: No evidence of leak or bowel obstruction. Brief Hospital Course: Mr [**Known lastname 110682**] was admitted from the Emergency Department and taken to the operating room for debridement of his gastrostomy tube site. He was monitored in the intensive care unit for approximately 12 hours before being transferred to the surgical floor on HD #3. His hospital course is outlined below by organ system: Neurologic: He did not appear to have any changes from his baseline neurological dysfunction (unable to follow commands, does not speak). He opens his eyes to tactile stimuli. He has a spontaneous cough and is able to clear his secretions via his trach tube. Cardiovascular: He was in sinus tachycardia post-operatively, presumed to be from his systemic inflammatory response from the G-tube site infection and/or UTI. He was given intermittent intravenous metoprolol with good effect. His metoprolol continues via the feeding tube. After his surgical debridment, he has been afebrile. His white blood cell count has decreased to 7. He continues to have episodes of tachycardia controlled with metroprolol. Pulmonary: He had clear secretions from his tracheostomy site. He had no evidence of pneumonia on chest x-ray. He had a strong spontaneous cough and was able to expectorate secretions via his trach. Gastrointestinal: His prior G-tube was removed in the operating room on HD #1. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was placed and later changed to a dobhoff with the resumption of feedings. The patient removed both the [**Last Name (un) **]-gastric tube and the dobhoff. After replacement of the dobhoff, the patient once again removed it. In order to provide him with nutrition, he was taken to the operating room on HD #6 where he had placment of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1003**] gastrostomy tube. His tube feedings were resumed and he has attained his goal. On POD #6, he began having emesis and his g-tube was placed to gravity drainage. He was started on reglan and underwent a x-ray of the abdomen which showed gaseous distention of the stomach. He was placed on bowel rest for 24 hours. His tube feedings were resumed within 24 hours with tolerance of the tube feedings. He was noted at this time to have mild erythema around the stoma site with mild macular lesions extending beyond the stoma. He was started on nystatin powder and his abdominal binder was removed. His tube feedings were changed from continuous to cyclic tube feedings to lessen his chance of removing the tube. On HD # 19, he was reported to have bloody ooze from the stoma edges which did not resolve with pressure. Silver nitrate was applied to the bleeding edges and the oozing subsided. His hematocrit has remained stable at 42. His G-tube was removed on HD # 22, and a #14 foley catheter was placed into the stoma tract with resumption of cyclic tube feedings. The [**Last Name (un) 1003**] tube was buttoned and cyclic feedings resumed. Renal: He had a chronic foley and presented with a very dirty urine specimen. A urine culture showed klebsiella. His foley was changed on arrival to the intensive care unit. He was treated with empiric Vancomycin, zosyn, and cefepime for both the presumed UTI and abdominal wall collection. His antibiotics were discontinued on HD #5. His final urine culture report did identify pseudomonas and klebseilla. His foley catheter was reinserted on HD #10 because of ineffective urine collection with the condom catheter. Upon insertion of the catheter, he was found to have cloudy urine and a urine specimen was sent. His foley was left in place and a repeat urine done on HD #12 did again grow Klebseilla and pseudomonas. He was started on a 1 week course of bactrim with completion of the course on [**5-1**]. He was still showing cloudy urine after completion of the bactrim. His foley was again changed on HD #22. The urine appeared to be clearer with less sediment. He was again ordered for an additional week of bactrim. Hematology: His hematocrit has remained stable. He was maintained on subcutaneous heparin during his stay. Endocrine: His blood sugar was controlled by an insulin sliding scale. Skin: He was found to have left heel pressure ulcers and erythematous coccyx. Wound consult was called and recommmended waffle boots and frequent repositioning. He has contractures of his upper extremities. He has been out of bed into the chair utlizing a [**Doctor Last Name **] lift. Excoration around the [**Last Name (un) 1003**] tube treated with application of a dry dressin. Social: Social services and case management have been involved in his discharge planning. A court appointed guardian has been selected and discharge to a extended care facility has been undertaken. . Medications on Admission: Metoprolol, unknown doseage Discharge Medications: 1. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) cc PO twice a day: via g-tube, hold for loose stool. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 4. Miralax 17 gram/dose Powder Sig: Seventeen (17) gms PO once a day as needed for constipation. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: via g tube. 6. ascorbic acid 500 mg/5 mL Syrup Sig: Five Hundred (500) mg PO DAILY (Daily): via g tube. 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): apply around g tube site. 8. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): via g tube. 10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for systolic blood presure <110, hr <60. 11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): week course, stop date [**2122-5-10**]. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Malpositioned G-tube urosepsis Discharge Condition: Non-verbal, opens eyes to tactile stimuli OOB ( [**Doctor Last Name 2598**] lift) Discharge Instructions: You were admitted to the hospital due to a mal-positioned feeding tube. You were also found to have an elevated white blood cell count and fever. Your urine specimen grew some bacteria. You were started on antibiotics in the emergency room. You were monitored in the intensive care unit and later went to the operating room for abdominal exploration, removal of feeding tube, placement of JP drain, and placement of [**Last Name (un) **]-gastric tube. You were transferred to the surgical floor 24 hours later. You were started on tube feedings via the [**Last Name (un) **]-gastric tube. The feeding tube was later changed to a Dobhoff tube and tube feedings resumed. You removed the Dobhoff tube. You were taken to the operating room for placement of an open gastrostomy and the tube feedings were resumed. A special button was placed into the gastrostomy stoma to provide cyclic feedings and reduce the chance of removal the tube. Your vital signs have been stable and you have been afebrile. Your antibiotics have been discontinued. You are preparing for discharge to your rehabiilitation facility where you can continue to receive care. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: TUESDAY [**2122-5-26**] at 1:30 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 Name: [**Last Name (LF) **],[**First Name3 (LF) **] A Specialty: Primary Care Location: [**Hospital **] MEDICAL GROUP Address: [**Hospital1 62440**], [**Location (un) **],[**Numeric Identifier 62441**] Phone: [**Telephone/Fax (1) 40575**] *Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Completed by:[**2122-5-5**]

[ "599.0", "707.22", "707.07", "427.89", "041.3", "041.7", "536.41", "536.42", "348.1", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "97.51", "54.91", "43.19", "54.0", "96.6" ]

icd9pcs

[ [ [] ] ]

15102, 15143

9077, 13840

330, 518

15218, 15302

2358, 9054

16497, 17277

1534, 1539

13919, 15079

15164, 15197

13866, 13896

15326, 16474

1554, 1988

263, 292

2005, 2339

546, 1336

1358, 1465

1481, 1518

18,869

170,442

44919

Discharge summary

report

Admission Date: [**2154-3-25**] Discharge Date: [**2154-4-2**] Service: CHIEF COMPLAINT: The patient's chief complaint was hypoxia, status post bronchoscopy. HISTORY OF PRESENT ILLNESS: This is an 80-year-old female with a history of bronchiectasis and Mycobacterium avium-intracellulare in sputum, admitted on [**2154-2-18**] with diarrhea times 12 hours for four days followed by gasping dyspnea on exertion and then shortness of breath at rest. At that time, her SpO2 was 91% on room air. A chest x-ray showed hyperinflation with new right middle lobe consolidation, an interval increase in the amount of right upper lobe patchy airspace consolidation. Electrocardiogram showed new T wave inversion in V2. A CT scan of the chest with intravenous contrast angiogram protocol showed no evidence of pulmonary embolism, multiple areas of patchy consolidation with ground-glass opacity in the right middle lobe, right upper lobe, lingula, enlarged pretracheal right hilar lymph nodes increased from prior study. The patient received levofloxacin for presumed community-acquired pneumonia. The Pulmonary Service was consulted due to the complicated history. Their examination noted crackles in the right upper lobe and right lower lobe. Dr. [**Last Name (STitle) 575**] favored Mycobacterium avium-intracellulare as cause of new imaging findings. Levofloxacin was discontinued. He recommended an induced sputum for bacteria, acid-fast bacillus, fungal culture, and the patient was sent home with outpatient followup. At this point, her SpO2 was 92% on room air. Urinary Legionella antigen was negative. The patient continued to have increased shortness of breath. No fever. She saw Dr. [**Last Name (STitle) 575**] in clinic on [**2154-3-18**]. The examination was unchanged and Mycobacterium avium-intracellulare still suspected culprit. Repeat spirometry was unchanged, FVC of 66%, FEV1 of 61%, with a ratio of 91% of predicted. No response to bronchodilators. Her diffusing capacity of lungs for carbon monoxide was 64%. A chest x-ray showed interval clearing of right upper lobe process but persistent right middle lobe lingula and right upper lobe bronchiectasis. The patient was scheduled for outpatient bronchoscopy which took place on [**2154-3-25**]. Prior to procedure, the patient's SpO2 was recorded as 82% to 86% and 92% on room air. During the procedure, Dr. [**Last Name (STitle) 575**] observed an increase in systolic pressure at one time to 190. Procedural findings were dilated airways, friable mucosa, no endobronchial lesions, purulent secretions in the right middle lobe and lingua. Mucous plugs were retrieved. Bronchoalveolar lavage was sent for right upper lobe and left lower lobe culture. Bronchial washings were sent from the right middle lobe. Status post procedure, she did not recover from her peripheral oxygen saturation. She had recordings of 83% to 88% on a nonrebreather mask. She vomited times one. Lasix 20 mg intravenously was given. Arterial blood gas at that time showed a pH of 7.36, PCO2 of 55, PO2 of 53 on nonrebreather. She was transferred to the Medical Intensive Care Unit for monitoring. Currently, on admission, Ms. [**Known lastname 71353**] felt a lot better breathing; felt like she had just walked up stairs. At baseline, she can walk up two flights of stairs before becoming dyspneic. She had a chronic cough for five years, worse while lying down. PAST MEDICAL HISTORY: 1. Severe focal bronchiectasis secondary to Mycobacterium avium-intracellulare and sputum in [**2149-6-27**]. This was status post four separate course of triple antibiotic therapy; three times six months, and one times 12 months. Most recent course was ciprofloxacin, clarithromycin, ethambutol. 2. The patient also has restrictive lung disease with pulmonary function tests in [**2152-4-27**] showing FVC of 64%, FEV1 of 62%, with a ratio of 97%. 3. Gastrointestinal workup showed normal upper gastrointestinal, small-bowel follow-through in [**2154-4-27**], C-scope in [**2154-1-25**] showed two adenomas in the descending colon with diverticulosis. 4. The patient had positive purified protein derivative in the past. 5. Transthoracic echocardiogram in [**2151-2-25**] showed normal left ventricular and right ventricular function, mild-to-moderate aortic insufficiency, mild mitral regurgitation, mild pulmonary artery hypertension. PAST SURGICAL HISTORY: Tonsillectomy. MEDICATIONS ON ADMISSION: None. ALLERGIES: None. SOCIAL HISTORY: Single, no children. Lives with sister. A retired research technician. He worked in multiple [**Location (un) 86**] hospitals. Occasional use of alcohol. Quite smoking four years ago. No recreational drugs. Does aerobics twice weekly. FAMILY HISTORY: Father died at 74 of prostate cancer. Mother died at 93 of colon cancer. Sister is still alive at the age of 68. PHYSICAL EXAMINATION ON PRESENTATION: The patient was an elderly, cachectic, cyanotic, using accessory muscles. Head, eyes, ears, nose, and throat showed normocephalic and atraumatic. Conjunctivae were pink. No scleral icterus. Mucous membranes were moist. No lesions. Neck was supple. No lymphadenopathy. Chest revealed right lung field with decreased breath sounds at apex, rales at base, left lung field pops and squeaks throughout except for base which also has fine rales. Cardiovascular revealed borderline tachycardic, second heart sound louder than first heart sound at the apex with early systolic murmur. The abdomen had normal active bowel sounds, soft, nontender, and nondistended. Extremities were mildly cyanotic. No edema. Able to appreciate slight Quincke pulsations. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data from [**3-18**] revealed platelets of 191, PT of 12.1, INR of 1. On [**3-25**] bronchoalveolar lavage showed white blood cell count of 3500, 99% polys, 1% lymphocytes, 11,144 red blood cells. Arterial blood gas revealed pH of 7.36, PCO2 of 55, PO2 of 53. Bronchoalveolar lavage Gram stain on [**2154-3-25**]; final showed 4+ polys, 1+ gram-positive cocci in pairs, 1+ gram-positive rods. Bronchoalveolar lavage washing Gram stain from the middle lobe showed 4+ polys, 1+ gram-positive cocci, 1+ gram-positive rods, 1+ squamous epithelial cells. RADIOLOGY/IMAGING: Chest x-ray showed new bilateral confluent alveolar opacities concerning for acute aspiration event, new small bilateral pleural effusions, background pattern of multifocal patchy opacities, as well as underlying bronchiectasis, and curvilinear opacity in peripheral right lung may reflect pneumothorax versus structure external to patient. Subsequent chest x-ray showed curvilinear opacity no longer identified, suggesting it was external to patient. No evidence of pneumothorax. No change from prior study. Electrocardiogram showed sinus tachycardia at 100 on admission, borderline left axis, normal intervals, tall T waves in lead II, suggesting right atrial enlargement, persistent low voltage in limb leads; however, there were Q waves in leads III and F, apparently new since [**2-18**]. ASSESSMENT: An 80-year-old with recurrent Mycobacterium avium-intracellulare infection and bronchiectasis. She has been progressively dyspneic and hypoxic for over one month with right upper lobe infiltrates that resolved on their own. Most concerning for recrudescent Mycobacterium avium-intracellulare infection. Multiple etiologies might explain new bilateral alveolar opacities. The patient with new Q waves on electrocardiogram and known valvular disease. Cardiac etiology such as ischemia or worsening pump dysfunction cannot be excluded. Things, such as bacterial pneumonia are certainly a possibility. PLAN: 1. PULMONARY: Supplemental oxygen as needed. Await microbiology results from bronchoalveolar lavage and bronchial washings. Await culture and further data before giving antimicrobial therapy. Check complete blood count with differential. Monitor closely for signs of ventilatory failure. Congestive heart failure workup and management. 2. CARDIOVASCULAR: Check transthoracic echocardiogram on [**3-26**] in the a.m. to re-evaluate for worsening valve pathology and left ventricular dysfunction. Cycle cardiac enzymes give new Q waves. Give aspirin 325 mg p.o. q.d. Hold off on beta blockers since concern for systolic failure. Continue to diurese with Lasix. Monitor fluid output. 3. GASTROINTESTINAL/RENAL/FLUIDS/ELECTROLYTES/NUTRITION: Give the patient a cardiac diet. Follow electrolytes, blood urea nitrogen, serum creatinine since the patient will be on diuresis. 4. LINES: She has peripheral intravenous line, prophylaxis with subcutaneous heparin. 5. DISPOSITION: The patient is aware of condition. The patient is full code. HOSPITAL COURSE: The patient initial required 5 liters nasal cannula and shovel mask at 50% oxygen. The patient progressively improved and was brought to the floor after day one. On the day of discharge, the patient required only 2 liters to 3 liters nasal cannula with oxygen saturations of 92% to 94%. The patient still noted shortness of breath and desaturation of oxygen down to 88% with ambulation while on oxygen. The patient's chest x-ray on [**3-31**] showed no significant change in chest over the past four days with continued patchy densities in the right upper lobe and left lower lobe. An ill-defined density in the anterior left second rib. The patient's bronchoalveolar lavage was negative for viral culture. The patient's Gram stain showed 4+ polys, 1+ gram-positive cocci, and 1+ gram-positive rods. Respiratory culture was positive for Streptococcus pneumoniae with sparse growth which was pan-sensitive. Positive mold on respiratory culture with no identification as yet. The patient had no acid-fast bacillus or nocardia. The patient was put on Levaquin 500 mg p.o. q.24h. for 14 days total due to positive Streptococcus pneumoniae culture. The patient was started on [**2154-3-27**] and will continue the antibiotic until [**2154-4-10**]. The patient will utilize salmeterol meter-dosed inhaler for breathing as needed. The patient did have a dobutamine stress echocardiogram which showed no anginal symptoms, and no ischemic electrocardiogram changes on stress. Echocardiogram showed an ejection fraction of 60% to 65% with no evidence of inducible ischemia. The patient's white blood cell count on discharge was 4.9, hematocrit of 35.8 and stable. The patient ruled out for a myocardial infarction. Her creatine kinases were negative times three with a troponin I of less than 0.3. The patient did have immunoglobulin workup. Immunoglobulin G was 889 and within normal limits. Immunoglobulin A subset was 165 and within normal limits. Immunoglobulin M was 29 which was low. ? Etiology of low immunoglobulin M not known. While in the hospital, the patient had two episodes of desaturation requiring intravenous Lasix which resulted in resolution of her shortness of breath. The patient with a long history of underlying pulmonary disease with resolving exacerbation of lung function, status post bronchoscopy. The patient with hypoxia, most likely due to bacterial pneumonia on top of slight fluid load from bronchoalveolar lavage. The patient was resolving on antibiotics, will be discharged to pulmonary rehabilitation. The patient now requiring oxygen at baseline which was new, yet progressively improving. The patient will most likely need oxygen at home. Goal will be to wean off oxygen while at rehabilitation if possible. The patient will continue physical therapy and oxygen therapy at rehabilitation. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 575**] (pulmonary doctor) in three weeks, and we will continue to monitor the patient's positive mold on culture for identification of species. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Pulmonary disease exacerbation. 3. Oxygen requirement. CONDITION AT DISCHARGE: The patient's condition was stable on 2 liters to 3 liters of oxygen. MEDICATIONS ON DISCHARGE: (The patient's medications on discharge were) 1. Levaquin 500 mg p.o. q.d. (until [**2154-4-10**]). 2. Salmeterol meter-dosed inhaler. 3. Colace 100 mg p.o. b.i.d. 4. Ambien 5 mg p.o. q.h.s. p.r.n. for insomnia. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 4724**] MEDQUIST36 D: [**2154-4-2**] 15:49 T: [**2154-4-2**] 17:20 JOB#: [**Job Number 96083**]

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Discharge summary

report

Admission Date: [**2119-4-24**] Discharge Date: [**2119-5-2**] Date of Birth: [**2041-12-2**] Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1257**] Chief Complaint: Hypertensive emergency Major Surgical or Invasive Procedure: Placement of tunneled hemodialysis catheter History of Present Illness: 78 yo male with history of HTN (poorly controlled on 4 antihypertensives), HL, CRF stage IV (baseline 3.4, considering peritoneal dialysis initiation as outpatient) who is being transferred from [**Hospital3 **] for hypertensive urgency and evaluation for HD initiation. He presented to NWH on [**2119-4-21**] with one day of increasing nausea and vomiting. On the day of presentation, he also experienced some nonradiating substernal chest pressure, which he reports as occuring intermittently for at least a few months, usually at night, and without any clear precipitants. He denied orthopnea or PND; lower extremity edema had been improving with uptitration of diuretics. . On presentation to the ED, VS: BP 196/93, P 74, RR 22, O2sat 92 on bipap, 98% on NRB at 15L. Cr was 4.4 (baseline 4), K 4.7, trop 0.12. CXR showed evidence of pulmonary edema. He was given NTG paste and admitted to the floor. He also had a left lung opacity c/w pneumonia and was started on ctx/azithromycin. However, he subsequently developed chest pain with accompanying ST depressions in V4-V6 in the setting of SBP in the 170s-180s. He was given ASA 325mg and NTG SLs with improvement in blood pressure. He was also started on a heparin gtt and transferred to the ICU. Troponins peaked at 0.48. He continued to have intermittent chest pain in the setting of poorly controlled blood pressure so given IV lopressor and started on a nitro gtt which was increased up to 100 with SBP ranging 130 to 170s on this plus metoprolol po (increased 300mg to 400mg), amlodipine (home dose), hydralazine (increased 100mg tid to qid), and verapamil (new med - 40 mg q8h, possibly increased to 80mg). TTE showed LVH, thickened valves without stenosis, mild TR with preserved EF, no WMA. Renal was consulted to assist with diuresis as he was diuresing <1L a day on his home torsemide 100mg [**Hospital1 **]. He was given lasix 160mg with metolazone and diuril and initially put out 100-200c/h. However, UOP began decreasing to 20-30 cc/h. Given persistent hypertension of renovascular etiology with concern for ischemic heart disease and volume management, plan was made to transfer to our ICU for question of initiating dialysis as well as possible cardiac cath. . On the floor, pt currently without chest pain or dyspnea. He has no complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Headache previously with NTG. No sinus tenderness, rhinorrhea or congestion. Has cough, only mildly productive. No shortness of breath or wheezing. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HTN, poorly controlled Hyperlipidemia Chronic kidney disease stage 4, Cr last 3.4 as outpt Anemia Gout Pruritis Diverticulitis BPPV Tubular adenoma [**7-/2116**] Hyperparathyroidism (secondary) R inguinal hernia repair BPH Social History: Lives at home with wife, no home O2, questionably independent in ADLs, has had some falls (e.g. while weeding) - Tobacco: Denies; per records quit 25 years ago - Alcohol: Denies - Illicits: Denies Family History: Noncontributory Physical Exam: On Admission: Vitals: T 97.3, BP 122/64, RR 13, O2sat 91% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP elevated to angle of jaw Lungs: Bibasilar rales; no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: +Foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace-1+ edema bilaterally . On Discharge: Vitals: T 98.6, BP 147/71 (SBP rage over 24 hours 98-147), RR 20, O2sat 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM Lungs: CTAB CV: S1, S2 RRR Abdomen: Soft, non-tender, non-distended Ext: Warm, well perfused Pertinent Results: Admission labs: [**2119-4-24**] 01:34PM BLOOD WBC-9.8 RBC-3.17* Hgb-9.8* Hct-26.2* MCV-83 MCH-30.7 MCHC-37.3* RDW-13.3 Plt Ct-240 [**2119-4-24**] 01:34PM BLOOD PT-12.1 PTT-45.3* INR(PT)-1.0 [**2119-4-24**] 01:34PM BLOOD Glucose-176* UreaN-108* Creat-4.6* Na-130* K-4.2 Cl-89* HCO3-23 AnGap-22* [**2119-4-24**] 01:34PM BLOOD CK-MB-5 cTropnT-0.09* [**2119-4-24**] 01:34PM BLOOD Calcium-10.2 Phos-7.4* Mg-2.1 . Troponin/CK/MB: [**2119-4-24**] 01:34PM BLOOD CK-MB-5 cTropnT-0.09* [**2119-4-25**] 04:40AM BLOOD CK-MB-3 cTropnT-0.10* [**2119-4-25**] 02:45PM BLOOD CK-MB-4 cTropnT-0.11* [**2119-4-26**] 02:26AM BLOOD CK-MB-4 cTropnT-0.12* [**2119-4-26**] 05:14PM BLOOD CK-MB-4 cTropnT-0.17* [**2119-4-27**] 10:00AM BLOOD CK-MB-4 cTropnT-0.20* [**2119-4-28**] 07:15AM BLOOD CK-MB-4 cTropnT-0.24* [**2119-4-24**] 01:34PM BLOOD CK(CPK)-31* [**2119-4-25**] 04:40AM BLOOD CK(CPK)-31* [**2119-4-25**] 02:45PM BLOOD CK(CPK)-42* [**2119-4-26**] 02:26AM BLOOD CK(CPK)-35* [**2119-4-26**] 05:14PM BLOOD CK(CPK)-35* [**2119-4-27**] 10:00AM BLOOD CK(CPK)-34* [**2119-4-28**] 07:15AM BLOOD CK(CPK)-35* . [**2119-4-26**] 02:26AM BLOOD calTIBC-293 VitB12-477 Folate-15.1 Ferritn-206 TRF-225 [**2119-4-25**] 02:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2119-4-25**] 02:45PM BLOOD HCV Ab-NEGATIVE . Discharge labs: [**2119-5-2**] 06:40AM BLOOD WBC-10.4 RBC-3.39* Hgb-10.1* Hct-29.1* MCV-86 MCH-29.9 MCHC-34.7 RDW-13.5 Plt Ct-289 [**2119-5-2**] 06:40AM BLOOD PT-21.8* PTT-100* INR(PT)-2.0* [**2119-5-2**] 06:40AM BLOOD Glucose-89 UreaN-54* Creat-4.5*# Na-129* K-4.8 Cl-92* HCO3-25 AnGap-17 [**2119-5-2**] 06:40AM BLOOD Calcium-8.9 Phos-5.5*# Mg-2.0. . [**2119-4-24**] Chest X-Ray: 1. Probable resolving left lower lobe pneumonia. 2. Acute pulmonary edema. . [**2119-4-25**] ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild global left ventricular systolic dysfunction. Mild to moderate pulmonary hypertension. . [**2119-4-25**] Chest X-Ray: 1. Worsening pulmonary edema. 2. Worsening right lower lobe pneumonia or aspiration. . [**2119-4-26**] Chest X-Ray: Comparison is made with prior study performed [**4-25**]. Moderate-to-severe pulmonary edema has minimally improved. There is less mediastinal widening. Left supraclavicular catheter tip is in the lower SVC. There is no evident pneumothorax. If any, there are small bilateral pleural effusions associated with adjacent atelectasis worse on the left. . [**2119-4-27**] Renal Ultrasound with Dopplers 1. Increased cortical echogenicity compatible with the known chronic renal disease. 2. Multiple simple cysts bilaterally. 3. Technically inadequate Doppler but evidence suggesting poor vascularization of the left kidney relative to the right. If there is concern for left renal artery stenosis, further imaging would be required, as adequate Doppler waveforms could not be obtained from the left kidney. Limited views from the right side show relatively normal arterial and venous waveforms. . Repeat Renal US with Doppler [**2119-5-1**] 1. No evidence of renal artery stenosis bilaterally. 2. The left kidney is again noted to be somewhat atrophic and demonstrates cortical thinning. Simple bilateral renal cysts are again noted. . Bilateral upper extremity vein mapping [**2119-5-1**]: 1. Patent bilateral basilic veins. 2. Patent cephalic veins, however, they could not be visualized in the upper arm. 3. The bilateral brachial and radial arteries presented with normal triphasic Doppler waveforms, with diameters described above. 4. Decreased phasicity noticed in the left subclavian vein, which may be an indirect sign of central venous obstruction. Brief Hospital Course: Mr. [**Known lastname 11818**] is a 77 yo man with poorly controlled HTN, HL, CRF stage IV presenting with hypertensive urgency transferred from [**Hospital3 1196**] for management of volume status. Patient with acute on chronic renal failure requiring dialysis. He was initially admitted to the MICU, was begun on hemodialysis, and was called out from MICU [**2119-4-26**]. . # HYPERTENSIVE EMERGENCY: Most likely renovascular etiology in the setting of stage IV chronic renal failure. Also with component of fluid overload. At NWH, SBPs remained difficult to control with nitroglycerin gtt, uptitration of oral meds (hydralazine and metoprolol) and initiation of verapamil in addition to his home amlodipine and spironolactone. In the [**Hospital1 18**] MICU he was weaned off nitroglycerin gtt and verapamil was stopped because he was already on a calcium channel blocker. Stopped metoprolol and added labetalol for better blood pressure control. Patient was diuresed with IV Lasix boluses and metolazone. Patient started dialysis for ESRD and his blood pressure improved. Renal dopplers not concerning for renal artery stenosis after further review with radiology/nephrology and repeat study. On the floor SBP was persistently 150-190 but he became hypotensive in dialysis on several occasions and hydralazine was weaned. His regimen on discharge was lisinopril 10mg daily, amlodipine 10mg daily, and labetalol 150mg q 8 hours. BP was well-controlled 120s-140s. . # VOLUME OVERLOAD: Initial presentation with elevated JVP, crackles on exam, and CXR c/w fluid overload. TTE shows preserved EF and only mild TR with no WMA. Attempts to diurese at NWH reportedly increasingly difficult so transferred here for evaluation for HD initiation. On admission, patient was satting low 90s on oxygen. He started dialysis on [**2119-4-25**] and tolerated dialysis well. Fluid status improved after initiation of dialysis and he was able to be weaned off oxygen. He was maintained on a fluid restricted diet of 1500mL daily. He appeared euvolemic on the day of discharge. . # END-STAGE RENAL DISEASE: Patient's baseline creatinine prior to admission was ~3.5, and patient under discussion for consideration of outpatient dialysis. On admission Cr was 5.1; he likely had some acute worsening in setting of poor forward flow. It is also possible he had some component of ATN in setting of relative hypotension. Hemodialysis was initiated [**2119-4-25**] for hypervolemia, and he had a tunneled line placed [**4-28**]. He was started on sevelamer and nephrocaps. He had a PPD placed which was negative, and hepatitis serologies were also negative. He received HBV vaccine #1. Vein mapping was done in anticipation of fistula placement. . # CHEST PAIN/TROPONIN ELEVATION: Patient had troponin elevation (peaked at 0.48), chest pain, and dynamic EKG changes at NWH. EKG at [**Hospital1 18**] returned to baseline. Likely demand in setting of hypertensive urgency; less likely acute thrombosis. No further chest pain at [**Hospital1 18**]. Seen by [**Location (un) 2274**] cardiology, and continued on a heparin gtt for >48hrs for management of NSTEMI. He was medically managed with aspirin 325 mg daily, Lipitor 80 mg daily, and beta blocker as above. Repeat TTE at [**Hospital1 18**] was unremarkable. Cardiac enzymes were trended while inpatient; CK and MB flat and troponin slowly rising which was difficult to interpret in the setting of ESRD. As he had no further chest pain and was otherwise asymptomatic, stopped trending troponins as no further intervention was planned unless his clinical picture changed. There is no plan for outpatient cardiac catheterization per discussion with consulting [**Location (un) 2274**] Cardiologist the day prior to discharge. He is being discharged on 40mg atorvastatin, 81mg ASA, and labetalol as noted above. . # ATRIAL FIBRILLATION: Patient appears to have been in atrial fibrillation on overnight telemetry [**2119-4-27**], then had periods of tachycardia and periods of sinus bradycardia with pauses, longest pause 3.7 sec. Patient asymptomatic, spontaneously converted to NSR when returned to floor after hemodialysis [**4-27**]. However, had a syncopal episode during hemodialysis on [**4-28**] while off telemetry, and given concern in light of prior telemetry findings an EP consult was called. He was begun on a heparin drip and bridged to Coumadin. INR 2.0 on the day of discharge, and should be followed in rehab. EP did not feel a pacemaker was needed at this time. Prior to discharge from rehab, he will need to be connected with anti-coagulation management at [**Hospital1 **]. . # PNEUMONIA: LUL opacity noted on chest imaging, and patient started treatment for community-acquired pneumonia at NWH. He remained afebrile at [**Hospital1 18**]. He completed a 5-day course of azithromycin and a 7-day course of ceftriaxone. After treatment of his pneumonia and pulmonary edema as above he no longer required supplemental oxygen. he was satting mid-90s on room air on the day of discharge. . # ANEMIA: Hematocrit improved with removal of excess fluid. Iron supplementation was continued. Hct was otherwise stable throughout admission. . # HYPONATREMIA: Likely hypervolemic hyponatremia. Serum sodium improved with removal of excess fluid after hemodialysis and better forward flow with BP control. He he had no mental status changes. . Pt was confirmed full code this admission. Medications on Admission: Medications (per pt med list): Torsemide 100 mg [**Hospital1 **] Hydralazine 100 mg tid Metoprolol 200 mg qAM, 100 mg qhs Amlodipine 10 mg daily Spironolactone 25 mg daily Aspirin 81 mg daily Multivitamin 1 tab daily Colace 2 tabs daily Senna 2 tabs AM, 2 tabs PM Iron 27 mg 2 tabs daily . Medications on transfer: Aspirin 81 mg dailiy Acetaminophen 500-1000mg q4h prn Atorvastatin 80 mg qhs Azithromycin 500 mg q24h Docusate 100 mg [**Hospital1 **] Ferrous sulfate 27 mg [**Hospital1 **] Hydromorphone 0.25mg-0.5 mg q2h prn Heparin gtt Hydralazine 100 mg q6h Metoprolol 100 mg q6h MVI 1 tab daily NTG gtt Ondansetron 4 mg q6h p rn Pantoprazole 40 mg q24h Senokot 2 tabs [**Hospital1 **] Sprironolactone 25 mg daily Tamsulosin 0.4 mg daily Verapamil 40 mg q8h (?increased to 80 mg q8h prior to transfer) Amlodipine 10 mg daily Ceftriaxone 1 gm q24h Metolazone 20 mg daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for loose stools. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 9. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP < 100. 11. labetalol 100 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8 hours): Hold for SBP < 100 or HR < 60. 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. iron 27 mg (Iron) Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: PRIMARY: - Hypertensive emergency - Pulmonary edema - Community-acquired pneumonia - End-stage renal disease requiring initiation of hemodialysis - Non ST-elevation myocardial infarction - Atrial fibrillation . SECONDARY: - Iron-deficiency anemia - Hypervolemic hyponatremia - Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname 11818**], . It was a pleasure to care for you at [**Hospital1 827**]. You were transferred from [**Hospital1 16961**] with hypertensive emergency and volume overload for better blood pressure control and initiation of hemodialysis. You were originally in the Intensive Care Unit but have improved and it is now safe for you to go to rehab to continue your recovery. . Your blood pressure has been difficult to control for many years. We changed your medications around and have found a regimen that seems to work for you right now. You will need to follow up closely with Dr [**Last Name (STitle) **] to ensure that your blood pressure remains under better control. . Your kidney function has been worsening and we started hemodialysis while you were in the hospital. You will continue dialysis at rehab and after you return home. You have a tunneled access catheter on the left side and we did an ultrasound vein mapping at [**Hospital1 18**]. If you opt for a dialysis fistula in the future you can access these records at ([**Telephone/Fax (1) 39110**]. . You had a mild heart attack due to the strain on your heart from your elevated blood pressure. You also had some irregular heartbeats (atrial fibrillation) and long pauses in your heartbeats. The cardiology team has seen you and has recommended anticoagulation with Coumadin. You will need to follow closely with Dr [**Last Name (STitle) **] to adjust your Coumadin dose. . We have made the following changes to your medications: - STOP torsemide [blood pressure] - STOP metoprolol [blood pressure] - STOP multivitamins [vitamins] - STOP hydralazine [blood pressure] - STOP spironolactone [blood pressure] - START lisinopril 10mg daily [blood pressure] - START labetalol 150mg three times a day [blood pressure] - START tamsulosin (Flomax) 0.4mg each night [prostate] - START sevelamer [kidney] - START Nephrocaps [kidney vitamins] - START atorvastatin (Lipitor) 40mg daily [heart attack] - START warfarin (Coumadin) 5mg daily [blood thinner]. Your levels of this medicine will be checked at rehab, so this dose may be adjusted. . You will need to follow up with your PCP and your nephrologist as noted below. Followup Instructions: Name: [**Last Name (LF) 3112**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD Location: [**Location (un) 2274**]-Nephrology Address: [**Location (un) 4363**], [**Location (un) 86**], MA Phone: [**Telephone/Fax (1) 2263**] Appt: We are working on an appt for you within the next [**12-18**] weeks. Dr[**Name (NI) 15932**] office will call you at home with an appt. If you don't hear from them by tomorrow afternoon, please call them directly to book. . You should follow up with Dr. [**Last Name (STitle) **] after discharge from rehab.

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Discharge summary

report

Admission Date: [**2154-1-20**] Discharge Date: [**2154-2-18**] Date of Birth: [**2094-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Attending:[**Known firstname 922**] Chief Complaint: Ruptured thoracoabdominal aneurysm Major Surgical or Invasive Procedure: [**2154-1-20**] - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm with a 34-mm Dacron tube graft using deep hypothermic circulatory arrest. [**2154-1-22**] - Chest and abdomen exploration, Removal of packs, Chest closure. [**2154-1-25**] - abdomen closure/ feeding jejunostomy [**2154-2-4**] tracheostomy History of Present Illness: 59 M transferred from [**Hospital3 15402**] with ruptured TAA. Presented to OSH with back pain - CT scan done-> intubated and transferred here.Taken directly to OR for surgery for ruptured TAA. Past Medical History: hypertension Social History: lives with fiance Family History: Unknown Physical Exam: PE: 120/65 HR 85 Intubated, sedated RRR decreased BS on left soft NT, distended obese abdomen no edema, feet warm, 1+ PT and DP B/L Pertinent Results: Admission: [**2154-1-20**] 11:45AM FIBRINOGE-260 [**2154-1-20**] 11:45AM PT-13.8* PTT-29.3 INR(PT)-1.2* [**2154-1-20**] 11:45AM PLT COUNT-405 [**2154-1-20**] 11:45AM WBC-21.4* RBC-3.30* HGB-9.6* HCT-30.5* MCV-92 MCH-29.1 MCHC-31.5 RDW-13.0 [**2154-1-20**] 11:53AM GLUCOSE-366* LACTATE-3.4* NA+-137 K+-5.5* CL--110 [**2154-1-20**] 12:35PM GLUCOSE-358* LACTATE-4.1* NA+-141 K+-4.8 CL--111 [**2154-1-20**] 08:05PM ALT(SGPT)-34 AST(SGOT)-88* ALK PHOS-37* TOT BILI-1.8* [**2154-1-20**] 08:05PM GLUCOSE-187* UREA N-15 CREAT-1.2 SODIUM-152* POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-31 ANION GAP-11 Discharge: [**2154-2-18**] 02:58AM BLOOD WBC-10.1 RBC-3.05* Hgb-8.7* Hct-26.9* MCV-88 MCH-28.5 MCHC-32.3 RDW-15.2 Plt Ct-399 [**2154-2-18**] 02:58AM BLOOD Plt Ct-399 [**2154-2-18**] 02:58AM BLOOD PT-25.1* PTT-33.0 INR(PT)-2.4* [**2154-2-18**] 02:58AM BLOOD Glucose-111* UreaN-53* Creat-1.4* Na-135 K-4.3 Cl-103 HCO3-24 AnGap-12 [**2154-2-18**] 02:58AM BLOOD ALT-82* AST-59* AlkPhos-131* Amylase-100 TotBili-1.1 [**2154-2-18**] 02:58AM BLOOD Albumin-2.8* Calcium-8.5 Phos-4.2 Mg-2.3 Cholest-99 [**2154-1-22**] 03:13AM BLOOD %HbA1c-6.0* eAG-126* ECHO -[**1-20**] This is a directed and limited study to assess the aorta. The patient was booked as a Type A dissection. On placement of the TEE, it is clear that there is no ascending dissection and no AI. The descending aorta and mediastinum are distorted by clot. It is not possible to discern an aortic lumen or to fairly assess the heart's fxn. It is possible to see the aortic valve well. No AI or ascending dissection seen. Other intracardiac structures are too distorted to assess. TEE was used to help place the venous cannula in the right atrium. Aortic wire could not be seen. Pre-CPB: The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is a small pericardial effusion. After Circ Arrest and CPB: There were several instances when the right heart ceased to function because the lungs were full of blood and he could not be ventilated. With frequent pulmonary lavage and high dose epi, we were able to regain some cardiac fxn. No AI was seen. After heroic resuscitation, he had good biventricular systolic fxn on moderate doses of norepi and epinephrine by infusion. The patient was taken to the ICU for further care. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 86264**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 86265**]Portable TTE (Complete) Done [**2154-1-28**] at 3:07:53 PM FINAL Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.8 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.6 m/s Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 59 ml/beat Left Ventricle - Cardiac Output: 5.00 L/min Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: *4.0 cm <= 3.6 cm Aorta - Ascending: *4.3 cm <= 3.4 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 13 Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 175 ms 140-250 ms TR Gradient (+ RA = PASP): *38 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. 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. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta. AORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**11-24**]+] TR. Moderate PA systolic hypertension. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is elongated. 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. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild -moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Pulmonary artery systolic hypertension. Mild right ventricular cavity enlargement. Dilated ascending aorta. These findings are c/w a primary pulmonary process (COPD, bronchospasm, pulmonary embolism, obstructive sleep apnea, etc.). CLINICAL IMPLICATIONS: Based on [**2150**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2154-1-28**] 17:47 CHEST (PORTABLE AP) Study Date of [**2154-2-15**] 7:25 AM Final Report INDICATION: 59-year-old male with thoracic aneurysm repair and fever. COMPARISON: [**2154-2-7**]. CHEST, AP: Mediastinal widening is roughly stable, measuring 14 cm in greatest transverse measurement. Left lower lobe atelectasis is unchanged. The right lung is clear. There are no large pleural effusions. Cardiac and hilar contours are normal. Surgical clips are noted in the left upper quadrant. IMPRESSION: 1. Cardiomediastinal silhouette appears stable, but evaluation should ideally be performed by transesophageal echocardiography, CT, or MR. 2. No acute pulmonary process. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 10307**] HO DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] MR HEAD W/O CONTRAST Study Date of [**2154-2-3**] 2:42 PM [**Hospital 93**] MEDICAL CONDITION:59 year old man s/p TAA, chest/abd closure now blind REASON FOR THIS EXAMINATION: ischemic vs hemmorrhagic event Final Report:MRI OF THE BRAIN AND MRA OF THE HEAD AND NECK CLINICAL HISTORY: 59-year-old man status post TAA, chest, abdomen closure, now blind. TECHNIQUE: MRI of the brain was performed without the use of intravenous contrast. MRA of the head was obtained utilizing time-of-flight technique (no intravenous gadolinium contrast). MRA of the neck was performed both before and after the administration of intravenous gadolinium contrast, utilizing bolus triggering and subtraction technique. Complex multiplanar reformatted images were obtained of the MRA of the head and MRA of the neck. MR BRAIN: Multiple foci of decreased diffusion are noted in the brain, the largest of which is in the right occipital lobe, with corresponding T2 and FLAIR hyperintensity, consistent with acute infarcts. There is also gyriform T1-hyperintensity in the right occipital lobe, likely representing cortical laminar necrosis. Additional smaller foci of decreased diffusion are noted in the frontal and the parietal lobes, bilaterally, with involvement of the left precentral gyrus. There is no mass effect, shift of midline structures, or evidence of a space-occupying lesion. There is no extra-axial fluid collection. Scattered foci of susceptibility artifact are noted within the brain, which do not appear to correlate with these foci of decreased diffusion. The flow-voids of the major vessels are present. Mild mucosal thickening is noted in the ethmoid air cells. Fluid is noted layering in the nasal cavities and in the right maxillary sinus, likely related to the patient being intubated. There is also fluid within the mastoid air cells bilaterally, also likely related to the intubation. The visualized orbits and soft tissues are otherwise unremarkable. The bone marrow signal on the sagittal T1 image appears heterogeneous with foci of decreased T1 signal intensity. MRA HEAD: There is normal flow-related enhancement of the intracranial internal carotid arteries, the anterior, middle and posterior cerebral arteries, the anterior and posterior communicating arteries, the vertebral arteries, and the basilar artery. There is a slightly patulous basilar tip, with a prominence to the origin of the left superior cerebellar artery which may have an infundibular origin. Otherwise, there is no evidence of a hemodynamically significant stenosis, dissection, or aneurysm (within the limitations of this MRA technique). MRA NECK: Image quality is degraded by patient motion and the timing of the contrast bolus injection. However, allowing for this limitation (and using both initial and delayed acquisitions), the common, internal and external carotid arteries demonstrate normal enhancement, without evidence of hemodynamically significant stenosis or dissection. The vertebral arteries are grossly normal in caliber and enhancement, again without evidence of hemodynamically significant stenosis. IMPRESSION: 1. Multiple acute infarcts, bilaterally, the largest of which is in the right occipital lobe. Given that (by DWI, ADC map and FLAIR sequences) these lesions appear to be of the same age, the distribution as well as the history, these are likely embolic in nature, related to a single event. 2. A few foci of susceptibility artifact, appearently unrelated to the foci of acute infarction, may be represent prior microhemorrhage, perhaps related to underlying hypertension or, less likely, prior embolic disease or underlying cavernous malformations. 3. MRA of head and neck is unremarkable, without evidence of hemodynamically significant stenosis, dissection, or aneurysm (within the limitations of the MRA technique). 4. Heterogeneous bone marrow signal with foci of T1-hypointensity in the bone marrow of the calvaria and the visualized spine. In a male patient of this age, this raises the possibility of a marrow-replacing process, and close correlation with laboratory data is recommended. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Brief Hospital Course: Mr. [**Known lastname **] was transferred to the [**Hospital1 18**] on [**2154-1-20**] for emergent repair of his ruptured thoracoabdominal aortic aneurysm. He was taken immediately to the operating room where he underwent an emergent salvage repair of ruptured thoracoabdominal aortic aneurysm with a 34-mm Dacron tube graft using deep hypothermic circulatory arrest. Please see operative note for details which included cardiac arrest x2. Postoperatively he was taken to the intensive care unit for monitoring with an open chest. He remained intubated and sedated on pressors and inotropes. On [**2154-1-22**], he returned to the operating room where he underwent exploration and chest closure. On [**1-25**] he returned to the OR for abd closure JP/ drain placement/ feeding jejunostomy placed at that time for nutritional support. Neurology consult done [**1-26**]. Pressors slowly weaned. ID consult obtained on [**1-27**] for fever,leukocytosis, and recomendations for antibiotic management. Multiple bronchoscopies were performed for secretions/ pulm. hemorrhage. Developed intermittent A Fib on [**1-28**] and treated with amiodarone and cardioversion x4, has had several episode of going in and out of atrial fibrillation since that time. EEG done [**1-29**] revealed severe encephalopathy for continuing neurologic deficits including bilat. LE paralysis and right arm paralysis. MRI revealed multiple acute infarcts, with the largest in the right occipital lobe. When the patient woke it was found that he had developed blindness. Ophthalmology was consulted and stated that the patient likely had posterior ischemic optic neuropathy bilaterally due to hypotension, in addition to occipital infarcts. Electrophysiology was consulted and recommended titration of beta blocker and observation of rhythm. Tracheostomy was performed on [**2154-2-4**]. On [**2154-2-11**] BC were + for GPC treated with-IV vanco. Coumadin was titrated for afib. with target INR being 2-2.5. His tube feeds have been at goal rate for past several weeks. By system: Neuro: Moves all extremities and follows commands. Still not able to tolerate Passy-Muir so unable to assess orientation. At times becomes restless and agitated, has history of benzo use preoperatively and has responded well to PRN ativan during post-op course. Pulmonary: s/p tracheostomy on [**2-4**], has tolerated long periods of trach collar over past week however tires and has been on CMV or PSV overnight to rest. Continues to have moderate to large amount of secretions daily. CV: Intermittant Atrial Fibrillation treated with Bblockers and Amiodarone and now in sinus rhythm. Also anticoagulated for afib. Hemodynamically stable since initial recovery from surgery. Renal: ARF in initial post-op period now largely resolved, never requiring HD. Continues to be diuresed with Lasix Abdm: soft/NT/+BS. Tube feeds at goal rate (NovaSource Renal) Ext: warm with palpable pulses, 1+ edema bilat ID: +BC wcoag neg staph tx with Vanco last level on [**2-18**] 27.2-course completed Wounds: thoracoabdominal wound healing well with exception of very small open area mid wound that is @1cm around and 1/2cm deep, no surrounding erythema. Packed with dry gauze and covered w/DSD-[**Hospital1 **] Medications on Admission: benicar Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**] Drops Ophthalmic PRN (as needed) as needed for dryness. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezes. 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily for 7days then 200mg daily. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin yeast. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation/anxiety. 14. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: 3mg on [**2-18**] target INR 2-2.5 (received 5mg last 4 days) . 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: Type A aortic dissection with rupture s/p thoracoabdominal repair Hypertension atrial fibrillation blindness respiratory failure s/p Trach and G-J tube Discharge Condition: alert and responsive, at times agitated/restless moving all extremities, follows commands new blindness, needs assistance with ambulation and ADL Thoraco-abdominal wound healing well with exception of mid wound 1cm are that is about .5cm deep/packed with dry gauze and covered with DSD Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Surgeon Dr. [**Last Name (STitle) 914**] [**2154-2-26**] 1:00 pm [**Telephone/Fax (1) 170**] Please call to schedule appointments Primary Care Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 86266**] in 2 weeks Referral for a cardiologist needed from Dr. [**Last Name (STitle) **] and please make appt in [**11-24**] weeks Completed by:[**2154-2-18**]

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